GUEST BLOG: Ian Powell – Politics, Ideology and Health Targets

On 14 October I had the pleasure of being one of two speakers to address the monthly public meeting of the Fabian Society in Wellington.

My fellow speaker was Dr Ganesh R Ahirao (aka Nana) who described himself as a ‘boring economist’ (translation: a very un-boring economist). He was the former Chair of the ideologically disestablished Productivity Commission.

In a lively address (he had the misfortunate of having me as his ‘warm-up act’ he made many telling observations including the folly of using ‘market price’ as the basis for health funding.

My topic was ‘Where health targets fit in with the future direction of our public health system’. The text of the address is reprinted below with some visual enhancement and minor tweaking.

Learning from Wilhelm Tell

Wilhelm Tell had an expert understanding of targets and outcomes. A 14^th century folk hero in Switzerland, Tell was an expert shooter with the crossbow – most known for successfully shooting an arrow through an apple on his young son’s head.

Wilhelm Tell understood the relationship between targets and systems improvement

According to legend, this incident launched the struggle for Swiss independence against the Austrian Hapsburgs. Tell was widely considered to be the symbolic father of the Swiss Confederacy.

The only point of similarity between Tell and Minister of Health Simeon Brown is their focus on targets. But they are widely apart on their approach to them.

For Tell, mythically at least, targets involve precision (arrow through the apple) and systems improvement (Swiss independence).

Contrast this with the Minister of Health’s approach: imprecision, an absence of health system improvement, and interwoven with benefiting for-profit private healthcare.

As I discuss this further hold onto these three thoughts in the meantime.

1. To be effective targets need to both make good clinical sense and lead to systems improvement.
2. What happens when the rate of acute hospital discharges is greater than the rate of population growth.
3. The evolution of health targets from a policy response to a misplaced understanding of health system productivity into a rationalisation for privatisation.

Origin of health targets

Health targets first emerged in the second half of the 2000s. They arose out of Treasury’s misplaced but widely reported claim that while health spending had increased significantly in real terms, productivity had not.

The productivity claim was based on what is commonly known as elective or planned treatment. This is when general practitioners  referred patients to a public hospital for further investigation known as a ‘first specialist assessment’.

Depending on the diagnosis this often leads to the scheduling of non-acute surgery or other forms of treatment.

The claim was misplaced because elective or planned treatment was not an indicator of hospital productivity. Much clinical work falls outside this part of a hospital’s job.

If there was to have been a genuine endeavour to include, as part of a productivity assessment, chronic illnesses (which are managed rather than cured) and acute care (which is treatment that can’t be deferred).

Pete Hodgson the first health minister to introduce a health target

Nevertheless, the then Labour-led government responded. Under health minister Pete Hodgson introduced ‘elective services performance indicators’ (ESPI – a target by another name) was introduced for first specialist assessments.

National’s expansion of health targets

With a change of government in late 2008, National new health minister Tony Ryall established six targets.

Health Minister Tony Ryall expanded the number of health targets

Three of these targets were useful but not necessarily system improvements – better help for smokers to quit, more heart and diabetes checks, and raising healthy kids.

They did contribute to better outcomes, but it was difficult to differentiate between these specific targets and other measures. Another target – increased immunisations – was successful as an illness prevention measure.

However, achieving this became a greater challenge because of increased activism and misinformation arising out of the Covid-19 response by the small but strident anti-vaccination movement.

The other three targets are the ones that attracted the most prominence and controversy. One was improved access to planned (elective) treatment, mainly surgery.

The objective was that, following a general practitioner referral to a public hospital and the consequential first specialist assessment, a patient would be put on a waiting list to be treated within four months.

Another was faster cancer treatment. That is, 90% of patients who are graded with a high suspicion of cancer should first be seen within 14 days. Then, subject to diagnosis, they should have their treatment within 62 days of receipt of their referral.

Finally, there were shorter stays in emergency departments. This was often called the ‘six-hour target’. That is, 95% of patients should be either discharged or admitted into the main hospital within six hours.

The experience of the last three targets, in particular, was mixed. The objectives were good, and some outcomes were positive.

Of the three, the six-hour target was the most significant in terms of systems improvement. What made the difference was the high level of emergency medicine clinical leadership in its design.

Emergency departments like Gisborne Hospital’s introduced the six-hour target as part of hospital-wide approach

Further, it was not just about what happened in emergency departments. It required a hospital-wide response because the key challenge was not patients who could be discharged but rather those requiring hospital admission. This meant that ‘bed-blocking’ (discussed further below) had to be addressed.

