- Date published:
7:14 am, November 29th, 2012 - 60 comments
Categories: Ethics, health, national - Tags: elective surgery, medical decisions, micro managing
With unemployment grinding upwards, the economy stagnant, the education system in turmoil, and the exodus to Australia at record levels, the Nats must have thought that at least they had a success story to tell on health. Here’s a press release from back in August:
Big increase in elective surgery and reduction in waiting times
More patients are getting the operations they need and they’re getting them faster, according to the latest information from district health boards.
“An extra 7,500 patients received elective surgery in the last 12 months, meaning 153,000 people got the operations they needed. This is the fourth year of record increases under National,” said Health Minister Tony Ryall.
“Since the change of government in 2008, thirty per cent more patients are getting elective surgery.
Good news – right? Maybe not. Last night, on 3 News:
Children kicked off surgery lists – Labour
Children are dropping off treatment lists as hospitals focus on the Government’s elective surgery targets, Labour says. …
Outside Parliament, Ms Street said clinicians and parents had told her about “some truly sad cases” of complex operations and appointments which had been cancelled. “In one case a solo mum couldn’t even get her four-year-old on a waiting list for a first specialist assessment because the district health board (DHB) has to keep waiting times low to look good for the minister of health,” she said. …
Ms Street says clinicians have told her the situation is demoralising. “They are compelled to make decisions for the wrong reasons – health is always about competing priorities but what we are seeing here are people being asked to make decisions they feel uncomfortable about.”
The Government sets targets for hospitals and 35,000 more elective operations are being carried out each year since National came to power in 2008. Ms Street says they are focusing on simple procedures so they can meet the targets.
This is the untold backstory to the “success” – to ramp up elective surgery something else has to give. It is also yet another example of the Nats micro-managing professionals, like trying to tell Universities what to teach, and ramming national standards down the throats of schools. Medical decisions should be left to medical professionals, not made hostage to the Nats’ desperation to generate at least some numbers that look good.
Why the hell is the government setting targets for hospitals? The only thing they should be doing is funding them.
Which is how authoritarians work. They truly cannot leave people who know what they’re doing alone. They have to try to make it look like they’re important.
Pretty hard to measure the success (or otherwise) of something if you haven’t a target.
Pretty hard to measure the success of something if you set false targets, manipulate the statistics, and refuse point blank to even do the measurements that matter.
Luckily, we can rely on less venal and dishonest observers to fill the gaps a bit.
Go on then, analyse the success of these targets.
Why would I bother doing that?
Surely the “target” is that everyone gets the treatment they need in a timely manner? And the only way to achieve that is to write a cheque.
Introducing micro-targets is a time-honoured way of governments pretending to do something in the health sector: arbitrary time limits on ED visits before ward admission (so some of the cannier hospitals measured the ED consultation from when the patient was seen by the consultant, not triage nurse or receptionist), waiting list lengths (so “pre-waiting list” lists were developed, where people sat in a queue for 6 months to even get on the waiting list), bringing down rates of specific conditions (tweak the aggregated diagnoses classes). Most of the time, all such specific targets do is create work for middle managers to juke the stats so they can quickly jump to another ship.
The only exception that springs to mind is the immunisation target, but that’s pretty thoroughly defined in what, how and when various criteria are met, and it’s centrally registered rather than reliant on internal DHB systems to aggregate data.
Of course Contrarian, but the problem is that the majority of the time, when you set out a target to be reached, it comes at the cost of some other activity that is not being recorded (otherwise you would be recording *everything*).
This in turn means that people will devote less time/resources to the non-monitored activity and more towards the monitored activity. This becomes very problematic when people start ‘gaming the system’ – the things that are being sacrificed in order to achieve the good results are actually more harmful in aggregate than the benefit derived from the measured result.
This is very evident in software all of the time and there are obvious examples of it: managers at a company decide to make it’s developers “more productive” by recording and rewarding them for the number of lines of code they write in a given week. Very quickly you get wasteful and sloppy coding styles designed to inflate the lines of code so as to appear good on the measured statistic. That is because the measure of productivity is flawed: productivity really has nothing to do with lines of code written in a given time frame, and in fact some of the best code improvements can be the result of deleting lines of code.
My comment was more directed towards Draco’s incredulity that the government would set targets.
