Taming of the Queue

Ottawa March 2012

Public Accountability Processes

In New Zealand

Ray Naden

New Zealand

•4.5 Million people

•Universal Taxpayer-Funded Healthcare + Private

•Strong Social Welfare System

Health Care and the Law

in New Zealand

No legal right to health care

“Human Rights Act” - the right to be free from unlawful discrimination (eg, by age or disability)

Human Rights Commission

Procedural fairness matters.

Health and Disability Commissioner

New Zealand’s Code of Consumer’s Rights recognise that patients referred for specialist assessment or waiting for surgery are entitled to

reasonable care in

assessment/treatment

reasonable information about their

condition, whether and when they will

be seen, and options

Patients’ rights

What do patients want?

a reasonable level of service.

to know what is available to me

to know when I will receive treatment.

to be treated fairly.

New Zealand Government Policy

Fundamental Principles for Access to Publicly

Funded Elective Services (2000)

•Reasonable level of service

•Clarity

•Timeliness

•Fairness

Reasonable Level of Service

Significant targeted investment

- specific and more flexible

Overall increase in number of patients treated

Substantial increase in

- cataract replacement

- hip and knee replacement

- cardiac surgery

- other

Reasonable Level of Service

2007/08 118,000 discharges

2008/9 130,000 discharges

2009/10 138,000 discharges

Reasonable Level of Service

Current situation

- steady increase of 3% per year

Unintended consequences

- variable level of service between services -

- ? increased inequity of access

- volumes ahead of value

Clarity

Patients know whether or not and when they will

receive publicly funded elective assessment or

treatment.

•Acknowledgement of Request (ESPI 1)

•Prompt advice on whether they will be seen

within 6 months (ESPI 1)

•Certainty of the plan of care (ESPI 4)

- whether treatment is indicated

- whether treatment is available within 6 months

•Written Information to Patient and GP

Timeliness

Available services are provided within

specified timeframes

•Health Targets

•Elective Services Performance Indicators (ESPIs)

Emergency

Department

< 6 hours

Elective Services

Increased Numbers

Cancer

Treatment

< 4 weeks

Health Targets

Cancer - % of patients beginning radiotherapy within x weeks

2008 - 97% within 8 weeks, 65% within 4 weeks

2010 – 100% within 6 weeks

2012 – 100% within 4 weeks

Timeliness - Elective Services

Patients are advised within 10 days of receipt of request

for assessment (ESPI 1)

Where assessment is available, this is provided within 6

months. (ESPI 2)

Where treatment is available, this is provided within 6

months. (ESPI 5)

Available elective services are provided within

specified timeframes

Fairness

Prioritisation for access to treatment is based on

nationally-recognised criteria and processes

(ESPI 8)

Patients whose priority score is above the access threshold

are given certainty of treatment. (ESPI 3)

Patients are treated in order of priority (……)

Elective Services Performance Indicators ESPIs

Outcomes Measure

Goal

Expected

Actual result

for the DHB

this period

Status “Traffic Light”

standardised result

for comparison

& prioritising

Trend

“Traffic Light” - Getting worse

- Static

- Improving

Cross DHB Results: All Services 31/03/02

(All)

Level St Level St Level St Level St Level St Level St Level St Level St

DHB

Auckland DHB 1416 2% 239 8% 5 1% 535 4% 631 57% 62% 0.825259848 29% 0.293991416

Bay of Plenty DHB 3059 23% 100% 115 2% 14 1% 3104 66% 72% 0.962651411 0

Canterbury DHB 5793 15% 100% 5397 39% 236 2% 272 69% 70% 0.939146976 0

Capital and Coast DHB 3078 7% 100% 1 1% 462 5% 424 53% 71% 0.948867338 0

Counties Manukau DHB 6911 23% 100% 100% 100% 100% 75% 1.006197088 0

Hawkes Bay DHB 3024 24% 100% 491 8% 1156 #DIV/0! 319 63% 77% 1.023627418 0

Hutt DHB 1103 8% 100% 949 31% 571 24% 55 100% 76% 1.011101516 0

Lakes DHB 887 10% 100% 879 27% 26 1% 19 43% 80% 1.072435864 0

Midcentral DHB 2960 13% 100% 191 3% 390 7% 11 12% 76% 1.019919309 0

Nelson Marlborough DHB 2205 12% 489 20% 59 1% 312 7% 518 46% 79% 1.059266961 74% 0.741721854

Northland DHB 2179 16% 100% 83 1% 196 4% 1231 62% 65% 0.860363046 0

Otago DHB 746 3% 100% 100% 233 4% 316 67% 79% 1.059220772 0

South Canterbury DHB 185 2% 100% 100% 302 12% 12 63% 78% 1.036487149 0

Southland DHB 688 6% 953 44% 356 10% 71 3% 283 34% 2% 0.024478044 139% 1.394557823

