Public health needs well-defined boundaries

There is more behind district health board deficits than repeated claims of management incompetence, writes Dunedin surgeon Dick Bunton.

I wonder how many changes in hospital management there have to be, on the assumption that they were incompetent, before the penny drops that there may be issues other than managerial and administrative competence that are driving most district health boards into states of insolvency.

Over my past 35 years as a senior doctor in Dunedin, I have worked with a large number of hospital managers and administrators and while I might be less than complimentary to some as opposed to others, the majority I have found to be caring and hard-working people. The cause of current DHBs' deficits is multifactorial and the blame should not be put solely at the feet of hospital management.

New Zealanders have been brought up with the belief that the government will provide for all our needs - particularly health needs.

A country's ability to finance the total health needs of its population has only been achieved by Saudi Arabia, based on its immense wealth.

In all other countries the public health system's failure to deliver to all is manifest in long waiting lists, non-availability of the most up-to-date drugs and failure to meet internationally acceptable targets for the assessment and treatment of various medical conditions - predominantly cancer.

One way to address this is for patients to have private insurance. For those of us brought up in basically a welfare state the need for and the expense of private health insurance is a concept that is not widely accepted. There is a belief paying taxes gives a universal entitlement to free and unfettered access to healthcare.

In New Zealand, private insurance is mainly aimed towards surgical interventions and does not cover all medical conditions.

In New Zealand, the average wage (Stats NZ 2017) is $50,000. This means that over a 40-year working life the average personal income tax paid by the individual is $310,000. A small proportion goes to vote health. This total amount ($310,000) can be the amount spent in a short period of time on one complex patient. It is clear the proportion of personal income tax directed towards healthcare cannot pay for a free health system for all people.

There is a commonly held belief that throwing more money at the problem will make the problem go away. I do not believe this.

While increased funding would be welcomed and might be a temporary patch, the ability of the medical profession to spend money and the cost of new, evolving technology and drugs will always outstrip the country's ability to pay to a level where free access is available to all in a timely fashion.

One way to look at the public health system is to consider it as the government's insurance scheme where you as a citizen of the country, through taxation, have paid a premium to give you access to healthcare. All insurances have various rules and exclusions with regard to what is covered and how much in total is reimbursed to the individual for healthcare. No private insurance policy would give you limitless access to healthcare because the company could not survive financially. Private companies also rely on the fact the government funds acute, complex and high-cost drugs/procedures.

The expectation of New Zealand society is the main driving force behind health expenditure. We have a well-educated population which has access to the World Wide Web and knows what is available to treat whatever health issue strikes them. In the field of medicine there is no shortage of innovative techniques/devices/therapies with various levels of success available. Not unreasonably, it is the patients' expectation they will be available for free through public health - even if the evidence for the efficacy of such treatment may be tenuous.

Theoretically, it should be possible for society to decide what should be available for government-insured individuals and like all policies it should include exclusions. This exercise was attempted in Oregon a number of years ago but failed because society couldn't agree what should and shouldn't be provided. Nowhere in the world has it been possible to define what should be "core" services for the population so the public system, through promising everything to all, fails and people either miss out or look to alternative providers.

In the situation where various groups are bartering for health funds it is inevitable that decisions are sometimes made in response to public pressure rather than good scientific evidence. It is no secret that if you are a child or female or have cancer your ability to attract government funding is greater than the rest of the population. Political expediency also at times intervenes to make "popular" decisions which result in a particular drug being funded, which again may not stand up to scientific scrutiny. This diverts valuable health funding away from areas of genuine need.

The crux of the problem of health funding is finding the balance between public health versus personal health and societal expectation. We do not apply the same principles to public health expenditure as we do to our own personal finances.

In our everyday life we make decisions on our own personal expenditure based on cost-benefit analysis. In theory we should do the same for government money but health is such an emotive issue on a personal basis that an individual will not surprisingly want any treatment that gives a chance of a better outcome for them, irrespective of cost and overall efficacy. With the advent of Dr Google there is no shortage of websites/action groups/experts that make claims and advocate therapies that may be ineffectual but to a non-expert this gives false hope and expectation.

Pharmac is a very important government agency and applies a cost-benefit analysis to therapies that the government funds. One only has to see the often vitriolic criticism directed towards it when a decision made based on good science and evidence conflicts with the views expressed by individual patients/action groups which are subjectively based having done their research on Dr Google.

If we accept the fact that government funding is not limitless and that decisions should be based on good evidence, then the solution should be simple - but clearly it is not. It has been calculated that if all the money that is spent on alternative health therapies that fill the shelves of all pharmacies and supermarkets, for which there is little or no evidence for efficacy, was directed towards our public health system, we could afford free health for all in a timely fashion with no waiting lists. It has to be acknowledged that the general population has not got the level of knowledge to make informed decisions regarding various therapies and that people make decisions based on clever advertising strategies or claims that start off with "scientific studies have shown ..."

There is at present a national debate on euthanasia and whether this is an area of "medical endeavour" society wishes to enter. At present, 90% of health funding is spent in the last 10% of life. We can spend significant amounts of health funding, gaining perhaps a few months of extra life for a patient, which has significant personal gains for the patient but in reality has little gain for public health as the funding might have been used for something like immunisations. Should we apply the same principles to health funding as we might do for our personal finances? Why should we have different principles for government money and our own finances?

The solution of health funding lies in the hands of those delivering it - the health professionals - BUT they must be guided by society. Society first has to come to the recognition that there is not unlimited funding (not everyone accepts this) and as such there has to be some rationalisation of how we used the limited funds. I stop short of using the word ration as this is a word that no politician would use or admit to but it is what we have to do.

Society has to give health professionals guidelines as to what should and shouldn't be treated because it is the health professional who is caught in the middle of the balancing act and will always lean towards the personal health of the patient.

Prof Robin Gauld has recently written in the ODT that in his view elected boards do not have the necessary skills to face the issues facing our health system. I very much agree with this. The well-meaning folk on a hospital board are often elected on the basis of single issues. They now have to steer a billion-dollar business when they have only had to deal with home finances in the past. The issues the board faces are complex and unless there is some knowledge regarding health and the health system, board members will lack the ability, through no fault of their own, to make good decisions.

Some would say that elected boards ensure that the general population is represented and that the public has a voice as to what healthcare DHBs should deliver. I agree with this view except I think the public input should be at a higher level and the DHBs should be clearly directed, by the government, as to what services should be available and what services shouldn't be delivered by public health.

This would ensure fair and equitable health service delivery. Do I think this is likely to happen? No. This involves a politician admitting to rationing and that will not happen. But if it doesn't happen, we will continue to generate deficits in our DHBs and the Crown monitor for the SDHB will be able to monitor our continuing insolvency.

Similar comments may well apply to executive teams. There has been far too much emphasis on having financial expertise as a basis to lead a DHB. Financial expertise is important, but can be provided to support individuals who may not be "financially" trainhed but have a greater understanding of the industry of health.

One has to only look at successful American hospitals where they are often led by individuals with a medical training. Unless you have an in-depth knowledge of the health industry, it is difficult to know where potential beneficial changes may be made or what questions to ask in order to identify issues. It is clear the executives of DHBs need a greater amount of medical input.

The future of our public health system is in the hands of society - via the government - which must become more directive to the DHBs and health professionals as to what its expectations are and fund to that level.

The public demand for health services cannot be an open book - this is financially untenable. For its survival public health needs well-defined boundaries so the population can make informed decisions as to how best they meet their healthcare needs.