I have finally managed to sit down and finish Gareth Morgan’s book, Health Cheque, on the New Zealand health care system (long international flights are at least good for something). I find most of Morgan’s books a little superficial for my tastes and Health Cheque is certainly no exception, lacking, as it does, any deep insight into the current problems of our struggling health system. Having said that, I certainly thought the first half of the book gave a reasonably good overview of the political history of the health system. The brief look at some of the underlying social and epidemiological problems was also worthwhile. The point about the link between the country having a First World income and having a First World healthcare is well made and seldom appreciated. I am not convinced about his point that aging GPs, who will retire at precisely the same moment that all those baby boomers need to access health care, will throw the country into a health crisis. It seems to me that Boomers already access plenty of health care resources and there is no reason to think this will get a great deal worse. On the contrary, Boomers tend to be extremely health conscious and are likely to be less of a burden on health than the previous generation – or the next one after them. In addition, the really resource-intensive “last year of life” tends to draw on hospital resources rather than GPs.
But this is a minor niggle. The real problem with Morgan’s analysis is that Morgan is an economist rather than a medical professional.
Do not mistake me here. I wholeheartedly agree with his horror at the fact that some of the DHBs are unable to provide the simple cost of a procedure. This is utterly unacceptable and sadly rife throughout the DHB system. I am all for making rational decisions about prioritisation of limited resources and this financial ineptitude makes such prioritisation practically impossible. However, I am unimpressed with his using the dreadful QALY (Quality adjusted Life Year) to prioritise resources. A QALY is a measure of the amount and quality of life regained by a procedure.
Morgan is keen to use QALYs because it monetarises the benefit gained by a procedure. He is clearly happier in the world of dollar figures. Unfortunately, QALYs were originally intended to provide an objective measure for comparing two “like” procedures attempting to achieve the same outcome. For instance, QALYs are quite useful for comparing the outcomes of two different hip replacement procedures or whether, after a broken hip, a replacement provides a better set of outcomes than a simple internal fixation (plate and screw). Where QALYs die a horrible death is when they are used to compare two dissimilar procedures with a differing set of outcomes. There is simply no way that you can compare a stomach stapling operation to a course of chemotherapy. Although it may look like the QALY is putting dollar figures to the procedures and allowing such a comparison, the underlying assumptions behind how the QALYs are created are vastly different in each circumstance. It is not merely comparing apples and oranges – at least they are both fruit – it is more like comparing aardvarks and spark plugs – you might be able to place dollar values on each, but a spark plug does little towards keeping down the ant population and your car would not do well with an aardvark instead of a spark plug.
Morgan unintentionally illustrates this nicely in Health Cheque. He berates National, and John Key in particular, for “compromising” Pharmac with their pledge to fund a full year of the chemotherapeutic drug Herceptin, used to treat breast cancer. Laying aside the fact that he completely fails to understand the reason why health professionals (not simply politicians) challenged Pharmac’s position – Pharmac based their suggested 8 week course on a subset of a single study, ignoring the vast weight of literature on the year-long course – Morgan suggests that the price of $100,000 per QALY was too steep. The very next page, he is justifying the treatment of haemophiliacs at a cost of $75,000 to $130,000 per QALY, apparently on the basis that this is a congenital disease and is not their fault (Breast cancer is the woman’s fault????). The QALY argument being used here is merely a proxy for making a value judgment of whether a extra year of life for a 16 year old haemophiliac is worth more than than an extra year of life for a 25 year old mother with three children below the age of 6. Clearly, this is not a value judgement than can be made by anyone – let alone an economist!
Morgan’s love of hard numbers crops up again when he praises the CPAC (Clinical Priority Access Criteria) system – the infamous “points” system that determines whether you can access a specialist appointment or a procedure. Unfortunately, he appears to fail to realise that the system is inconsistent and very subjective and, worst of all, entirely driven by funding decisions rather than genuine clinical need. It is CPAC that ensures that the waiting list is no longer than 6 months – by refusing access to all but the sickest people, despite the fact that this hides the extent of the need and is an exceedingly inefficient way of allocating resources. Waiting until a patient is critically ill instead of attending to his/her disease process at an early stage is not only dubious ethically but is massively wasteful of resources – late operations cost many times the amount of early interventions.
Health planning requires hard data. Morgan is bang on the money when he says:
The big problem is that the quality of reporting in our health system is still pretty poor, yet this is an essential starting point for a more mature, depoliticised debate about healthcare in New Zealand.
There are many ways we can improve that situation such as better, more robust IT systems; proper dedicated data capturers (as opposed to disinterested nurses and doctors); the simplification of administrative tasks to avoid duplication of data and data corruption. But in the process of making rational decisions about our healthcare, we should not overlook that these are real people we are dealing with, not abstract numbers. While we may have good reason for preferring to fund another couple of angioplasties rather than Mrs. T’s hip replacement, we should always bear in mind that we have condemned Mrs. T to another pain-filled year of immobility and possibly a fall and broken hip. We might even be condemning her to death. No amount of rational argument should be allowed to obscure this fact.