Emphasis on Finance and Waiting Lists Helps Obscure the Real Problems in the Health System
Listener: 15 June, 1996.
Bill English, just appointed Minister of Crown Health Enterprises (CHEs) commented “when we ask people what they mean by health reforms they say waiting lists. If we can limit the debate to waiting lists then we have essentially won the argument about the health reforms.” The minister seems to have meant that if the government can avoid having to defend its structural changes – such as the top heavy administration and requiring each CHE to be run for profit, then the government could pour money in to reduce waiting lists, and obtain political kudos.
Time will tell whether there will be enough money, although I am sceptical. For instance cardiologists recommend that anyone with a points score of need in excess of 24 should be given cardiac surgery. The government’s scheme only allows those above 34 to be put on a waiting list.
But it is the public’s perception with which this column is concerned, insofar as the minister is correct. The numbers on waiting lists are easily quantified, becoming the centre of public debate. But the significant outputs of the health system are not so easily quantified. It is not waiting list numbers, but the inconvenience to those who are waiting, be they in the queue or not. We do not even have a measure of psychiatric patients or the elderly who have been turfed out of hospitals with inadequate domestic support, or doctors short of the necessary resources taking calculated risks. Most expenditures in the health system are not about activities which can be summarized by waiting list numbers. As the public concentrate on this measure the health system becomes distorted, the significance of the non-quantifiable activities gets diminished, and the government raids resources from them to reduce its waiting lists.
One of the central problems of the health reforms is they encourage concentration on the quantifiable at the expense of overall health. The most quantifiable of all, with the possible exception of death, are the financial flows. We are spending a fortune on the accounting and (as the minister implicitly acknowledges) nobody cares except the accountants (who should, because it is their job). Everyone else is concerned which the health care and treatment, at best tangentially related to the accounts.
The focus on the financially quantifiable at the expense of what really matters occurs throughout the state sector, a confusion arising out of the 1989 Public Finance Act. Each minister “purchases” various services from the department. The level of aggregation of the purchase is at such a level that really the minister just hands over a dollop of cash to the department and becomes relieved of responsibility for what happens. There appears no routine way that politicians or the public can assess whether there is enough money. Instead we rely on some crisis to draw our attention to any inadequacy. It might be rising waiting lists in the health system; or poorly constructed platforms in the heritage estate; or demoralized and overworked public servants going on strike; or the border quarantine procedures becoming so overwhelmed that a billion dollar export trade is threatened.
There are two key conclusions to be drawn. First, all these events are manifestations of the same phenomenon of squeezing public sector resources. Second they are the tip of the iceberg. One massive failure is a signal that there are numerous minor failures – failures not big enough to get the front page but hurting someone, somewhere. Like patients who suffer early discharge from hospital, which puts additional pressure onto them and their family, while compromising their health to the point that they had to be readmitted. It is not just those deaths at Cave Creek which are disturbing, but that shortly after a whole raft of structures were promptly closed down following inspection. It is not until the boat sinks from hitting the iceberg do we observe the greater ice mass below the waterline.
Living in Wellington one is perhaps more aware of it than elsewhere, because of the informal talk of worries about the consequences of underfunding. Yet the talk is only about what is known. No one mentioned to me about the border quarantine service until after the flies were found (although the minister was warned in the 1993 post-election briefing).
Perhaps the most worrying is the depletion of the people in the public service. The teacher shortage is not to be seen as a quantity, but a return to the experiences of the 1950s when some students experienced a dozen teachers in a year. We seem to be promising their grandchildren the same unsatisfactory education.
The strategy of the Public Finance Act was ingenious. Overtly it was that reducing real public sector funding would squeeze out inefficiencies; covertly that by providing poor and lower quality service, people would be forced to provide for themselves using the private sector. As the waiting lists got longer it was hoped more would avail themselves of private surgery. The strategy does not seem to have worked – at least not very well. So what will be the next strategy?