Health Productivity
Treasury has been warning for some years about the lack of productivity or lack of increased outputs (let alone outcomes) in health despite the massive increases in funding.
Tony Ryall has pointed out that the number of first specialist appointments in 2007 was in fact 10,000 lower than in 2001 when records begun.
Note primary Y axis starts at 340,000 to align starting point with health spending.
The graph above shows both the level of first specialist appointments (a slight downwards trend) and the level of funding (in real terms) for Vote Health. Health spending has gone up 33% in real terms in six years, yet less people are seeing specialists for first appointments.
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Tags: Health, Tony Ryall
April 7th, 2008 at 9:31 am
What a lot of pople don’t realise is that much of the extra funding in health went into primary care, not hospitals, and most of that money was actually used to reduce patient co-payments in general practice, so it was actually government dollars replacing private dollars. It’s hard to see productivity increases stemming from that!
April 7th, 2008 at 9:36 am
Does anyone else remember something in the early 1980’s called the Gibbs Report?
What was the efficiency differential between public hospitals and private hospitals at that time, and has it improved or declined since then?
DUUUHHHH !!!!!!!
April 7th, 2008 at 9:03 am
edit: I said ‘eh’ under Philbest’s comment and it ends up at the top of the thread??
April 7th, 2008 at 9:25 am
PhilBest – Upton’s 1991 reforms (never implemented in their totality as outlined in the infamous green-and-white paper on health) were based on Gibbs’ findings. Maybe it was too much too soon; certainly health was shambolic at the time, with reform following reform following reform. I got out of health in 1995, but had been involved in around four sets of reforms/restructures in the space of six years. Certainly at the time I got out the writing was on the wall for those in management and administration – now it seems as though the wheel has turned, and frontline services are marking time or contracting while non-health services spiral almost out of control.
April 7th, 2008 at 9:26 am
Stephen – dpf must have reset his clock – not the time of PhilBest’s post
April 7th, 2008 at 9:36 am
I thought that the emphasis under the Labour-led governments’ health policies was to be on primary health care, in order to reduce unnecessary hospitalisation and specialist care. Mightn’t less specialist care be a good thing if the conditions are being dealt with earlier?
Had a close look at a hospital in L.A. last year, and it had an enormous, vast, huge “emergency” department, dealing with all the poor people who had no health insurance and finished up being hospitalised when their conditions became life threatening. Not something I ever want to see here.
People might find the article, “Do Hospital Bed Reduction and Multiple System Reform Affect Patient Mortality? A Trend and Multilevel Analysis in New Zealand Over the Period 1988–2001″ by Peter Davis, Roy Lay-Yee,Alastair Scott, and Robin Gauld in the December issue of Medical Care of interest. To summarise, the public hospital system has been quietly improving, regardless of the regime. (And, yes, that is the very same Peter Davis.)
I don’t have time to precis it myself, but here’s the abstract:
Background: The impact of hospital and system restructuring on the quality and pattern of care is an important issue of public policy concern.
Objective: To assess the effect on patterns of care and patient outcomes of a substantial reduction in public hospital bed availability and multiple reorganizations in New Zealand through the 1990s.
Research Design: Trend analysis using both tabular and multilevel techniques.
Subjects: Access to discharge data, amounting to 6,639,487 records, was secured for all 34 major public hospitals in New Zealand over the period 1988–2001.
Outcome Measures: Number of discharges, admission rate, access levels, mean length of stay, unplanned readmission rate, and 60-day postadmission mortality rate.
Results: Although the number of inpatient beds in use declined by one-third over the period and the national population grew by nearly one-fifth, discharge volumes increased significantly and rates of inpatient admission were maintained, as were access levels for vulnerable groups. These changes were accompanied by workload adjustments (a halving in length of stay and an increase by a quarter in readmission rates). Yet age-adjusted postadmission patient mortality decreased by a quarter over the period of study, a rate of decline that was slowed by the major workload adjustments but not
by reform phase.
Conclusions: Other things being equal, a substantial reduction in inpatient bed availability can be effected in national public hospital systems, while largely maintaining access and quality of care. However, the workload adjustments that are required may slow improvements in patient outcomes.
April 7th, 2008 at 9:59 am
Pete – a reduction in specialist availability is not a good thing when there is still a waiting list which there most certainly is. And also note we have had significant population growth also.
April 7th, 2008 at 9:59 am
Ahem, David, is First Specialist Appointment the sole output of Vote Health? If not, your comparison is invalid.
[DPF: Of course it is not the only output but it is insane to suggest that makes a comparison invalid - with that logic one could never compare any funding to outputs because they do not provide funding breakdown details. Especially valid criticism also when Labour campaigned in 1998 on increasing specialist appointments]
April 7th, 2008 at 10:06 am
DPF resetting the clock right in the middle of our exchange earlier has mucked up the meaning of half the comments in this thread.
