What does Dr Death have in common Sydney’s cross-city tunnel?

‘Economic reform’ gets blamed for many things. I heard someone complaining about growth at all costs, they then segued into its costs on the environment. Then we had the greenhouse effect and the poor person couldn’t help themselves and went on to wonder about the tsunami. Dear oh dear.

In any event for a long time there’s been a gung ho tendency in economic reform in which ‘private sector’ methods are seen as inherently worthy and better than public sector methods, ignoring the different circumstances in which the two sectors have evolved their own approaches to things.

Sadly the Cassandras who are nevertheless enthusiasts for reform properly done (like me and a few others) don’t get listened to too much and things roll along. In fact poorly designed reform rolls along and what begins as corners being cut turns into downright rorts. But things only come to a head (it seems) when they become worse again, and turn into outrages. Whereupon the media who have been soft-pedaling the issue rearrange their posture into one of righteous anger.

One recent example is the way in which the Cross-Sydney tunnel turned into something like a tax farming scheme. And the Review of Queensland Hospitals has turned up another example, where ‘case-mix’ type funding led to a cost cutting mentality not itself necessarily a bad thing, but obviously a bad thing if implemented without adequate regard for safety and quality of treatment and a bunch of other safeguards. Even allowing for the likelihood of a bit of a simplistic approach to the issue from the Commissioner, his comments seem pretty telling.

Some excerpts follow beneath the fold:

1.18 Notwithstanding the isolation from scrutiny that Dr Patel was able to achieve, it may now seem astonishing that the number and seriousness of the complaints against him did not cause either Dr Keating or Mr Leck to institute some thorough independent investigation of his conduct, at the latest by the end of October 2004. But their failure in this respect becomes less surprising, although no less reprehensible, when it is seen how they saw their role of running the Hospital, and where their priorities lay.

1.19 In the first place, both saw themselves as running a business of providing hospital services. They were not solely at fault in this for that is how Queensland Health officers also saw their role. Indeed, the terminology used was that Queensland Health was ‘purchasing medical services’ from the hospitals and that patients were ‘consumers’ of these services. The hospital budget was fixed on an historical basis, that is based on that of the previous year, with an additional incentive payment based on elective surgery throughput. Up until quite recent times it also provided for a small percentage reduction from the historically fixed budget on the assumption that improved efficiencies would enable that to be achieved. In other words the budget was fixed as if the hospital was running a business of selling goods or services. Patient care and safety was not a relevant factor.

1.20 There was a strong incentive to Mr Leck, and consequently to Dr Keating, to maintain that budget. Mr Leck said that District Managers had been sacked for exceeding budget. And because achievement of the elective surgery target was necessary to obtain maximum funding for the following year, there was considerable pressure on both of them to achieve that target.

1.21 In this respect Dr Patel was a considerable asset. He was very industrious and, no doubt also partly because of his careless surgery, and lack of proper after care, maintained a high throughput of general surgery. Without him, the hospital would not have been able to achieve its elective surgery target. Mr Leck’s and Dr Keating’s greater concern with maintaining their elective surgery target than with patient care or safety is reflected in a great deal of the evidence.

1.78 And the fifth problem was a tendency of administrators to ignore or suppress criticism. Bringing to light these and other problems in the public hospital system was made very much more difficult by a culture of concealment of practices or conduct which, if brought to light, might be embarrassing to Queensland Health or the Government. This culture started at the top with successive governments misusing the Freedom of Information Act to enable potentially embarrassing information to be concealed from the public. Unsurprisingly, Queensland Health adopted a similar approach, and because inadequate budgets meant that there would be inadequate health care, there was quite a lot to conceal. I make findings and recommendations in this respect against Cabinets in successive Governments, against former Minister Edmond and Minister Nuttall, against Dr Buckland and against Dr FitzGerald. Again unsurprisingly, the same approach was adopted by administrators in public hospitals, and this, in turn, led to threats of retribution to those who saw it as their duty to complain about inadequate health care.

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cs
cs
2022 years ago

“He was very industrious and, no doubt also partly because of his careless surgery, and lack of proper after care, maintained a high throughput of general surgery.”

Yes, just the logic of funding according to so-called ‘Outputs’ working itself out, which in the case of hospitals is presumed to be ‘Separations’, the definition of which is: “The discharge, transfer or death of a patient admitted to hospital”

Francis Xavier Holden
2022 years ago

nic – cs – I don’t think there is any evidence that “case-mix type funding” led to the problems in the Qld Health system. No doubt on the evidence the Qld system is over centralised and micro managed inapropriately from Brisbane. But Qld isn’t really based on a casemix type output funding at all, especially as approval and funding for individual medical positions is assessed centrally. True casemix (unit /output costing in normal parlance)takes into account, poor clinical outcomes, patient safety and unplanned admissions.

