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Missing The Health Target

Wilhelm Tell (more commonly known as William Tell in the English speaking world) was a 14th century folk hero in Switzerland then ruled by the Austrian Hapsburgs. Tell is widely considered to be the symbolic father of the Swiss Confederacy.

Among other things Tell was an expert marksman with the crossbow.  He is most known for shooting an arrow through an apple on his young son’s head. According to legend this incident launched the struggle for Swiss independence.

‘Restoring the targets’

A key election plank in the National Party’s health policy was what it called restoring the targets that it put in place when last in government (2008-17). I discussed this issue in a column published by BusinessDesk (26 January): To target or not to target.

In summary I covered:

  • how the targets developed and what they then comprised;
  • how the targets worked up to 2017;
  • the Labour government’s alternative approach of health indicators;
  • the National Party’s modified targets in its election manifesto; and
  • my advice to Minister of Health Dr Shane Reti on the approach he should now take.

For targets to succeed

For targets to succeed I advised that:

…two initial baselines are required.  First, they must make good clinical sense. This requires their development to be clinically led by those with the relevant expertise. Second, they should lead to systems improvement rather than be confined to a specific clinical or diagnostic service.

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But I then added four qualifiers with specific reference to public hospitals (general practice was excluded from the targets); in particular, to the targets for planned surgery waiting lists, access to cancer treatment, and emergency departments:

  1. Targets can only apply to what can relatively easily be counted, whereas much of hospital diagnosis and treatment can’t be counted for meaningful systems improvement purposes. This means that targets are confined to a relatively small part of what public hospitals do. Excluded, for example, acute surgery, mental health, and much of inpatient and outpatient care.  Consequently, targets can’t realistically measure hospital system performance or productivity.
  2. Through punitive monitoring targets can (and did) incentivise perverse ‘gaming’ of the system in order to meet the target. This was through measures such coding and focusing too much on less complex and quicker surgical procedures, such as cataracts, at the expense of more complex and therefore slower procedures.
  3. Achievability depends on workforce capacity. Increasingly severe health professional shortages since the late 2000s seriously hinders meeting critical hospital-based targets.
  4. Achieving hospital-based targets would be made much more difficult if there was an increasing rate of acute patient demand, leading to bed shortages and a slowdown of non-acute surgery. This has been the case since the early to mid-2010s.

Overall the Labour government’s health indicators were superior to National’s previous targets.

This was  because their scope was more comprehensive (although cancer treatment access is inexplicably excluded) and not narrowly focussed on things that can relatively easily be counted).

However, the health indicators unreasonably exclude the importance of addressing the severe workforce shortages and enhancing health professional engagement.

These shortages and the lack of a genuine engagement culture will overwhelmingly determine whether either health indicators or health targets will be achieved.

Free advice to Minister of Health

This led me to advise Dr Reti in BusinessDesk that:

…he would do well to consider blending them in with the first 10 existing health indicators. He might also wish to consider changing the name ‘targets’ to ‘indicators’ because, in reality, that is actually what they are.

Both the way National has described its previous targets and the emphasis it has given to its intended health targets suggest  that they are neither a magic nor silver bullet.

The former 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. But they do encourage overthinking. The mythical Willhelm Tell sensibly noted that “He who thinks too much, will not act.”

If  Minister Reti wants to achieve his targets, either as in National’s election manifesto or as blended in with the existing health indicators (as discussed above), he needs to act and quickly.

He must give the highest immediate priority to resolving the health professional workforce shortages in public hospitals.

[Dr Reti must also actively and assertively work to change the culture of the system from top-down command and control to distributive engagement.]

Last July a video of me discussing this crisis was published by The Common Room:    Scary public hospital crisis

In two  Otaihanga Second Opinion posts earlier this year I further elaborated on the seriousness of this crisis. The first (25 January) discussed how unsafe our public hospitals are: Unsafe hospital staffing.

The second (7 February)  discussed the magnitude of the blow-out of delayed appointments for first specialist assessments of patients referred by general practitioners for further investigation: Ballooning hospital specialist appointments.

When Labour’s Annette King and National’s Tony Ryall became health ministers in 1999 and 2008 respectively (both as part of a change of government) they both already had a clear plan on what they wanted to do.

Shane Reti should take the lead from these predecessors by requiring Te Whatu Ora (Health New Zealand) to engage with the health unions on specific recruitment and retention strategies and action plans for each of the health professional occupations.

In doing this he would do well to consider another Wilhelm Tell pearl of wisdom: “The bow that’s stretched too much breaks.” Excellent advice from someone who never existed.

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