Derry Seddon: Impartial advice will solve puzzle of health service

Opinion

A Weekend Herald editorial headlined "The puzzle of how to spend health funds" looked at a serious subject in a light-hearted manner. But it still managed to pose the correct question: why are we not doing better with our healthcare system?

What is, indeed, puzzling is why we as a society have not learned and changed over time.

Looking at some of the blocks to change - sclerotic organisations, resistance, ignorance, belief in simple solutions, failure to measure, to list the main ones - can give us an understanding and lead to their removal.

What is also needed is the setting up of systems and organisations capable of, and insistent on, continuing change.

There has been a lot of work internationally on what provides the best healthcare system, having regard for equity, effectiveness and efficiency - the three qualities that need to be in balance (the New Zealand restructuring of the early 1990s focused on efficiency to the others' detriment].

In summary, a health service functions best when: all services are integrated; there is one funding source; it is regionalised, with flexibility and continual change actively encouraged; and information-gathering on performance and needs is continuous and public.

Health economist Alan Maynard said in 1990 that "it is curious that the debates about the design of healthcare systems worldwide are dominated by assertions and almost religious beliefs to the exclusion of construction of hypotheses and their testing by careful collection of data".

My experience in 1998 when put on the advisory committee for the waiting list project designed to be introduced that year confirmed Maynard's gloom. There was no built-in continuing evaluation of this radical and extensive change to our system of care.

I resigned in protest after the first committee meeting because I could not obtain agreement or recognition that this was unethical and a fault that must be corrected. Nothing was done.

Resistance to change is partly structural, as in our adversarial political system and the state organisations, along with the professional health care groups - the guilds. The absence of an organisation representing all consumers is especially significant.

The special-interest groups highlight areas of poor performance and need but overall needs and priority-setting lack a public forum, leaving the Ministry of Health struggling in this area.

Similarly there is no forum for economists, sociologists, technologists and others to contribute to the understanding of a continually changing and improving health service.

The medical professional organisations, including the medical schools, can be described as sclerotic. Other commentators are pointing out the need for them to change, not to another steady state but to become flexible, relevant and fitting the rapidly changing knowledge and technology of today's health sector.

Several of the blocks to change continue to exist because there has been no consistent and continuing effort to collect information on what is happening, what are the needs and what are the effects of changes to the system. Beliefs can be stated, firmly held and introduced; simple solutions are suggested for complex issues; and new services push aside those existing with no realisation of the consequences.

It is essential that the health service has a widespread public information system that allows for continuing evaluation of services and needs.

The editorial had some sympathy for any Minister of Health trying to improve our system and being the target of anger and frustration because of its failings, real or perceived.

The media play a part in reporting on the system but mainly this comes over as competing claims and counter-claims. We need to do better.

In 1988, an effort was made to establish an academy of medicine, an organisation that would be an open forum for all, suppliers and consumers, where options were debated and hence could supply broad-based advice to its members, the Government and the ministry.

It would be an organisation that could insist on, and commission, data-gathering and its analysis and encourage and measure new methods of healthcare delivery.

Such an organisation would provide the political parties and the Minister of Health with non-partisan advice and information.

There was no interest in the concept. The reaction was defensive and dismissive, typical of the response to any suggestion for changes. The lessons of the 1990s may now be sinking in, and this idea should be revisited.

It would go a considerable way to relieving all the puzzlement, while making the health service one that serves us better.

* Dr Derry Seddon, of Tauranga, is a retired GP and health services researcher.