With the current activity around Clinical Integration warming up politics and providers in the health sector, Don Matheson’s paper Great to Good has provided an insight into the fiscal and philosophical dilemmas and dicotomies that DHBs have been exposed to, as they attempt to meet targets imposed by the Minister, whilst balancing the need to address the ever increasing inequities between NZ Europeans and NZ Maori and Pacific people.
In his efforts to examine the issues behind the reduced funding of PHC services, Professor Matheson describes the importance of distinquishing between higher order goals such as improved health outcomes and equity, and those that provide the more operational goals of how to provide the services within budget restraints.
Matheson has identified that the 40% of discretionary funding that a DHB had to fund PHC services has been chipped away by increasingly tight budgets and the directive by the Ministry of Health (MoH) to focus funding to achieve targets that provide little in terms of solutions to improving the health outcomes of people with complex health and social needs, or than narrow the ever widening inequity gap.
Targets such as ED waiting times and improved access to elective surgery are nonsensical in the face of burgeoning chronic conditions, increasing unemployment and all the social woes that follow a fiscally challenging time.
Better to identify targets that will truly measure how well we are providing the care, not how many surrogate markers we manage to collect from people who can barely afford prescriptions and medications as they struggle to pay higher power prices on minimum non livable wages. Providers and organisations are constantly distracted from providing quality evidence based care by having to reach targets that may not be at all relevant to the person sitting in front of them. To educate a patient on the benefits of having a low CVRA when they are struggling to breathe because of their emphysema or being diagnosed with a non curable illness is ludicrous, and yet if the box is not ticked, the ultimate penalty may be loss of income for the provider’s employer.
Best to have a system that rewards quality service by identifying improvement of quality markers such as patient satisfaction with a service, clinical competencies of providers, a multidisciplinary team approach and successful team components. Markers of a well functioning clinically integrated health system could also be utilised as targets to hasten the implementation of this throughout NZ.
Indeed this is what Cathy O’Malley – the Deputy Director of Health- has signalled will occur over time, as the PHO contracts are examined this year. DHBs and PHO will be asked to do more towards becoming an integrated health system. Unfortunately whilst DHBs have so little funding and influence over the PHC sector, with it’s privately owned and commercially driven business models, this work programme will be fraught with power struggles and political bargaining, with the biggest loser being the patient at the centre of a maelstrom rather than the calm epicentre of patient focused PHC!
And where are the nurses in this storm? At the bedsides in hospitals, and with people in their homes, but not at the top tables in any great numbers debating and developing the contracts and policies. It never ceases to amaze and frustrate that the largest workforce in the health system, and thus potentially the most affected by any structural, legislative or contractual changes is not included as of right, but must insist on being consulted.