Targets in a business sense are wrong for hospital but a target like “train an extra 300 nurses in 2013” is a better approach than just writing a cheque without a goal in mind if you follow.
Which is why firing public servants is a dumb idea – how do we know we need to boost nurse training by 300 nurses without effective analysis of population needs?
But even then, that’s not specifically a hospital concern: the ministry provides a bridge between the dhbs and the training sector (or overseas recruitment). Maintaining national levels of resources is a strategic issue, and very different from “maximum time on a waiting list is 6 months, your hospital has five patients at 8 months, you get a bad performance review which will hurt your pay or career unless you fudge the stats”.
Ah right, I see, I didn’t read his original comment.
Yeah, he does say some stupid things.
yes but they are always entertaining.
I didn’t say anything about not having targets just that the government shouldn’t set them.
“They are compelled to make decisions for the wrong reasons…”
Hippocracy? What do you do when the minister orders you to break your oath?
‘cept it’s my guess that the miinister is instructing managerial types in the Health Service. And the managerial types then instruct the doctors/ surgeons etc either directly or through policy formation and what not. Which begs the question: Why are hospital boards and such like staffed with any people who have a business background though not a medical background?
“Which begs the question:”
Actually it “raises the question”.
“Why are hospital boards and such like staffed with any people who have a business background though not a medical background?”
Because modern hospitals are run like businesses, which actually is the proper way to do it, if you want to keep costs under control (which the government does). If you required all higher-up types to have medical and business backgrounds, there wouldn’t be very many people to choose from to fill those roles, furthermore you create a chicken-and-egg situation of where do those people actually come from.
And yet prior to the 90s that’s exactly what we had: medical people with managerial skills. Are you suggesting that those people weren’t competent at managing budgets? I think it’s more likely that they understood very well that cutting budgets was a false economy in terms of the health of the NZ population, and so were considered to have conflicting interests with the ideology of the govt of the day.
“Are you suggesting that those people weren’t competent at managing budgets?”
I’m suggesting that if those people were still in positions now, the health system would cost more than it does today. The output of the health system would probably also be better, however. The question would be, is the extra level of output worth the extra cost.
This is of course all really theoretical.
There is plenty of evidence that, “being run like a business” adds costs and fucks off skilled staff. Making them less effective.
“Many corporations and State or private enterprises run despite management, not because of them. In fact the constant parade of new brooms trying to make a name for themselves, with rapid changes and cost cutting, cause competent staff to resign and demoralise the rest.
How many times, within a company, when you want the person who get things done. You ignore the suits staring out the windows in the corner offices and talk to the person, usually a women, who actually does things. Normally someone several pay grades below the suits.
Or when you are ordering something. The bright well dressed manager calls some wizened old guy from the shop floor to ask if it can be done”.
While working in the corporate world I have noticed many times that the best thing to do, as the Japanese proved after WW2, is to run firms less “like a business” and more co-operatively. Sacking the manager and employing his secretary in his place would also be effective.
In fact it was an American business guru, Deeming, who laid the foundations for Germanies and Japans more co-operative, and strikingly successful, productivity.
Nothing on that blog post is specific to hospitals.
Nothing you said proves that running hospitals as businesses “keeps costs” down. The American/USA experience with free market health does indicate that health sector as profit increases costs without a corresponding increase in efficacy.
How exactly does “run as a business” automatically mean “run at a profit”?
Answer: National’s health reforms in the 1990s completely changed the managerial culture in the health system away from medical staff towards business managers, as part of shifting the system to a business model. The problem now is that NZ probably doesn’t have medical staff with the experience to run the managerial level any more.
Those reforms also included the introduction of PR managers. The press and the general public, were no longer allowed direct access to senior staff, all questions about policy and the running of hospitals had to go through the hospital’s PR person.
In the early 90s National also sacked the democratically elected Area Health Boards and replaced them with appointees.
What percentage of the tax take was the health budget, then and now? Has the business model saved anything at all?
Doesn’t look like it.
“NZ real spending growth very high relative to GDP growth in recent years [1995-2005] – more than double (4.3% to 1.9% annual average)”
Which is really a false premise, because we don’t know how much health care costs would have changed if we had stuck with the status quo.