Clearly the Medical Board was incompetent and worse than usless, Leck and Keating the same, Patel a butcher and so on.

Anyway I’ve sent my colleague Prof Stephen Duckett up there to sort it out. I’ve taught him a lot of what I know – so expect to see thing get sorted out. And a real casemix funding system introduced.

Nicholas Gruen
2022 years ago

Yes FX, that’s why I said ‘case-mix’ type funding. It’s obviously a travesty of case-mix funding done properly.

cs
cs
2022 years ago

Every jurisdiction has its case-mix varitations, and they all claim to have the one true case-mix, as amended to be better than everyone else’s. The logic of output-funding based on separation rates leads to gaming, it’s just a matter of how long or complicated or lucky or not you are. Ultimately, the services rely on professional ethics to kick into the system’s holes. It will be interesting to see what happens when a second generation of case-mixed professionals, brought up on case-mix alone, move into place.

James Drysdale
James Drysdale
2022 years ago

I’m not sure who is regulating the quality of health care in this picture. There seems to have been no monitoring of outcomes locally, regionally (e.g. by the commissioner) or nationally (e.g. by something akin to the Healthcare Commission established in the UK). The lesson here is clearly that if payment is to follow the patient (rather than having block contracts) creating incentives to increase throughput then there must be some monitoring of quality. It is entirely appropriate to view commissioners as purchasing from providers (which thye do) who in turn view patients as customers (which they are if there is a degree of choice). The roles of different players need to be understood within a system that is set up correctly which obviously links back to the reform agenda. The way that tariffs are set (i.e. according to case mix) is only a small part of the bigger issues of how the system is set up to function (commissioners, providers, patients and regulators).

cs
cs
2022 years ago

Privacy is the big barrier to outcome monitoring (apart from ‘customer complaints’), which invariably means that quality control depends on input monitoring, which undercuts the output-funding model. The long mooted ‘co-ordinated care’ model, which involved patents signing away their privacy rights (and budget control) is the only breach in this wall that I’m aware of, but I’ve lost a little contact with it.

Nicholas Gruen
2022 years ago

I can’t see where the privacy issue arises? I can’t see too grave a threat to privacy if independent quality control people have access to patient records (if you like with their consent). I’d certainly be consenting if it were me. Its another ‘team’ having knowledge of your case along with your doctor(s), nurse(s)and next door neighbour in the bed beside you.

Am I missing something?

cs
cs
2022 years ago

Privacy issues automatically arise in tracing the relationship between outputs from the health system and outcomes in terms of citizen health, i.e. in measuring health policy effectiveness. Believe it or not, most citizens don’t like being traced from this health service to the next, and then allowing the calculation of these interactions and their relationship with overall citizen health. In fact, there are laws against it. I’ve chaired a few national committees on ways of trying to break this impasse, without luck (apart for backing the co-ord care loop model). You need to get closer to the policy content to follow this.

Nicholas Gruen
2022 years ago

CS,

That doesn’t seem to me to be relevant to measuring the quality of a hospital’s clinical practice. The Doctors and nurses have the private information about the patient (and are bound by privacy obligations) and you can give the same information -(subject to the same privacy obligations) to some independent unit within the hosptital (or outside it) to measure quality control both in individual cases and more generally.

We seem to be talking about different things. Obviously system wide co-ordination can raise privacy issues, but I can’t see how they are raised when measuring the quality of clinical practice in a hospital. Having an independent quality control outfit pointing out that Dr Patel’s patients were suffering adverse events and turning up their toes at a surprising rate doesn’t raise any privacy concerns that I can think of. I guess if you think it does, you can ask people if they want proper quality control for their operation. Most will agree and those who don’t can’t complain.

cs
cs
2022 years ago

You can do all sorts of regulatory things, but they have nothing to do with output-funding, let alone outcome-management, the insensitivity of the former being the basic regulatory problem here (together with the impossibility of the latter, for reasons already explained), like it or not. You can regulate to monitor the outcome (effect) of every single output (cause) if you wish, and make specific regulatory recommendations accordingly, which is roughly sort of what used to be done in the days of investigating cause and effect by trial and error, prior to regulation by output funding (and royal commissions), which is designed to remove this sort of historical, evidence-based, professionally mediated word-of-mouth understanding and explanation (official or otherwise) level of regulation.

James Drysdale
James Drysdale
2022 years ago

The same sort of privacy issues exist in the UK but this doesn’t prevent hospitals from publishing aggregated outcome data devoid of patient identifiers. See below.

http://www.stgeorges.nhs.uk/press061.asp

From an outsiders view I’d have to agree with NG. Clearly as you say CS there are some issues to be resolved here (which seem quite nebulous). Fundamentally this case shows that there needs to be some degree of transparency in the monitoring of quality. Patients cannot continue to labour under the assumption that they will receive the same level of care wherever they go.