By international standards the New Zealand healthcare system appears satisfactory – certainly no worse generally than average. Yet it is undergoing another redisorganisation.
While doing some unrelated work, I came across some international data on the healthcare sector which seemed to contradict my – and the conventional wisdom’s – view of the healthcare sector. Broadly, the sector seems to be performing relatively well and does not seem underfunded compared to other OECD healthcare systems.
The details are here but, in summary, the OECD report thought that we were close to the OECD average on most of its health indicators, but we were better than average in regard to self-rated health, smoking, air pollution, and effective secondary care (dealing with heart attacks and stroke). We were doing badly only on obesity (we knew that). In the international pecking order our health expenditure is seventh as a share of GDP and sixth if we adjust for the age-structure (we have a relatively younger population than those ranked close to us) and for price differences (the cost of the same care is lower).
The US-based Commonwealth Fund confines its international comparisons to only ten countries. New Zealand ranks in the top half on all its dimensions – fourth on overall rankings, third on health outcomes – with the exception of equity where we rank second-to-bottom above the US. (One is surprised they can even make a judgement given that unlike most affluent nations we have no unmet needs survey.)
There is so much widespread grumbling about the New Zealand healthcare system, I was surprised at this data although I am cautious because international comparisons tend to be treacherous. What we overlook in our insularity is that there is widespread grumbling everywhere else too. Even so, the grumbling deserves careful analysis.
Failures
First, occasionally failures happen in the health system, mistakes which can be tragic for the individual and their families. Usually, they involve an individual incident. To be realistic, such mistakes are bound to happen in any system as large as a healthcare one, where there are literally millions of potential incidents every year, and where clinical rather than mechanical judgement is involved. (There can also be impatience with delayed diagnosis; that’s because healthcare is more complicated than deciding who won a race.)
The aim has to be to minimise such occurrences and to give as good redress as possible when they happen. We probably have a reasonably effective arrangement with the Health and Disability Commissioner – perhaps the commission is underfunded and a bit slow as a result – and ACC. The grumbling is a part of this continuous improvement process. But it does not prove the system is failing. (There is a bias, because we do not hear reports of the successes, which happen far more often; good news is not news.)
Occasionally failures are systemic, involving the wider system. They will happen, but in the ones I have looked at, the remediation has taken too long, suggesting the upper bureaucracy is not as committed to continuous improvement in the way that medical professionals are. Typically, such systemic failures are local. Expecting even higher bureaucrats based in Wellington to do better seems implausible.
Access
There are different sorts of access issues. There are going to be locational challenges; it is not going to be possible to provide heart surgery in Hokitika. Similarly, there will be treatments which are too rare, specialised or new to provide anywhere in New Zealand so those needing them may have to go offshore. Again, continuous improvement bringing them onshore – often backed by research (as is happening with CAR T-cell therapy for cancer) – is the long-run solution.
Sometimes a treatment is just too expensive to be a realistic option. Consider a drug which costs a million dollars a pop (and if you don’t think that is expensive, I haven’t told you how many pops are necessary, nor how little quality of life the drug generates). Yet, the patient who needs the treatment may think it is their last chance; it’s an easy news story too. In a constrained budget system, providing the treatment is at the expense of other healthcare services and treatments which may generate far greater quality of life. This has been a particular concern in regard to expensive pharmaceuticals being pushed by their Big Pharma providers.
A big access issue is waiting times, including for emergency, seeing a specialist (and increasingly for some, alas, even a GP) or for treatment. This seems to be a mix of inadequate funding and inadequate staffing (which requires a far greater commitment to labour-force planning than has been evident for three decades). An especially uncomfortable issue is the ‘ghost’ waiting lists, those in need who do not even get to a doctor. A particular case involves Māori and Pasifika with cancer who are getting into the healthcare system when the disease is far advanced. (It is this situation which led the Commonwealth Fund study to down-rate us for equity.)
Is the healthcare system failing?
So the New Zealand healthcare system has a number of challenges, as do all the other systems we compare ourselves with. We are more ambitious than just pacing ourselves with the rest of the affluent. We want to do better – so do they. To do better we need to intensify continuous improvement. I am not sure that the generic management which dominates the system copes with this very well, because continuous improvement relies on the integrity of the professionals which the managers do not trust.
There may well be accounting problems. (See here.) But it would seem that is not impacting as badly upon the delivery of healthcare as much as one feared. Long may that be so.
And yet we keep redisorganising the top of the healthcare system. National’s second was announced last week, somewhat reversing its earlier one. I despair. Let’s agree they can’t get it right. Which is not surprising since there is rarely any careful review of why the system which is about to be replaced has failed. The next one is likely to fail too. The problem is that each redisorganisation fails to put the medical professionals at the heart of system. Look after them and they will look after their patients. If they are not trusted to perform as well as the international comparisons suggest, we end up with heavily over-managed and not well-performing layers above them.
The underlying message of this column is that rushing around claiming the system is in crisis without a careful analysis is dangerous. I first saw the danger when in the 1980s people of goodwill said the New Zealand healthcare system was terrible. (There were no international comparisons in those days.) The neoliberals said they had a solution. Their proposed redisorganisation of the early 1990s was quack medicine and, not unexpectedly, made many people worse off – some died because of it.
Yes, we can do better if we aspire to do better and we trust our professionals. It requires more funding to increase and retain the healthcare labour force (the drain to Australia is a threat), it requires a commitment to professional-led continuous improvement, it requires better analysis at the top which begins with careful diagnosis and does not end with a nostrum unrelated to the actual disease.