Croakey has previously argued that the Productivity Commission inquiry into public and private hospital performance has overly narrow terms of reference.
Below you can read some more suggestions for the Commission from several Croakey contributors, but first have a look at how much further the debate on hospital performance has advanced in some other countries.
In the UK, patients contemplating heart surgery can go to this website, for example, to examine the relative performance of hospitals.
In the US, this article from USA Today links to sites allowing patients to compare death rates for heart attack, heart failure and pneumonia for more than 4,400 hospitals.
Meanwhile back to the Productivity Commission:
Gordon Gregory from the National Rural Health Alliance would also like to see the inquiry consider:
• What is the relative role of public and private hospitals in ensuring that the ‘mainstream’ health system provides culturally safe and appropriate care to Aboriginal and Torres Strait Islander people? (ie what is their relative record on employing Aboriginal liaison offfcers; Aboriginal Health Workers; and in providing supported employment for Aboriginal nurses and interns?)
• Where private hospitals exist in regional areas, are they more or less part of the de facto primary care system than public ones? [hospitals doing primary care isn’t a good idea but needs must where there are no primary care providers. Are, for example, Catholic hospitals doing more or less of this than the public ones?]
• If one accepts the notion of a rural medical deficit (ie the extent to which rural and remote folks miss out on using Medicare), what is the extent of the rural and remote hospital deficit? (This is not so much a matter of public/private as metropolitan/rural and remote, but there may be some angles for the Commission to consider)
Associate Professor Merrilyn Walton, Director of Patient Safety at the University of Sydney:
The first two terms of reference for the Productivity Commission’s current inquiry have merit but I agree with Melissa Sweet that they are indeed narrow.
Terms of Reference 1: Comparative hospital and medical costs for clinically similar procedures performed by public and private hospitals
Variation of costs is not the only issue for patients, variation in the provision of health care is also a significant issue for patients. A significant amount of variation is caused by differences in practice between providers of health care rather than differences between groups of patients. Research shows substantial levels of inappropriate care including under and over treatment.
Terms of Reference 2: The rate of hospital-acquired infections by type, reported by public and private hospitals
We do need to publish infection rates but the bigger issue is to minimise the transmission of infection in all health care environments. World expert on system failure James Reason says that breaches of infection control are routine in health care and equate to an intentional violation. We need to change the culture in health care as well as collect data.
Patrick Bolton, a senior public hospital manager, would like the Commission to consider these two points:
1. Turning the Commission’s question around a bit: Which bits of the healthcare system are best provided publicly, and which privately?
Whilst the evidence is not strong, my understanding is that not for profit hospitals (I use this term because much of the data come from North America and therein lies a comparison issue) deliver better outcomes than for profit ones. Outcome is of course only half of the efficiency story(!)
The interim report of the NHHRC seemed to accept that the private sector might be a better funder/purchaser of health, with not much analysis of the alternatives at that level or evidence that I recall, but there is an important question there.
I would like to see the role of the private sector in health capital management further discussed: This is a separate set of skills from health service provision. In my experience it is not generally well developed in the public health sector and might be better provided privately.
One advantage of such an approach is that it changes the incentives around flogging equipment until it breaks as often happens under public sector priority setting, because the cost is sunk and so the incentive is to drive the private provider to provide good capital.
2. I refer you to “The Science of Health Care Reform” RH Brook JAMA 301(23)2486-7 which I found through the Hospital Alliance for Research Collaboration newsletter.
This is a short and stimulating review of the reason for the gap between health expenditure and outcome, which has to be a concern of anyone with an interest in efficiency.
Essentially it attributes the gap to poor quality (ie doing things wrong) and poorly targeted interventions (doing the wrong thing). If this is correct then (a) one might expect the private sector to be more distorted than the public sector by incentives to provide inappropriately targeted services, but (b) the dichotomy between public and private might be looking at the wrong questions entirely.
Perhaps the question should really be how do we ensure that we do the right things right in any setting?
Certainly Brook says that high level policy approaches, which must include the public-private balance, are too crude to address the problem that he has identified.
A health policy expert who did not want to be identified offers the following comment to the Commission:
Private hospitals tend to have a much lower level of quality improvement activity, such as audits of series of procedures (eg looking at rates of deep surgical infections, or deaths within 7 days of an anaesthetic), or data driven improvement projects. It would be interesting to compare participation in quality activities.
Professor, Chris Baggoley, CEO, Australian Commission on Safety and Quality in Healthcare adds:
What I can say is that we have found the private sector very willing to take on and implement the safety and quality initiatives from our work that Ministers have endorsed, across the full range of these initiatives, including the Australian Charter of Healthcare Rights.
Michele Kosky, Health Consumers Council WA:
We would be very interested in seeing a comparison of the accurate reporting of adverse incidents in public and private hospitals, the overt commitment to patient safety in public and private hospitals, the involvement of patients and their families in the reduction of unintended medical harm in public and private hospitals, and the adoption of the open disclusure standard in public and private hospitals.
Emeritus Professor Kerry Goulston, University of Sydney:
I like and agree with Croakey’s points. I strongly agree that the Commission’s terms of reference are too narrow.
Whilst nearly half of elective and day surgery is done in private hospitals, there are not many private Emergency Departments. And relatively little training of healthcare workers occurs in the private sector There are some notable exceptions – Carina and Epworth in Melbourne, and Greenslopes in Brisbane.
We really need more medical students in private hospitals – patients accept them and it exposes students to private hospital medicine.
Robert Wells, Director Menzies Centre for Health Policy, Director Australian Primary Health Care Research Institute, ANU
Broadly speaking, there can be three possible findings from the inquiry:
1. no appreciable difference between private & public;
2. private generally performs better against the areas of inquiry; or
3. public performs better.
If the answer is 1, then we probably can just muddle along as we are
If the answer is 2, then should we privatise all hospitals?
If the answer is 3, then why would we continue to subsidise the private sector via PHI measures?
Therefore the really pertinent question is: what do the study’s creators intend for it to find? (bearing in mind the maxim that one never sets up an inquiry withiout first knowing what the answer will be).