There are several drivers behind the increase in healthcare spending, to name a few:
– ageing population
– newer, expensive treatments
– better treatments that allow people to be saved (with ongoing huge medical expenses) where previously they may have just died
– more entitled population that demand healthcare
That’s true Lanth, plus increased poverty leads to more hospital admissions because people can’t afford primary health care and/or essential health needs like decent housing, diet, freedom from stress. In fact, the economic reforms in the 80s may only just be becoming apparent now as children from then start to hit their later years. I’m guessing it will be worse in another decade or so.
However I doubt that the business model is successful even on its own economic terms (unless simply controlling the upward move of the overall budget is the goal). I’d love to see an audit done on this but I doubt that we have anything close to a real analysis.
Lanth: the quote (from page 7) is from a comparison of other OECD members. The figures show that our health costs rose more steeply than the average over the period in question.
PS: your list of “drivers” is incomplete: you forgot to mention that executive salaries have risen faster than the average. Wouldn’t want those magic talented business managers heading to the private sector for more dosh, now would we? That would never do.
Ok, so our healthcare costs rose faster. Off of what base did they rise? It’s likely that other OECD countries had existing more expensive technology available in their hospitals already compared to NZ and that a large part of the increase is really just us “catching up” to where the others are at.
I’ve had very little to do with the health system in general, however on one visit to the hospital I commented on all the fancy gadget they had around. The nurse, who was original from America said “really? these models are about 3 or 4 generations behind what we had in the US”.
Well, if we can’t draw conclusions from the information we have, there’s nothing to support the premise that employing “business” managers leads to cost savings, is there?
But there’s also nothing to reject it, because as I said, we don’t know how much costs would have risen under any other regime.
Nothing to reject it? How about the fact that every other neo-liberal fantasy has proven false?
“…modern hospitals are run like businesses, which actually is the proper way to do it…”
What is your opinion based on?
The increased cost of technology is a well known issue in health care globally. But so is the increased cost of poverty. It’s a complex situation, and as I said above, I doubt that there has been any real, in depth analysis of the situation in NZ.
We know that the changes in the 90s were ideological. The issue is whether they worked at capping the budget rises. Leaving all the above mentioned variables aside, I’m not convinced they did – can point to plenty of examples of false economies in the last 20 years.
What does ‘business model’ mean in this context? I know that many of the clinical managers and others in the health system in the 90s thought it was a mad idea. A business model was one that operated in a system that was designed to turn a profit, and that that profit would be sustainable over time (and generally there was profit over costs so that dividends could be paid). The health system doesn’t generate any income, is completely dependent on external funding, and always runs at a loss.
I’m sure that there were things that needed to be done more efficiently, and that new systems could have been developped that increased efficiency while maintaining core values, but adopting a business model was just idiotic. It would be like trying to run welfare on a business model.
“What is your opinion based on?”
The fact that hospitals have huge expenses that need to be managed efficiently and effectively if costs are going to be reduced as much as possible. The people who have those kinds of skills are those in the business world, because that’s what they’re trained to do. Doctors are trained to treat people.
Note that that doesn’t mean the business people are making decisions completely divorced from the industry that they’re operating in (health), because obviously they have advisors and a lot of input from the health professionals that they use as part of their decision making. They also have a ministry behind them with more health experts that are tasked with maintaining the health of the country – they aren’t operating in a vacuum where they get to do whatever they want to cut costs.
Ok Lanth, you’ve articulated the theory pretty well.
And Weka has produced a pretty good counter argument.
I think the practice probably support Weka – it (the move to a business model) was nonsense from the start, ideological claptrap. It hasn’t done any of the things it was intended to do, except perhaps advance a privatisation agenda.
What exactly was broken that needed so much fixing? Bearing in mind this came from the same crowd that took unemployment to record levels and “led” the country into a double dip recession, sacked the mining inspectors and deregulated the shipping lanes.
But by some pure fluke perhaps, they managed to get healthcare right?
Of course health resources have to be rationed. That was already happening.
Actually I don’t think Weka said anything compelling at all, or indeed had any evidence. The second post basically just says “because this doesn’t generate a profit, it’s stupid to run it as a business”, which really is a silly thing to say. First post didn’t really say anything at all.
