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Some hard truths about health care

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.

Bolton writes:

“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.

Comments 6

  1. Interesting piece Patrick. I agree with most of what you’re saying but it concerns me to hear you perpetuating the line, popular in this era of social determinants, that health has nothing to do with healthcare. While we can’t ignore the importance of equality and broader social, environmental and political conditions as population-level determinants of health, the health sector still has a critical role to play.

    Your piece reminds me of McKee’s (2002) observation that McKeown’s influence on public health was to popularise the view that improvements in mortality were mostly due to improvements in living conditions (McKeown 1979). Mackenbach and his colleagues refuted this by demonstrating the decline in deaths from conditions that were altered through health care represented a major part of overall improvement in life expectancy in the Netherlands between 1950 and 1984 (Mackenbach et al 1988).

    The recent WHO Commission on the Social Determinants of Health confirmed the importance of health sectors in addressing health directly and acting on the social determinants of health (WHO 2007). I think there’s still an important role for health services in contributing to a reduction in health inequalities and ensuring population health gains and saying that the health sector is just a bucket with a hole in it is inviting Treasury to gut non-emergency health services, such as the population and preventive interventions that will actually make a difference.

    I did like your point that demands on healthcare are essentially infinite. I do think a broader public debate is required about what sort of treatments and technologies we, as a society, are willing to fund and what taxes we’re willing to pay to achieve that.

    References

    Mackenbach J, Looman C, Kunst A, Habbema D, van der Maas (1988) Post-1950 mortality trends and medical care: gains in life expectancy due to declines in mortality from conditions amenable to medical interven-tion in The Netherlands. Social Science and Medicine 27:889-894.

    McKee M (2002) What can Health Services Contribute to the Reduction of Inequalities in Health?, Scandanavian Journal of Public Health, 30(Supplement 59) p 54-58.

    McKeown T (1979) The role of medicine: dream, mirage or nemesis? Oxford: Blackwell.

    WHO (2007) Challenging inequity through health systems – final report of the Health Systems Knowledge Network, World Health Organization: Geneva. http://www.who.int/entity/social_determinants/resources/csdh_media/hskn_final_2007_en.pdf

  2. Darren says:

    Patrick offers up some interesting but important observations about the health care system and the pressures on it to reform. The health care system, and the difference perceptions about it, seem analogous to the “Emperor’s new cloak”. Each government wants to make its mark and be shown to be doing something that improves a service that touches us all, increasingly so as we approach death. Death is apparently a failure of the system despite our increasing longevity which is widely touted as a leading indicator of how well we do. If we don’t ask questions about who and where the system is failing then for more it is good than bad.

    But there are several questions that are often overlooked, such as who benefits from the current organisation and delivery of health care, and who should be heard in proposing and progressing changes. Hospitals have changed their focus over the years from an isolation role for infectious and communicable disease, to a greater capacity to deal with trauma and lifestyle related diseases such as neoplasms and cardiovascular disorders, and are seeking a prominent role in treating chronic conditions. Because the infrastructure exists, because it is familiar, there are pressures to use it but questions remain about how effectively and how efficiently.

    There are four different unreconciled mindsets in health care, each with different expectations and preferences. The first mindset is Community, comprising those who seek unfettered access at least personal cost and who were represented through Boards of Directors. The second mindset is Control, comprising those who seek to manage resources in some way and include politicians and bureaucrats. The third mindset is Cure, comprising those with a medical orientation based upon a biomedical model of health and individualised clinical practice. The final mindset is Care, comprising those with nursing and allied health orientations that have a team or multidisciplinary view of health care. Everyone wants a quality health care system but agreement on the personal and collective cost and differing remuneration for outputs and outcomes is where the debate begins to heat up. If we cannot agree on more then we will continue to praise the Emperor’s new cloak without recognising our naivety.

  3. EnergyPedant says:

    The debate about limitations is important. Society needs to make an informed decision on the trade off between care and cost.

    In theory to maximize care, everyone would need their own personal doctor and constant check-ups, tests, etc… This is clearly too expensive. Unless you are Michael Jackson and it didn’t work out so well for him.

    This debate exists in electricity. What is an acceptable security of supply? Some people try to argue that there should never be any blackouts. The trouble is that a one in a hundred year heat wave requires significantly more capacity than a one in ten. And for almost every year you end up with a very large expensive asset not getting used.

    Final parallel is with defense. We have a big enough army/navy/airforce to deter Indonesia. Possibly big enough to stop them. But we don’t even bother thinking about trying to stop China.

  4. gabe says:

    Having worked in hospitals, then in the healthcare industry, what surprises me most about this whole debate is the completely different attitude of both government and healthcare staff to ‘problems’.

    In most industries, ‘problems’ are solved relatively quickly because a company or person comes up with a better product to solve the ‘problem’.

    The real ‘problem’ with healthcare is that it is inflexible. It’s over regulated, dominated by guilds that threaten to walk out if their inefficient practices are ursurped. All in all – it’s like 1930’s communism in the 2000’s (apologies to the communist believers out there but I don’t think it really worked to well).

    Many will say ‘oh but America has a free-market model of healthcare and they are worse off than us’. But the reality is they have just as much regulation as we do – just in a different form.

    Real health reform will not come through top-down attempts at proper management – that is usually a sign in the real world that a company is in major trouble and is no longer competitive. It will only truly change when we rethink our entire approach to health beginning with opening up the workforce to reflect the structural and financial realities and unmet needs of consumers.

  5. Warwick@PEER:connect says:

    Thank you Patrick (other those who’ve made comments) for taking the time to share your thoughts and some interesting facts.

    What struck me most was that whilst error rates and the high level of unnecessary care were identified as part of the problem but did not rate a mention in the solutions. To my thinking these are the two areas where we have data against which to track progress.

    As distinct from bureaucratic micromanagement which ‘results in alienation of the workforce without improving performance’ we have to create forums for the health care workforce to communicate and better understand each other.

    According to your statistics our ‘overworked’ health care sector that is spending a third of their time (and a third of the financial resources society allocates to health) doing what is unnecessary (and potentially harmful!)

    The solution is not trying to squeeze more of less – which is the mantra of every health reform in living memory – but to slow down and create the space for the intellectual capacity we have tied up in knots to improve the system.

  6. Croakey says:

    This comment is posted on behalf of Steven Lewis (co-author of this recent pertinent article in the MJA: http://www.mja.com.au/public/issues/191_05_070909/lew10514_fm.html).

    He says: “Two fundamental points are debatable:
    1. There is always more that can be done than money to do it. Literally, of course, this is true, but if we apply any sort of “reasonable” test to marginal benefit, it is at least plausible that we have passed the point of over-medicalizing what ails us and/or intervening at such a rate that we are actually doing more harm than good. That conversation needs to take place.

    2. The only way to make the health system cheaper is to reduce services. Not so: the other way is to reduce prices. New Zealand’s generic drug costs are 23% of Canada’s.

    But the rest is very good and raises the right questions. The system is designed to drive up costs of course, precisely because we have collectively either concluded, or conceded, that very fragmented, autonomous decision-making is in the best interests of both the individual and society. That is conceivably correct, but as Patrick Bolton points out, you’d better eliminate conflict-of-interest temptations if that’s your stance and you hope to achieve a modicum of financial prudence.”

    Steven Lewis is a health consultant in Canada and holds appointments at the Menzies Centre for Health Policy at the University of Sydney, and at the University of Calgary, and Simon Fraser University.

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