Tairawhiti DHB 1052 17% 100% 1001 41% 116 #DIV/0! 2 1% 71% 0.945507252 0

Taranaki DHB 351 3% 239 8% 441 10% 147 4% 10 63% 81% 1.074255736 94% 0.944444444

Waikato DHB 2144 6% 324 #DIV/0! 233 2% 44 1% 173 4% 73% 0.975429737 11% 0.111773472

Wairarapa DHB 1143 23% 100% 5 1% 35 3% 5 1% 77% 1.028351369 0

Waitemata DHB 1507 5% 100% 156 2% 709 12% 253 100% 76% 1.009628968 0

West Coast DHB 639 13% 13 2% 77 5% 112 8% 33 58% 84% 1.11755474 63% 0.629032258

Whanganui DHB 293 3% 100% 118 3% 168 7% 56 82% 71% 0.948587075 0

41363 2257 10557 5835 7727

8 Prioritisation

Quality

As at: 31-Mar-02 Service: (All)

1 Referrals

acknowledged

2 Patients wait

FSA>6m: 31-Mar-

2002

3 Patients above

FST not offered

treatment

4 Patients waiting

without plan of

care

5 Patients waiting

>6m for treatment

6 Patients waiting

>6m for review

7 Percent contract

completion to plan

Within DHB - Surgical Services

31/03/02

Canterbury DHB

Level St Level St Level St Level St Level St Level St Level St Level St

Surgical Service

Cardiothoracic 0% 100% 5 1% 1 1% 100% 263% 3.500307395 0

Dental 0 1% 100% 100% 100% 100% 66% 0.874936898 0

ENT 394 9% 100% 1046 41% 31 1% 100% 72% 0.960498416 0

General Surgery 0% 0% 100% 100% 100% 67% 0.897247318

Gynaecology 581 26% 100% 100% ## 100% 66% 0.875316132 0

Neurosurgery 13 2% 0% 143 41% 2 1% 100% 72% 0.964850616

Ophthalmology 551 13% 100% 628 39% 12 1% 100% 79% 1.049087186 0

Orthopaedics 1243 41% 100% 1515 88% 100 6% 100% 61% 0.809931919 0

Paediatric Surgery 0 1% 100% 100% 100% 100%

#VALUE! 0

Plastics 140 5% 100% 598 57% 24 3% 100% 69% 0.919119117 0

Urology 288 19% 0% 424 35% 13 1% 100% 69% 0.920284248

Vascular 27 3% 0% 0% 0% 0%

#VALUE!

3237 0 4359 183 0

5 Patients

waiting >6m for

treatment

8 Prioritisation

Quality

6 Patients waiting

>6m for review

7 Percent

contract

completion to

plan

1 Referrals

acknowledged

2 Patients wait

FSA>6m: 31-Mar-

2002

3 Patients above

FST not offered

treatment

4 Patients waiting

without plan of

care

Canterbury DHB - period ending: 31-Mar-2002

Clarity - targets met

Timeliness - targets met

Fairness - targets met, but ?

New Investment

Prioritisation important

“There was no way we could invest in a system that was clearly not meeting the ethical guidelines set by the Medical Council and the Health and Disability Commissioner, let alone basic expectations of fairness.”

Hon Pete Hodgson

Minister of Health

Media Statement 2 October 2006

New Investment

$200 million into elective surgery

Phase 1 (2006) - goal to increase the number

of NZers who get elective surgery by 10,000

per annum.

Phase 2 requires acceptable prioritisation

and audit process.

“Prioritisation systems should be fair,

systematic, evidence-based and transparent.”

Health and Disability Commissioner 2006

Office of the Auditor-General

“There is also no certainty that the "right" patients are

always seen or treated in the appropriate order.”

“I encourage … focus on putting in place systems and

tools to make sure that the right patients get access to

services at the right time.”

http://www.oag.govt.nz/2011/scheduled-services

“Progress in delivering publicly funded

scheduled services to patients” - June 2011

The Media and Politicians

Processes of Public Accountability

Legal System (the Courts)

Human Rights Commission

Health and Disability Commissioner

Ministry of Health Performance Measures - Number of services provided - Elective Service Patient Flow Indicators (ESPIs) - Health Targets

Office of Auditor-General

Politicians

Media

Conclusions and Reflections

Explicit patient-oriented goals

Simple measures drive performance

Complex System

Conflicting priorities and pressures

Considerable progress….

? how to continue to improve

Valuing the patient as an individual

http://www.health.govt.nz

search on “elective services”

http://www.oag.govt.nz/2011/scheduled-services