Journal of the New Zealand Medical Association, 14-March-2008, Vol 121 No 1270
Just how safe is the New Zealand health system?
Des Gorman, John Kolbe
The first annual report of the Government’s Health Quality Improvement Committee released on 10 February 2008 could be of great comfort; if we are compared by way of the cited data to the United Kingdom and North America, we would seem to be doing very well.1–4 Alternatively, the report could be of great concern if the relevant reporting rate and veracity is as low and poor as is likely.5 Most probably, it is of no use whatsoever, as even a rudimentary analysis of the integrity of the system used to collect the reported data shows it to be somewhat wanting.6
Committee Chairman Mr Pat Snedden might have been better off quoting the old statistical aphorism about “rubbish in equals rubbish out.” Some attention is certainly warranted by Mr Snedden’s committee to modern perspectives of quality measurement and management in health;6–8 best practice in this context is a far cry from the burgeoning data collection exercise undertaken by District Health Boards as part of their reporting obligations to the Ministry of Health. In the USA, a similar obsession with high quantity, poor quality “quality-data” is thought to have “paralysed” elements of the health services.9 We would refer readers to a very appropriate analogy in this context.
...Perhaps the culture of accountability that we are relentlessly building for ourselves actually damages trust rather than supporting it. Plants don't flourish when we pull them up too often to check how their roots are growing: political institutional and professional life too may not go well if we constantly uproot them to demonstrate that everything is transparent and trustworthy.10
The increase in complaints cited by the Health and Disability Commissioner, Mr Ron Patterson,11 may reflect deterioration in the quality of our health services. However it might just demonstrate a growing “culture of complaint.” It needs to be remembered, by anyone interested in understanding just how safe our health system is, that the first thing to suffer in any culpability-based system of reporting is honesty.2,12,13
“Beating up” on doctors predictably and understandably encourages doctors to engage in doctor-protective behaviour and this can be at the expense of patient safety. The unfavourable “safety” comparisons with the aviation industry, made recently by the United Kingdom’s chief doctor, Sir Liam Donaldson,1 overlook the blame-free nature of reporting that has led to such an enviable safety record for the airlines and general aviation.14
There are good reasons why the New Zealand health system could be sick. Successive reforms have created a schism between managers, clinicians, and public health advocates. District Health Board key performance indicators are hospital-oriented and throughput-obsessed, such that a perverse “widget factory” culture pervades our hospitals.
Industrial relations between these health boards and their employees (such as evidenced by the current senior medical officer dispute) are poor. The industrialisation of the junior doctor workforce has largely dismantled the apprenticeship basis of continuing medical education for those in the early postgraduate years.15
General medical practitioners—the sector of the medical community that is most capable of driving up health quality and driving down costs16—have been significantly undervalued and undermined by Government and Ministries for several decades. The current relevant ideological obsession for primary care is for (incentive-free) capitation.
New Zealand never caught the Prime Minister’s knowledge wave; we are the most reliant country in the OECD on overseas-trained doctors.17 For example, only one in three of our practising rural doctors are New Zealand-trained. And we are no longer able to recruit from countries of equivalent medical educational standard, as witnessed by the recent failed attempt to lure several hundred United Kingdom graduates to New Zealand in the face of a supposed glut there—only about 20 were recruited.
Student debt is now a major determinant of career choice for our medical graduates,18,19 and (in this context) there is a strong financial incentive for them to either go overseas and or to take up specialist practice, which is rich in procedures and technology.
This has to be seen against a background of the pharmaceutical industry in the USA alone spending more money on direct-to-doctor propaganda than the combined budgets of all the medical schools.20,21 Somewhat flippantly, it is fair to say that doctors are not accidentally stupid.
There are a plethora of reasons why our health system should be performing badly. On face value, the data reported by Mr Snedden should encourage us to look for the reasons why in such an apparently pear-shaped system we are doing so well. What we actually need are meaningful data, and the nature of this report and the reaction to it are unlikely to get us to a better position.
If New Zealanders want some hard data to chew on, the average life expectancy of a Māori man is 9 years less than that of his Pākehā (New Zealand European) equivalent; a greater gap (by 2 years) than for Europeans living in North America compared to indigenous Americans.22,23 That fact alone should be a cause for discomfort as compared to the Quality Improvement Committee’s “data.”
Competing interests: None known.
Author information: Des Gorman, Head of the School of Medicine, The University of Auckland, New Zealand; John Kolbe; Head of the Department of Medicine, School of Medicine, The University of Auckland, New Zealand, and, Chair of the Adult Division of the Royal Australasian College of Physicians, Sydney, Australia
Correspondence: Professor Des Gorman, Head of the School of Medicine, The University of Auckland, Private Bag 92019, Auckland, New Zealand. Fax: +64 (0)9 3737599; email: firstname.lastname@example.org
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