Facing what became an agonizing end to his life, 61-year-old Andrew McMillan and his wife, Jeanette, wished they’d screened for bowel cancer earlier, Stuff’s Cate Broughton reported.
Like many others, I understand. Truly. My wife died. 39. Breast cancer.
With any cancer, finding it early can dramatically improve health outcomes. And reduce the anguish and devastating emotional and economic distress affecting countless families every day.
Jeanette McMillan spoke about her husband’s death in the hope that it might help others. If more people screen for the disease, it should.
But the story revealed something more. Something that goes to the heart of New Zealand’s health system, like many other countries’, and public administration generally.
I don’t know what lies behind Health Minister David Clark’s decision to scrap national health targets, or what will replace them, but the question remains: Is New Zealand’s health system focused on medical processes, or better health outcomes for New Zealanders? Similar questions apply elsewhere. The McMillans’ tragic story offers clues.
Small steps, slowly
For bowel cancer, a $60 self-testing kit is available from drugstores (known as pharmacies in New Zealand), and a free screening program has started.
After cancer groups lobbied for more than a decade, four (of 20) district health boards began implementing a national bowel cancer screening program for people aged 60-74. With other health boards not scheduled to follow suit until late 2021, “national” may be a misnomer, but the delay might be understandable. It takes time to roll out nationwide programs.
In the meantime, Bowel Cancer NZ encourages everyone over 50 to use the testing kits. They report that overseas studies show the test helps reduce bowel cancer deaths by 15-33 percent. Given New Zealand’s high cancer rates, this suggests a big opportunity for significant health benefits.
No support for early diagnosis?
But Broughton reported that the Ministry of Health doesn’t endorse the kits. Apparently not for any concerns about accuracy. They have a proven record in Australia for over 10 years, according to Bowel Cancer NZ.
What caught my attention was the apparent rationale for not supporting a simple test to help boost early cancer detection. The health ministry was reportedly worried about the “impact on demand for diagnostic services”. A university medicine professor echoed the official narrative, expressing concern that the kits “could increase demand for colonoscopy services and overwhelm the system”.
Ministry’s systems focus ‘deeply disturbing’
From an outcomes perspective (in terms of health outcomes and policy effectiveness), the expression of such fears is deeply disturbing. It suggests a focus on processes within the health system potentially conflicting with core objectives of that system.
This can be illustrated graphically (below). The primary objective of district health boards, enshrined in legislation, is to improve, promote and protect New Zealanders’ health. This objective, and its corresponding intended outcome, is represented by the dark blue boxes.
A series of inputs (resources such as budget, staff, facilities), activities (processes used to transform inputs into outputs, such as planning and accountability systems) and outputs (services produced, such as diagnostic tests and operations) are designed to help achieve intended better health outcomes.
But the final stage, achieving intended outcomes, doesn’t work in the same way as earlier components. Within the system (the green boxes), inputs flow inexorably to outputs, within managers’ control. However, while meeting output targets may be a necessary precursor for, it doesn’t necessarily lead to, intended outcomes.
So-called “external influences” (such as accidents, or patients not taking their medication) also influence health outcomes. More importantly, in the present context, the greater the intensity of focus on inputs, activities and outputs, the more that intended outcomes may be adversely affected.
That is why having targets is not enough. They must be the right targets. To be effective, they should more strongly connect with better health outcomes.
If mere ‘activity’ and ‘output’ measures, the targets themselves can perversely affect intended health outcomes.
‘Outputs’ focus blunts capacity to achieve better health outcomes
The concern expressed by those within the system is legitimate. Unplanned demand for diagnostic services would put pressure on the system.
But the concern also chillingly signals awareness or expectation of significant numbers of undiagnosed cancers. If they remain undiagnosed, the system will cope. But many people will die.
In other words, a focus on outputs that ostensibly ‘should’ or ‘might’ lead towards better outcomes, rather than a focus on outcomes themselves, ironically, and tragically, may result in worse outcomes.
Moreover, the health system is remarkably resilient. If more people are diagnosed, the system may well struggle to cope, as experts predict, but presumably some additional lives would be saved. And the increased pressure feared by bureaucrats might itself help prompt additional resources, thereby saving even more lives.
It is of course not possible to make any firm assessment about prospective outcomes in a brief article, particularly based on media reports. Nor do I criticize the health experts. Their responses may have been more nuanced than reported. It is also safe to assume that they are dedicated, committed professionals. They want the best outcomes for patients.
But a concern that increased demand for diagnostic and treatment services would overwhelm the system illustrates a health system focused on inputs, activities and outputs, not necessarily a system focused on better health outcomes.
The question then subtly shifts. How can we have a health system focused on activities and outputs, if health professionals genuinely want something subtly but critically different (better health outcomes), and the system’s primary objective is expressly intended to improve, promote and protect people’s health?
Misplaced signals when outputs obscure a clear view towards outcomes
It is not possible to diagnose potential systemic failings of an entire health system here. But New Zealand’s (now, former) national health targets (with no replacement, yet) offer clues.
Shorter stays in emergency departments (95% of patient admissions resolved within 6 hours), faster cancer treatment (90% of patients treated within 62 days), etc, were laudable goals. But they are efficiency targets. They address the efficient management of inputs, activities and outputs. If these are metrics by which health boards are judged, it is understandable that bureaucrats might focus likewise. But, absent strong connections with intended outcomes, meeting the targets prove efficiency, not necessarily effectiveness in the sense of better health outcomes for New Zealanders.
For example, faster cancer treatment times can improve health outcomes, but interposing an additional consultation “improves the metrics” without affecting outcomes.
Likewise, more elective surgeries can improve health outcomes, but thousands of eye injections measured against surgical targets masked fewer surgeries with greater impact, and health outcomes may fall even as “the numbers” looked good.
The list of examples is virtually endless. They are common in all activity and output-oriented target systems. Others may be found in education, housing, anti-crime initiatives, and elsewhere.
Administrative focus on efficiency objectives harks back to so-called “new public management” (NPM) which dominated public services administration since the 1980s. Tellingly, however, as one academic observed, NPM performance metrics often “measure ‘outputs’ rather than ‘outcomes’, what the organisation does, rather than what, if anything, it achieves”.
Recognizing those issues, contemporary public administration in many countries has started to refocus from efficiency towards effectiveness, and from outputs towards outcomes. The world has moved on. Perhaps New Zealand’s health system didn’t get the memo.
Or, by scrapping the former targets, the minister may have delivered it. But it’s too early to tell, because his inelegant delivery method offered little explanation or replacement. (Nor, by early March 2020, has he delivered new targets). He did, however, say that many of the health targets measured only activities. That is at least consistent with the prospect of a modern outcomes-oriented focus on policy effectiveness; in this case, better health outcomes.
But the real policy effectiveness test lies in the new targets. If they replace inherently sub-optimal metrics with another simplistic easy-to-measure set of activity and output measures, New Zealanders may need to wait another few decades (again) for the health outcome-oriented professionalism of medical staff to be matched by those in the policymaking realm.
In the meantime, it is timely to conclude with a reminder that a genuine outcomes focus, unlike health industry siloed activity measures, can deliver benefits beyond the health sector. With fewer deaths, and less anguish permeating families, it could also mean improved social and economic outcomes for communities. Presumably what Andrew McMillan would have wanted. And, maybe, what the minister intends.
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Originally published at https://www.stuff.co.nz on 28 June 2018, modified.