“Some is not a number. Soon is not a time.” – Don Berwick

More than eight months ago, the Health Minister of New Zealand cancelled public reporting on performance of DHBs.1 New performance measures for public sector hospitals are reportedly under development but have not been released to date. In the interim, the indicators are available in an excel file in a format that would be relatively indigestible to the general public.2

Reportedly, the reason the Government announced the change is because of concerns that they would set up ‘perverse incentives’.1 That is, by requiring DHBs to measure and report on certain indicators, it may induce DHBs to act in a way that is harmful to the health of patients or detrimental to the public interest. For example, a DHB refusing GP referrals of patients in order to manage specialist wait times.

Why is it important to set targets for DHB performance and publicly report on them? Because it creates an incentive for the Government to care about DHB performance, lets us know what’s working and creates an accountability structure for DHB performance. A 2010 review undertaken on behalf of the NSW government found there is “strong and consistent evidence in supporting the notion that public disclosure of performance data stimulates quality improvement activities at hospital level”.3 It also found that while the picture is at times mixed, most studies found a positive effect on clinical outcomes.

Perverse incentives can be real. In the New Zealand setting, research has been done on the broader organisational implications of target setting within performance measurement.4. It found that targets for ED waiting times, for example, induced a mix of positive and negative consequences within hospitals4 along with improved clinical outcomes.5 This research gives us a good basis to understand which targets are most likely to induce unintended consequences and be selective in which targets we turn off, rather than an across-the-board stoppage of public reporting of results as we have now.

The longer we wait, the more potential harm for the New Zealand health system. Studies from the UK have shown that when an indicator was withdrawn, there was a rapid decrease in performance from health providers. In GP practices for example, the number of patients with basic measures such as blood pressure readings, or a recent cholesterol dropped precipitously when monitoring and financial incentives were withdrawn.6 When hospital waiting list targets in the NHS were withdrawn or ‘relaxed’ then wait times spiralled.7

Perverse incentives can have a real impact on healthcare delivery. However, the alternative of a prolonged period without adequate public scrutiny of performance may be more detrimental.

‍

“Some is not a number. Soon is not a time.” – Don Berwick

More than eight months ago, the Health Minister of New Zealand cancelled public reporting on performance of DHBs.1 New performance measures for public sector hospitals are reportedly under development but have not been released to date. In the interim, the indicators are available in an excel file in a format that would be relatively indigestible to the general public.2

Reportedly, the reason the Government announced the change is because of concerns that they would set up ‘perverse incentives’.1 That is, by requiring DHBs to measure and report on certain indicators, it may induce DHBs to act in a way that is harmful to the health of patients or detrimental to the public interest. For example, a DHB refusing GP referrals of patients in order to manage specialist wait times.

Why is it important to set targets for DHB performance and publicly report on them? Because it creates an incentive for the Government to care about DHB performance, lets us know what’s working and creates an accountability structure for DHB performance. A 2010 review undertaken on behalf of the NSW government found there is “strong and consistent evidence in supporting the notion that public disclosure of performance data stimulates quality improvement activities at hospital level”.3 It also found that while the picture is at times mixed, most studies found a positive effect on clinical outcomes.

Perverse incentives can be real. In the New Zealand setting, research has been done on the broader organisational implications of target setting within performance measurement.4. It found that targets for ED waiting times, for example, induced a mix of positive and negative consequences within hospitals4 along with improved clinical outcomes.5 This research gives us a good basis to understand which targets are most likely to induce unintended consequences and be selective in which targets we turn off, rather than an across-the-board stoppage of public reporting of results as we have now.

The longer we wait, the more potential harm for the New Zealand health system. Studies from the UK have shown that when an indicator was withdrawn, there was a rapid decrease in performance from health providers. In GP practices for example, the number of patients with basic measures such as blood pressure readings, or a recent cholesterol dropped precipitously when monitoring and financial incentives were withdrawn.6 When hospital waiting list targets in the NHS were withdrawn or ‘relaxed’ then wait times spiralled.7

Perverse incentives can have a real impact on healthcare delivery. However, the alternative of a prolonged period without adequate public scrutiny of performance may be more detrimental.

‍