I’m just arguing against what, appears to me, to be a knee-jerk “running hospitals like a business is bad” that doesn’t seem to have any real basis apart from “businesses are bad”.
“Businesses are bad.”
No, they aren’t. But that misses the point also. Brian Easton weighs in:
Did you happen to notice the GFC? Yeah, that was caused by the people trained in the business world.
Lanth, I think you’ve fallen for the cult of managerialism, just a tad.
Hospitals need operational managers with deep technical and subject area competence. Doctors and other healthcare professionals who have had suitable additional OPERATIONAL (not merely “business”) training are perfect for the role.
Then you have a bunch of bean counters who look after the financial efficiency and cost tracking side of things.
Now that’s interesting – the Treasury doc shows in 2005 NZ had a lower percentage of GDP spent on health than comparable countries. I’ve understood that the Labour government deliberately increased health expenditure as a catch-up because our spending per person was well below the OECD average.
If you look at the tables produced by the OECD health spending as a percentage of GDP, over the last few years has increased to exceed that of Australia (10.1 to 9.1). Maybe to do with the slow GDP in NZ compared with Australia?
However, the spending per person is US$3670 in Australia but only US$3022 in New Zealand. So we’re still behind in per person terms (part of the explanation will be Pharmac).
If you want a comparison with a country which runs health care as a business you only have to compare the coverage and cost in the USA to countries that have a publicly funded health system.
They spend a total several times more than New Zealand for much less overall benefit.
Yes, according to the Commonwealth Fund the U.S. actually spends more thantwice the amount on health than 6 comparable countries for worse results – that’s a privately run health system for you.
That’s just for efficiency, for actually meeting the health needs of the population it’s just as bad e.g. last in infant mortality and last in preventable deaths before age 75.
So they won’t acknowledge child poverty and then they undermine treatment for the kids affected by poverty (among others) for political gain.
Very deliberate here from Ryall (a very dark background player) and one of the reasons we’re seeing medical talent depart to go with other talent in other industries but I digress.
He’s also pushing the gain onto private operators and if it goes wrong they get shipped back to public to be rectified/recovered, classic taxpayer funded wealth shifting.
Combine this with the ACC changes and a cap on increased funding, which as health runs at 10% CPI is a slash, and it’s a double whammy effect.
If only we had a MSM who actually did some research and objective reporting as this issue has been around for years now.
Recall this is the bloke who lies in the house on increased nurses etc and yet he keeps being reported without balance or questioning.
It is called cooking the books.
These corrupt ministers should be tried and sent to prison
Yes, make statements in Parliament subject to the laws of perjury and enforce them ruthlessly and with extreme prejudice and assumption of guilt.
Investigate the sale of government policy by the National Party for a start.
Well said tc. There always had to be something dodgy about the Ryall ‘success story’.
And Street and TV3 seem to have uncovered it.
This takes hard work, persistent digging, speaking truth to power.. great stuff.
Let’s not forget that Opposition MPs are paid $150+ salaries to do this…not to wallow in comfort while the government makes the running. Good to see some action.
The proper way for the government to increase elective surgeries is to increase funding for hospitals, not re-prioritise existing funding.
And Key said in the House this week:
Of course, the selection and use of facts can distort the truth, as done with the government’s selective use of elective surgery – facts. No to mention that they have skewed the system to produce the statistical facts they want to selectively use.
I haven’t the time to go into this at great length but I use to work in this area ( govt health spending prioritisation ) both under this govt and the previous. A few thoughts.
Healthcare is rationed all around the world – it is how it is rationed that differs. In the USA – by income. Here – prioritisation on the basis of clinical need and ability to benefit. Other places – a waiting list.
So there is nothing unusual about placing limits on healthcare spend – in fact, it is necessary.
Furthermore , though it is arguable, there is nothing wrong with setting targets either. They have been shown to work in improving performance. But of course targets must be set in alignment with good prioritisation processes. Elsewise, one very rapidly starts to see the sort of behaviour alluded to by others. The classic example is in the NHS when setting a maximum wait time target in ED resulted in patients being driven around in ambulances for hours so as to avoid admission to ED.
It was very clear to me that from 2009 , prioritisation of elective services started to fall out of favour with this govt. They wanted ” good news ” stories which tend to focus entirely on the volumes of electives provided . DHBs focussed on ” more”, rather than ” more of the right thing”. And we are now seeing the result.
