A chronic case of paperwork

Dwayne Crombie

To look at Dwayne Crombie, you wouldn't think he was up to his ears in paperwork. His desk is remarkably free of it but the chief executive of the Waitemata District Health Board smiles and admits he tries to throw as much as he can in the bin.

But it keeps arriving. An endless stream of demands from the Ministry of Health. Risk assessments, accreditation requirements, numbers of this, numbers of that, policies, strategies, performance measures.

Today, perhaps just a bit of steam is emerging from this usually unruffled customer. We are discussing a Treasury report which says spending at the country's 21 district health boards' provider/governance arms was up 7 per cent this year but inpatient treatment was up only 2 per cent.

That is bureaucrat speak which translates as extra money having been given to district health boards without much of it being spent on patients.

The report then qualifies this by saying that activity may have increased in outpatient treatment but data is not available centrally to confirm this.

What that means is that despite the screeds of information given to Wellington by district health boards each year, it is still not enough.

The Ministry of Health's response to the report is to increase monitoring of district health boards. It says PHOs, the general practitioner groupings known as public health organisations, will deliver more data.

This has made eyes roll at the coalface of health care, where no one is too happy about the thought of more paperwork.

Health workers know data is often useful and necessary but many are cynical about some of the data they are asked to provide and wonder where it ends up.

Crombie, for one, does not blame paperwork for less patient treatment. He points to other issues which have caused a big jump in spending. Doctors' salaries at Waitemata, for example, have increased 50 per cent over the past three years and doctor numbers are up 30 per cent.

He says this is not a criticism of doctors but serves to show that a lot of money is going into areas positive for patients.

He gets tired of complaints that health money is going on administration and says Waitemata and all district health boards make administration savings wherever possible.

This is evident when you visit Crombie. There is no receptionist for the management team, but a DIY approach provided by a telephone with a list of extensions. Crombie himself opens the door to his pleasant but not overly flash office.

Though Crombie points to health boards' attempts to be administratively lean he says the chasm between Wellington and the coalface is a big one.

The Treasury report bemoaned lack of outpatient data but this data already exists, he says. Treasury just doesn't count it.

Skin lesions, for instance, used to be treated in hospital but now lumps, bumps and melanomas are sent to GPs paid by the district health board to do them.

Treasury, however, comes along and only looks at hospital admissions saying, "Well, gosh, we're giving them all this money and they're not spending it."

Health managers say the ministry's demand for paperwork is enormous, a view shared by hospital doctors and GPs.

Deborah Powell, who represents resident doctors, firmly believes the ministry is a bureaucracy gone mad. It has more than doubled since district health boards came into being, going from 481 staff at the end of 2000 to a whopping 1060 as of March this year. " You know, the DHBs are constantly being put to the test of: 'Where are your outcomes? You've got this money, now prove productivity, prove outcome.' I wonder if the same test shouldn't be applied to the ministry, quite frankly."

The doctors Powell represents watch with cynical amazement, and with some sympathy for the managers who gather all this information because they see no real outcome in terms of health delivery for patients.

"That may be just because they see patients every day, too many, and with not enough resources and they're wondering what on earth the ministry is doing with this information."

Crombie says that aside from all the facts and figures, district health boards have to supply in monthly, quarterly and yearly doses, the hundreds of people who work at the ministry generate "a hell of a lot of policy and strategies", too much to implement.

"We've figured out it's better to make a credible attempt at a relatively small number of things and just ignore the rest, because you just cannot deal with it."

Asked why the ministry bothers if most of its policies cannot be achieved, Crombie says: "Because it's the appearance of doing something, probably."

Managers acknowledge some of what is requested is valid, but say Wellington does not seem to understand the amount of time and energy required.

Last year, for example, Waitemata underwent its accreditation process, where all its policies and documents are examined by an outside auditor - it took six to nine months to prepare and in two years it has to be done all over again.

"They spend more time sort of showing how well-dressed I am as opposed to actually trying to improve how well-dressed I am - that's the problem," Crombie says.

But it's not just bureaucrats who are gumming-up the works. Politicians send a constant stream of parliamentary questions which need immediate answers, plus endless time-consuming Official Information Act requests.

Politicians are also responsible for ever-changing structures and philosophies. In the past 15 to 20 years, the entities which run hospitals have morphed from hospital boards to area health boards to crown health enterprises to hospital and health services and now to district health boards. At the other end of the country from Crombie is the West Coast District Health Board's Kevin Hague, general manager of planning and funding. He is philosophical about the paperwork, saying he can see its relevance. But there are a lot of projects he would like to start, that would improve health in the community, but he cannot because his staff are tied up on paperwork.

He can do so only by taking staff off paperwork, and not fulfilling all the ministry's requirements.

GPS are also bogged down in paperwork, estimated to take three hours of an eight-hour day, affecting the amount of time available for patients.

Dr Tom Marshall, chairman of Procare, points to a programme called Care Plus, a service for people with chronic illnesses, which has been deferred.

"Because practices are so caught up in the paperwork of the meningococcal thing - which we all want desperately to succeed at - we've thought it prudent to deal with the Care Plus thing later."

Marshall, in general practice for 40 years, says that when he started very little documentation was required. That has changed greatly. He, too, wonders where all the data goes. "Certainly, there are areas where the data that is supplied doesn't seem to be made very much sense of. But we remain optimistic that will improve over time."

Dr Peter Foley, chairman of the Medical Association's General Practitioner Council, says paperwork has created a new tier of staff in PHOs and general practice. They have titles such as "practice manager" and administration manager" and there are "practice register management staff".

Despite such staff, doctors are spending too much time on paperwork. Act's health spokeswoman, Heather Roy, says district health boards are drowning. "It is bureaucracy. It's about all this report-writing stuff. It's about the Holidays Act - DHBs have had the Holidays Act imposed on them with no reimbursement and they've had wage and salary demands that have increased way beyond what they've been given in funding at budget time."

Powell believes bureaucracy breeds bureaucracy. She points to the creation of the Clinical Training Agency, which is part of the Ministry of Health and has the role of improving training for all manner of health jobs. It started in the 1990s during the user-pays phase when hospitals were to be run as businesses. The CTA is still called a business unit.

It took money from the district health boards of the time and formed a separate organisation to handle that money, Powell says. "So it set up its own bureacracy which had to be paid for, the DHBs suddenly had to have a bureacracy to deal with the ministry bureacracy - and training didn't improve."

Training still hasn't improved, she says.

Getting the right information

The Ministry of Health says it has started a review of compliance costs to make sure unnecessary or inappropriate collection of information is stopped.

"We prefer in principle to collect and use information DHBs would want to use themselves because it is likely to be more relevant," says Gordon Davies, deputy director-general for DHB funding and performance.

"If they use this information it should be no trouble for them to forward it to the ministry and it is likely to be accurate as it is used by DHBs."

There had been a lot of change in the primary care sector and a considerable investment of Government money. This meant changes in information had been needed so the Ministry could ensure money was spent appropriately.

Because health funding will reach $9.2 billion this financial year the service had to demonstrate the effective use of the money.