April 7th, 2008 at 10:08 am
keithng
Try getting an operation without a specialist appointment/assessment. Oh I know Labour good – National bad… people die on waiting lists – it’s the price we pay for a Labour govt. Move on.
April 7th, 2008 at 10:15 am
DPF: Oh, does “number of first specialist appointments” mean the same thing as “specialist availability”? How did I miss that?
In any case, it’s only one of a large number of measures of *output* (NB: not productivity, which is a ratio) in the health sector, and is meaningless without a lot of other measures, which is why Ryall will finish up looking like a twat if he tries to take on Cunliffe at question time using this data. Can we have the other measures so that we can have a sensible discussion?
If you look at the article that I have added to the discussion, you will see an analysis that uses some of the more useful actual measures of health sector productivity to show that, well, things improved under your lot as well as under mine. Not that I expect good news of this sort to get a good reception from the more rabid members of the kiwiblog right (Redbaited, etc), who have trouble dealing with any sort of cognitive dissonance.
But, yes, we do have shortages of specialists in some areas. It’s a world-wide phenomenon. I could say that National’s leading us down the path to a low pay economy in the early 1990s didn’t help things there.
PS It’s “fewer” people, as you know.
[DPF: It is only one stat, but really almost all the other surgical and hospital stats are the same. For a massive (think doubling in nominal terms) increase in expenditure, outputs and outcomes across the board have declined or only marginally increased. This is not just my view - Treasury has reported with great concern on this area. Anyone who argues we are getting value for the extra money is ignoring reality]
April 7th, 2008 at 11:01 am
Hi DPF: “Treasury has reported with great concern on this area.”
Yes, was at Whitehead’s presentation in Auckland last week where he kicked off the productivity series. But having trouble finding the pdf icons to download the papers on the Treasury site. Have you had any luck?
And yes, we do seem to be shovelling money into a hole. But we must remember that productivity has always been a problem in the health sector if measured in terms of money/patient or similar. A professor of health economics explained this to me in the 1970s thus: they keep inventing devilishly expensive new machines and treatments… And this was just before CAT scanners and cisplatin treatment, etc.
April 7th, 2008 at 11:13 am
Yep technology does cost. This is why at some stage we need to debate what should and should not be reasonable expectations of publicly funded health service.
April 7th, 2008 at 11:22 am
Oh hell, we agree on something.
PS If you’re in Auckland in May there’s a book launch you might like to attend.
[DPF: I end up in Auckland most months but never sure when]
April 7th, 2008 at 12:01 pm
About time.
http://www.nzherald.co.nz/section/1/story.cfm?c_id=1&objectid=10502429&pnum=0
April 7th, 2008 at 3:46 pm
jafapete:”Had a close look at a hospital in L.A. last year, and it had an enormous, vast, huge “emergency” department, dealing with all the poor people who had no health insurance and finished up being hospitalised when their conditions became life threatening. Not something I ever want to see here.”
Er, jafapete, what is the difference between THAT and what we have here, besides the fact that there are a whole LOT MORE people HERE in that boat?
April 7th, 2008 at 4:11 pm
Cha, Quite agree. Time for another plaudit for Cunliffe, I guess. If it’s any comfort, I think he’d fit quite well in a certain other party, where he’d also be one of the more competent ministers.
PhilBest, No, there are a whole lot more people there in that boat, believe me. At any time of the day there were hundreds of people sitting in the “emergency” waiting rooms waiting patiently for their number to come up, literally, because they were using the ticket system. It will take time for the benefits of shifting health spending onto primary care in NZ to become apparent.
April 7th, 2008 at 4:27 pm
Still Peter Haussman and those associated with him have done very nicely thankyou.
April 7th, 2008 at 6:18 pm
David, the criticisms of the number of specialist appointments are fine, I just have problems with the comparisons with total health spending. Specialist appointments not increasing doesn’t mean that health spending is without effect. For example, it could’ve gone to primary health care, public health (that’s under Vote Health, right?), better post-ops care (leading to fewer complications), etc. None of those would have shown up in the first specialist visit figure.
Aren’t there more useful statistics? For example, average waiting time between GP referral and seeing a specialist? I know that’s much more difficult to find than the big fat number on Vote Health, but that comparison is just plain useless.
Burt – people dying on waiting lists imply that they’ve already seen a specialist (or they wouldn’t be on the list). That’s another way in which the first specialist visit figure doesn’t tell us jack.
April 8th, 2008 at 11:56 am
oh yeah, jafapete, and how many people in NZ get their ops done in our public system in 10-14 days after seeing their GP, which happens to be the US average.
“It will take time for the benefits of shifting health spending onto primary care in NZ to become apparent.” Oh yeah, we just need to give it a few more decades of Heleban administration, yeah, right…..