KEY POINTS:
Roger Kerr argued that the health service was not providing value for money in light of the Productivity Performance of New Zealand Public Hospitals report 1998/9 to 2005/6.
As an emergency department consultant in a major urban hospital, I do not believe Mr Kerr's assertions should be left unanswered. He castigates David Cunliffe for dismissing the report and lists its very competent authors.
However, as is well recognised with pharmaceutical company-sponsored drug trials, the results may be true but the authors (or sponsors) may reach a different conclusion from that reached by a truly independent researcher.
Furthermore Graham Scott describes in the report the difficulty of reaching adequate conclusions about health sector performance given the paucity of good quality data.
Therefore can the report authors' opinions be taken at face value?
I would like to offer my spin on the results that Mr Kerr outlines. He defines efficiency within the health service as the volume of health services divided by staff numbers employed.
A key question here is: Is efficiency the best means of determining value for money within the health sector. The simplistic measure described by Mr Kerr does not reflect the situation within our public hospitals.
The population is ageing - a simple problem in a 20-year-old may be a complex situation in an 80-year-old. Therefore productivity reduces.
With increasing technological expertise, more can be done for the sicker individual. One of the most celebrated health interventions at my hospital over the last few years was the separation of conjoined twins.
Arguably, given the resources spent on those two children at the expense of multiple uncomplicated operations, this was inefficient. Hernia repairs, cataract operations and stripping of varicose vein are relatively rapid, non-complex, easily planned operations which tend to be completed efficiently.
Would Mr Kerr have us not do cancer operations, facial reconstructions on accident victims or the separation of these twins in the interest of improved health system efficiency?
Emergency departments cannot ask unwell individuals to only turn up when it suits their ability to deliver healthcare.
Such departments around the world have an increasing problem with overload so that even if health practitioners are available to see individuals, they cannot get them into the department due to insufficient physical space.
This problem is not caused by people who present to emergency departments with what may turn out to be minor problems, but rather by an inability to get people out of the department due to in patients waiting several weeks to be admitted to a rehabilitation or rest home bed - often within the private sector.
I am also unsure how Mr Kerr's model deals with people who present to hospital extremely unwell and undergo extensive resuscitation efforts only to die. How does it deal with those who are transferred from a private hospital to a public hospital intensive care unit following a complication during private elective surgery?
Both of these scenarios may add thousands of dollars to public hospital costs without any visible productivity outcome.
Mr Kerr also mentions the prior Government's assertions that they invested money in primary health care and infrastructure but states that these have not resulted in productivity gains. Campus redevelopment and provision of new technologically advanced services does not necessarily mean productivity will increase and as someone who is experiencing campus redevelopment (and faced the horrors of living through a house renovation), productivity might decrease in the mess of building.
The comments on primary care require even more attention. Primary care can be rapidly ruined but it takes considerable time to rebuild.
I would not expect primary health interventions to produce rapid improvement in public hospital productivity. By shifting some investigations into primary care, patient care may be improved but hospital productivity decreased.
The changes to the health services of the last National Government had a significant impact on primary health care and it will take some time to improve population health as a whole.
It is also important to note that many of the greatest health interventions have little to do with the health system but rather government-mandated nanny state interventions.
Many people are alive now or will live longer because of government legislation such as clean air acts, anti smoking initiatives and compulsory seat beats and child restraints in cars.
Patient safety is an important measure of quality in the health service. Mr Kerr does not address how this relates to his request for greater efficiency.
A major source of adverse outcomes in the health sector relates to inadequate documentation or hurried assessments.
I sometimes have to advise trainees to take time to document more clearly and consider the full range of potential problems a person may have to reduce the risk of mistakes being made.
Patient safety is the reason that only life- or limb-threatening surgery is done overnight as it is well recognised that tired individuals are more likely to make mistakes. Night shifts must be staffed though workload is reduced.
Would Mr Kerr, in the interests of improved efficiencies, not run a night shift at all or should surgery be done throughout the night to maximise productivity during this inefficient period?
The American health model shows that neither pouring money into the health sector nor adopting an aggressive free market ideology will improve health outcomes.
New Zealand's health system has room for improvement but productivity as it has been defined is not the best measure of whether our public hospitals are meeting the health needs of New Zealanders.
Politicians and clinicians need to work together to look at better performance indicators than productivity to develop a health service we can be proud of.
* Andrew Wilde is an emergency physician at Waikato Hospital.
