Health reform is in the wind but perhaps it won’t really make the difference that is being sought unless it acknowledges and addresses some hard truths about health care.
That is the suggestion of this very interesting piece below from Patrick Bolton, who has long and diverse experience in the industry. He has worked as a GP and hospital administrator in urban and rural Australia in several states and territories. He has researched and published in health data, information management and health systems evaluation. He is national vice-president of the Australian Hospitals and Healthcare Association, and Conjoint Associate Professor, School of Public Health and Community Medicine, University of NSW.
“When he is not solving the world’s climate and economic problems, I understand that the Prime Minister is touring the nation consulting about the future direction of the healthcare system. I’ve knocked around in, and been an observer of, that system for a while, and I offer the following observations in the hope of informing that debate.
There are always more things that can be done in healthcare than money to do them
As a result, some people miss out on some care some of the time, and this will always be so. This isn’t rationing because there is nothing rational about it. At present the system responds to this truth by pretending it doesn’t exist. A problem must be acknowledged before it can be addressed.
Some of the people who miss out make a noise – for example by complaining to an MP – and then get what they want. This is unfair on those who don’t complain because it means that limited resources are shifted to the loudest.
It is not irrational for the people who complain to complain. They will benefit, assuming the medical care they receive does more good than harm. It is society as a whole that loses. There is no-one arguing on the side of society as loudly as individuals argue in their own self-interest. The hit the individual faces is large, the personal cost to each individual in society small.
Of greater effect on the system is that healthcare workers make choices for individual patients, not for society. Again this is rational. As a healthcare worker I want to provide the best care for each individual that I look after, and as a patient this is the standard I expect of the healthcare workers who care for me. Even were I prepared to favour the interests of society over the individual, I would have to trust that others in the same position will do the same. If they do not, then my altruism is benefiting them and not me.
This factor creates a difficulty because doctors are arguably best placed to assess which patients will benefit most from which interventions, but any management system that asks them to do this puts them in a position of conflict of interest. This is a source of professional dissatisfaction for healthcare workers
The difference between what people want and what the system can provide is one of the sources of dissatisfaction with the system. It contributes to the perception that reform is required.
The only way to make the health system cheaper is to reduce services
Many of the initiatives proposed by the Hospitals and Healthcare Reform Commission are said to improve health outcomes and so make us live longer and healthier lives. This is desirable if it is correct. Unfortunately, we will all still be dead in the long run, and around 80% of healthcare resources are consumed in the last two years of life, whether we die at 70 or 100. None of the proposed changes are about reducing cost as an end in itself. If the proposed changes work we will live longer – so consuming healthcare resources for a longer period, albeit possibly at a slower rate, then cost the same amount when we finally die.
There a no great savings for the healthcare system in this, although there may be increased productivity as an offset. Health is a superior good, one on which individuals and communities spend more as they become wealthier, and this may justify additional expenditure.
It is not clear what the objective of the health system is
It is difficult to go somewhere unless one knows where one wants to go. Individual needs, expectations, and capacity to assess outcomes of the healthcare system vary. This means that the perceived purpose of the healthcare system varies depending on who you ask.
It would be surprising if the interests of the most vocal group – healthcare providers – coincided with that of the majority who pay for these services. There are no other areas where the interests of vendors and customers coincide, so why expect this in healthcare?
Healthcare doesn’t seem to make much difference to health
This is well known and such a show-stopper that everybody, me included, seems to acknowledge it and move on. I think it reflects several factors. These are:
a) There is good evidence that the health of first world societies is closely associated with the level of equality in that society, not to the level of healthcare. If this relationship is causal then it can be argued that one should invest in strategies to promote equality in preference to healthcare.
b) Individuals are not good at assessing the outcomes of the care they receive and the system is not good at measuring outcomes.
Most people recover from illness, but some do not. The outcome is multi-factorial, so it can be difficult to say which part of an individual’s health outcome is a result of the care that they received and which due to other factors. It is particularly difficult for lay people to judge the quality of the care they receive.
Changes in healthcare tend to be incremental, and so outcomes compare current treatments with alternatives which are likely to be only slightly better at best, as opposed to no treatment. It is generally held to be unethical to compare new treatments against no treatment. One might argue that this is irrational in cases where current therapy has not been shown to be superior to no treatment.
The quality of outcomes measurement of the healthcare system is woeful. Given that much of the money for healthcare comes from the public purse this is a significant failing of accountability.
c) There is a high error rate in healthcare. International studies repeatedly show that errors in healthcare delivery occur in around 10% of cases. In Australia these errors are associated with about half of all in-hospital deaths. If death is the outcome measure then Australian hospitals may be killing as many people as are killed by the conditions for which they were admitted. The harm that the health system causes may offset any benefit that it delivers.
d) Estimates are that one-third of what is done in healthcare is unnecessary. Two things follow from this. First, if unnecessary care can be identified and stopped, then the efficiency of the healthcare system can be improved by up to 30%. Second, unnecessary care still causes harm, and this offsets the benefit from effective and necessary care for the system as a whole.
Healthcare in Australia is not a very enjoyable place to work
This has important implications for workforce engagement and sustainability.
Poor work hygiene is bound up in the foregoing issues. It is hard to feel satisfied about what one is creating if the value of the product is at best unclear, and possibly negative.
The response of policy makers to these issues has been to tighten the leash and increasingly micromanage healthcare delivery. Healthcare workers are highly skilled employees, expert at making individualised decisions in complex settings. It is unlikely that directive management can lead to better outcomes that professionals can provide themselves, so micromanagement results in alienation of the work force without improving performance.
Suggested pre-requisites to change
There is nothing new in any of this, but it needs to be said because the healthcare system cannot improve until these factors are addressed. Some suggestions to do this are:
1. The new health system needs to be as clear as possible about what it is trying to achieve, and collect data which measures performance towards these achievements.
2. The new healthcare system needs to be able to demonstrate that the things that it does are effective, cost effective and done to people who will benefit, and not those who will not.
3. The new health system is going to have to allocate resources transparently on the basis of 1 and 2 above. This is so that equity and efficiency are maintained in the face of other interests.
Addressing these factors is necessary but may not be sufficient. If they are addressed, then healthcare will improve under the current governance model. Some other governance model may be preferable for the reasons currently being debated, but we can’t know this until the problems discussed here have been addressed.
No governance model can be properly assessed until these underlying distortions are addressed. Introducing the kinds of major change contemplated is not without risk. It will be impossible to manage and measure the impact of this risk until these factors are addressed.”
There I told you – it was worth taking the time for the read, wasn’t it? Plenty of food for thought there.