The government overhyped the targets by asserting that they were a measure of productivity improvement.

This was nonsense because they only focussed on what could reasonably easily be counted and excluded big areas of clinical activity such as mental health, chronic illnesses and acute demand.

Public hospitals were judged on the achievement of the targets. Targets were, so the misplaced narrative went the measurement of hospital performance.

Consequently, it led to a punitive public monitoring narrative that increasingly incentivised managerially driven gaming in order to appear to meet the targets. Gaming was through means such as coding and focussing on quicker less complicated procedures.

Please save health system from tightening vice (Parton, NZ Herald)

This situation was compounded by the impact on public hospitals trapped in the vice of (a) since 2014, acute demand rising at a greater rate than population growth and (b) increasing and entrenched workforce shortages. This was well before the Labour-led assumed the Treasury benches in late 2017.

These hospital-based targets could not be met because the health professional workforce capacity and capability to achieve them was increasingly compromised by this tightening vice.

From health targets to health indicators

When the Labour-led coalition government took office in 2017, it was accused of abandoning targets. Not so.

Labour health minister David Clark didn’t stop health targets as claimed but did initiate development of health indicators

Health minister David Clark continued with them but ceased the misleading productivity narrative. This was the right response, but the messaging was poor, thereby reinforcing the accusation.

Clark shared two characteristics with later health minister Shane Reti – human decency and the lack of a political nous bone in their respective bodies.

The government did, however, develop ‘health indicators’ as an alternative to the targets. In principle, this was a positive move which, towards the end of Labour’s second term, led to 12 indicators designed to be neither carrot nor stick.

Ten of the 12 indicators were a big improvement on the former targets. Their scope was wider, including going beyond what can be counted and venturing into acute care.

Significantly, while they were intended as indicators of performance improvement, they were not promoted as a measure of productivity.

The following three examples highlight their greater breadth and relevance:

• the percentage of children who have all their age-appropriate schedule vaccinations by two years;
• the percentage of under-25-year-olds able to access specialist mental health services within three weeks of referral; and
• acute hospital bed-day rate (number of days spent in hospital for unplanned care, including emergencies).

However, there were glaring omissions – addressing workforce shortages and enhancing health professional engagement – where most expertise for systems improvement resides. Further, accessing cancer treatment was inexplicably omitted.

Unfortunately, the robustness of the indicators was undermined by the final two. These were about the quality and management of funding. These two indicators were as much about government accountability as anything else.

Returning to health targets

The incoming National-led coalition government, following the 2023 election, would have done well to blend its targets into the first 10 of Labour’s health indicators.

Silver (and magic) bullets don’t exist in complex health systems

Instead, the government reverted to simplistic overhyping by suggesting that its targets were either magic or silver bullets.

The former bullet is something that easily solves a difficult or previously unsolvable problem while the latter is a simple solution to a complicated problem. Neither bullet is real in health systems.

New health minister Shane Reti brought back health targets but recognised workforce shortages impact

In March 2024 new health minister Shane Reti announced the return to health targets based on achieving specified percentages within set timeframes. Replacing Labour’s health indicators they cover:

• faster access to cancer treatment;
• improved childhood immunisation rates;
• shorter stays in emergency departments; and
• shorter wait times for first specialist assessments and elective treatment.

Subsequently five mental health targets were announced:

• faster access to specialist mental health and addiction services;
• faster access to primary mental health and addiction services;
• shorter mental health and addiction-related stays in emergency departments;
• increased mental health and addiction workforce development; and
• strengthened focus on prevention and early intervention.

Although Reti continued the narrative of overhyping the benefits of these targets and although less comprehensive and more prone to ‘gaming’  than Labour’s health indicators, there were two useful specified  target enablers – workforce and infrastructure.

For the first time there was express recognition of the importance of addressing the severe workforce shortages in order to achieve the targets.

Shane Reti deserves credit for this until now unrecognised truth. Unfortunately, this overdue recognition was short-lived. He got the ‘sack’.

From policy to legislation

Under successive governments from health ministers Pete Hodgson to Shane Reti, health targets (and indicators) were policy-based. Now, under Minister Simeon Brown targets are to be legislated for as part of a wider amending bill to the Pae Ora Act 2022.

Health minister Simeon Brown trying to shift health targets from policy to legislation

Specifically:

• cancer management care;
• immunisation of children;
• admission to, and discharge and transfer of patients from, emergency departments;
• specialist assessments;
• elective treatment; and
• access to primary care.