You can see the same cooking the books in Christchurch.
Locals who have a house which is uninhabitable and require extensive repairs are having to wait up to three years, while those with minor damage are getting it done immediately, so that Brownlee can claim a certain number of houses are sorted.
Yup apply ointment while the open wounds go unattended.
Selectively report convenient pieces of data and refuse to front any direct questioning about the whole picture.
CT would call that ‘framing the issue’ probably, a.k.a. propaganda/misdirection/deception.
You’re not comparing apples with apples. The press release you mention from August has hard numbers; the 3 News story is one Labour member giving anecdotal evidence that doesn’t get any more specific than “some” and “one.”
The point of your blog may well be correct. But if the source you’re working off uses quantitative data, it’s misleading to use qualitative data to refute it.
BUt but but Peter Jackson just made a lovely movie… get with the programme people.
Lanth at 10.11 re old school costs. Several years ago a woman speaking on 9 to Noon I think said that a few decades ago ( probably the 60s or 70s, I can’t remember) her husband a surgeon used to run Tauranga hospital with her as partime secretary and they used their own car. She had been astounded to find out how many people it now took to do the same job ( admittedly Tauranga was half the size then) but the current number doing their job was about 60-70 with 27 cars supplied to the administrative staff. Oh, by the way he did a full surgey list as well. I know it was the same in Blenheim and Nelson, a full time surgeon also ran the hospitals in each town, aided by a Matron in charge of nursing, they shared a secretary.
Got to be a flyshit cheaper wouldn’t you think.
Hospitals these days do a lot more than they used to in the past, and I’m not just talking about new surgeries and treatments, but also a lot more outpatients visits etc.
My sister works in older person’s mental health and visits multiple elderly people each week in their own residences or nursing homes to do psychological testing (dementia mostly). The car she uses is provided by the DHB.
They certainly weren’t doing that sort of thing in the 60’s or 70’s.
I am a “health professional” and I make a lot of money from DISEASE.
The more DISEASE the more money I make from the New Zealand Government and from “health” insurers.
The really satisfying part of this is I am the one who decides what the DISEASE is and “the treatment needed”.
And the patients always consent !!! Yay !!
“Elective surgery” is the chosen propaganda slogan of National and slimy Tony (Goebbels) Ryall.
I last went to the doctor not long ago, welcomed with a sign in their surgery, informing me and others they regrettably had to increase fees, due to funding cuts in certain areas.
There is a person I know who went to CADS for counseling a couple of years back, then learning, they were facing funding freezes and cuts, so they had to stop printing business cards for staff members and take numerous other steps to contain or reduce costs.
Here in Auckland there is another service provider called ProCare Psychological Services, also dependent on some subsidies from the DHB, to run their services.
Two years back they were able to offer 5 free counseling sessions for mild to moderate mental health sufferers, which were then still subsidised by the Health Board (and thus the state).
That had to be reduced to 4 “free” sessions a year ago, and now I am told, that service has this year had to start charging $ 50 per session without a Community Services Card, and $ 25 per session with a CSC.
This is also due to cuts and “reprioritising” of health funding!
There are also many other services being cut back all over the place, and that is what the Nats and their support wallies are not talking about!
I wish Labour would have learned this some time ago and raised it in the House. Maybe it is the expressed anger and frustration by many in this forum, that has finally been noticed and heard, so they may have “awoken” to some degree, to start doing the work they should have been doing since late 2008?
I agree xtasy, whether there is a trade-off between primary care, especially for the poor and elective surgery is where Labour should be looking, rather than one type of surgery vs. another. For sure DHBs have been cutting non-hospital measures to ease access for the poorest. Capital & Coast for instance has cut funding to Newtown Union Health Services which provides low-cost or free health services to some of the most vulnerable people in Wellington.
Labour promoted and funded access to primary care as a health priority with the aim of reducing Accident and Emergency waiting lists and other hospital care – especially for chronic illnesses like diabetes. This focus doesn’t seem to capture the media and public interest in the same way that needing an operation does. It seems to me the focus on surgical waiting lists is another easy to measure policy – a quick win for the government, so to speak, rather than an evidenced-based health priority.