Professor Malcolm1 has drawn attention again to the important concept that performance of providers in the New Zealand Health Service is not necessarily equal. If those who perform poorly can learn from those who perform well, overall performance will improve.

Figure 5 of Malcolm’s paper shows, based on Ministry of Health data, a 43% variation in standardised discharge ratios among the NZ District Health Boards. Although deficiencies in the standardisation process for age, gender and casemix on the one hand (and differing socioeconomic factors on the other) may have contributed to the apparent variation, the probability remains that some Health Boards use their resources more efficiently than others.

Measurement of performance needs to be applied more selectively throughout the Health Service. How effectively is breast cancer diagnosed and treated in different parts of New Zealand? How effectively are antibiotics used in different general practices? Performance in delivery of treatment is most easily measured for common diseases which have a relatively stereotyped clinical course.

For instance, in acute myocardial infarction, Ellis et al2 have shown that provincial hospitals perform less effectively than metropolitan hospitals in carrying out cardiac investigations. And I have suggested that a similar audit should be carried out of the pre-hospital phase of acute infarction.3

In most cases, data are already recorded routinely so that comparisons could be made and acted upon, and advances in information technology will make this progressively easier to do. In the past, comparison of doctors’ performances would have been unthinkable, but the world has changed. In the UK, performance of individual cardiac surgeons has been compared,4 performance of individual hospitals in delivery of thrombolytic treatment is routinely assessed5—and the best performing hospitals (according to a number of criteria) have been freed from direct government control, in order to allow greater freedom and flexibility.6

There are many opportunities in our unified health system with integration of primary, secondary, and tertiary care for performance to be measured, with the prospect of general improvements in efficiency and effectiveness of care for our patients.

Robin M Norris
Retired Cardiologist
Auckland