Hospital Productivity: What Does It Mean?
Hospital Productivity: How is it measured? What Does It Mean?
“The Minister of Health’s responses thus far to the report by Mani Maniparathy released by the New Zealand Business Roundtable (www.nzbr.org.nz) yesterday on productivity in public hospitals are a distraction from the public interest questions that it raises”, according to former Health Funding Authority chairman Dr Graham Scott. “I wonder if he understands the data and the analysis, what it claims and what it does not."
Dr Scott, who oversaw and wrote a foreword to the study, said that the motivation behind it was to bring out from under the covers of the Official Information Act basic data on two aspects of hospital performance – productivity and unit costs of services. These are crucial inputs to evaluation of the value for taxpayer money going into public hospitals and of the effectiveness of current arrangements for funding and delivering services.
“We were concerned at the lack of accessible and reliable data for researchers and the public on the performance of public hospitals. These data should be released from protection by the OIA, raised in quality and published routinely by Statistics New Zealand. In the meantime Mani Maniparathy will be making the data available.
“Our study went deeper into the data than an earlier Treasury study which showed that hospital efficiency fell 7.7% from 2000/01 to 2003/04 when it had been rising about 1% per annum in the preceding years. This aroused our initial interest in the subject. That study measured efficiency by comparing the growth in costs after allowing for inflation with the volume of services produced. In our study we recalculated that measure and extended it over two more years, which produced robust confirmation of the Treasury’s findings and also showed that hospital efficiency continued to fall.
“That measure of efficiency was influenced by the salary increases in the period studied. So we also tracked the volume of services produced, divided by the staff numbers employed, to remove the effect of the salary increases on the Treasury’s measure of efficiency. This is what we are calling hospital productivity, which is a standard measure of labour productivity used by economists.
“Hospital productivity is about the volume of services being produced per person employed. We’re not talking about how hard doctors and nurses work.
Productivity data are like taking a person’s temperature – you can tell if they have a fever but not what is causing it. This analysis raises important questions about the effectiveness of current policies for funding, governance and management of hospitals – it doesn’t answer them.
“The over-arching public policy questions Mani Maniparathy’s analysis poses are these: How are the rights of access to services for the public from their hospitals going to be met, now and in future, when there already waiting lists of qualified patients, the population is growing and aging, and future governments will not be able to keep increasing expenditure at the rate the present government has been able to due to favourable economic circumstances that we will not see again for a while? As the rate of growth of demand is going to exceed the rate of growth of funding, hospitals are going to have to increase their productivity to meet service obligations. The evidence is that in recent years it has been decreasing. Is this evidence right and, if so, why has this happened?
“Those of us outside the system have no access to the information that would support a careful diagnosis of the reasons for these trends. It is worrying that the Minister of Health seems untroubled by productivity and cost trends in a sector involving a large portion (one fifth) of government spending, particularly at a time of economic recession when all government spending must surely be under scrutiny.
Whoever is the next Minister of Finance will have good cause to be worrying about these trends and so will the public if they continue."
Dr Scott said that some possible causes were:
• data inadequacies
• unmeasured quality improvements
• the way the professional teams are paid, deployed, trained, managed and motivated
• the way cases are managed
• the quality, availability – or lack thereof – and scheduling of facilities use by professionals
• excess administrative and governance burdens on frontline staff inherent in the DHB model of administration, and
• the shift to bulk population based funding from paying standard prices for services, which coincides with the productivity deterioration.
“Aside from his ideological points, the minister’s answers so far are – with our comments in italics – that:
1 The Labour Party thinks raising salaries is positive. We would too if it is necessary for recruitment and retention, but what is the connection he has in mind between salaries and the volume of service per person employed?
2 The government has invested in primary health care and in hospital infrastructure. This was needed, but if these decisions have been made correctly we would expect to see productivity in hospitals going up, not down.
3 We have more front line health professionals. This is fine, but why, as more of them were employed, did their average output decrease? Also, in addition to more front line professionals, a lot more back office administrators and board members have been employed – what is their contribution to front line productivity?
Maybe they are lowering it.
4 The report doesn’t look at quality improvement. This is correct, and if there has been a quality improvement that offsets the productivity decline that deserves applause, but where is the evidence that such large improvements in quality have actually been made? An important dimension of quality is safety.
What has been achieved so far in responding to the Health and Disability Commissioner’s very critical reports in recent years on hospital safety?
5 More people are accessing health services. So they should be with 8.5% average annual increases in health spending in recent years, but what has this to do with productivity in hospitals? The important issue is the conditions of access. In October 2007, 70 people were on the Capital and Coast DHB waiting list who had qualified for treatment but had waited more than 6 months. Some of that waiting list was cleared by sending people to Australia for services – which was the right thing to do, but what does it say about New Zealand hospital productivity?
“It is most surprising that the Minister of Health has dismissed as “silly” a report that deepens and largely verifies work done by government officials and brings it to the attention of the wider public”, said Dr Scott.
“If he favours transparency about hospital performance, something he might attend to is the quality and availability of the base data needed to analyse value for money in our hospitals. These are inconsistent, often unreliable, in some cases not being recorded at all, and are difficult to obtain. Some previously available data have been discontinued. Treasury and Ministry of Health reports referred to in the study were only available through the Official Information Act."
Business Roundtable executive director Roger Kerr added: “Some commentators have questioned the timing of the release of the study. In fact it would have been available and released many months ago had the information been easier to obtain. The Ministry of Health insisted on selling it to us in hard copy form that would have cost us thousands of dollars to enter into a computer. We had to appeal to the ombudsman to get the data released in computer readable form.
“The Business Roundtable has been drawing attention to the disturbing fall in productivity growth across the economy in the sectors measured by Statistics New Zealand (essentially the business sector, accounting for around 73% of GDP). The study suggests that there are equal grounds for concern in the health sector, which accounts for a further 8% of the economy”, Mr Kerr concluded.