The upside of these legislative targets is that although narrow in scope (at least in respect of hospitals) they are not prescriptive.

Excluding ‘access to primary care’, their operational details have already been spelt out and can be revised by policy rather than further legislative amendment. However, this is as good as it gets. There is a deeper and sinister agenda sitting behind it.

Brown’s argument is to blame the previous government for the dropping off of health target achievement since 2018. This ignores the fact that this dropping off has been since 2013/14. He ignores significant underpinning factors such as:

• it is estimated that around one-third of our adult population has an unmet need for healthcare, much higher than reported in 37 European countries;
• people with unmet healthcare are at higher risk of presenting at an emergency department and, even worse, being admitted to the hospital as an acute patient;
• From 2013/14 to 2022/23 the number of people presenting to emergency departments increased by 22.5% (nearly 1.3 million people in 2022/23 out of a population of just over five million); and
• the number of immediately or potentially life-threatening presentations is growing at a much higher rate (51%) than less serious presentations.

Acute hospital discharges running rampant

This helps explain why acute hospital discharges increased by 24% between 2014 and 2023 (28% when adjusted for complexity) while population growth only increased by 16%.

Combined with widespread severe workforce shortages, this rise of acute (unplanned and unable to be deferred) cases displaced non-acute (planned and able to be deferred) inpatient discharges.

How did this tipping point arise

This becomes a tipping point causing ‘bed blocking’. That is, insufficient inpatient beds for both non-acute patients referred by emergency departments and GP referred planned treatment patients.

Targets find themselves on a spectrum of being superfluous to being irrelevant – a very short spectrum!

Why did this situation occur? Relative underfunding for much of the 2010s and political neglect of workforce planning contributed.

So did population growth. The aging of the population certainly impacted with a greater number of people with serious health conditions, including chronic illness.

Social determinants leading to increasing impoverishment the dominant driver of rising acute hospital demand

But the dominant factor was worsening external social determinants of health which are the biggest drivers of health demand (including acute) and health cost.

These determinants include low incomes (the most important), housing and educational opportunities. In other words, increasing impoverishment.

Simeon Brown argues that “what gets measured gets managed”. However, much of what happens in healthcare does not lend itself to measurement. Further, the Government is selective in what chooses to measure.

Acute hospital discharges can be measured. But to include them as a target would require the Government to address the external social determinants of health, along with severe workforce shortages and relative underfunding, which drive much of increased acute hospital demand. This would not be ideologically convenient!

The problem with legislating for health targets is more than mandating a flawed and overhyped policy framework that will compound health system inflexibility and accelerate the system’s tipping point.

Health targets as part of an ideological agenda

Enter ideology

More disturbing (and sinister) is that it fits in with the Government’s ideological agenda of favouring the for-profit private health sector.

A precondition for this is the running down of public hospitals which has been occurring since the early 2010s under successive governments. If our public hospitals were not so badly rundown privatisation would not have arisen.

Rundown of public hospitals like North Shore critical prerequisite for privatisation

This rundown enables privatisation by outsourcing to private hospitals to become the soundbite the ‘solution’.

Outsourcing is not new but was used on a short-term basis to address workforce capacity issues.

Canterbury DHB developed an innovative approach

It was necessary on a longer-term basis for the Canterbury District Health Board in the aftermath of the Christchurch earthquake devastation (over 40 buildings destroyed). However, the DHB was innovative.

The DHB rented private hospital theatres but used their own employed theatre staff to work in them. It was outplacing rather than full outsourcing.

Unfortunately, our health minister does not do innovation; at least if there isn’t a for-profit beneficiary. Instead, Simeon Brown wants longer-term contracts with private hospitals – initially for three years but now ten.

This makes them in effect Public Private Partnerships (we already have PPPs in our public hospitals; privatised laboratories and look at the parlous state they now find themselves).

Achieving health targets becomes the rationale for allowing private hospitals to ‘cherry-pick’ the relatively easier clinical work in order to enhance profiteering.

Health targets began as a response to a poor Treasury understanding of productivity in public hospitals. They morphed into a blunt and clumsy policy instrument. Then they almost evolved into potentially useful and realistic health indicators.

And now, further enabled by the additional rigid teeth of legislation, they are becoming part of the rationale for privatising the public health system.

 

 

 

 

Ian Powell was Executive Director of the Association of Salaried Medical Specialists, the professional union representing senior doctors and dentists in New Zealand, for over 30 years, until December 2019. He is now a health systems, labour market, and political commentator living in the small river estuary community of Otaihanga (the place by the tide). First published at Otaihanga Second Opinion.