System Failure

By Jim McVeagh 11/05/2010 1

When a serious error is made in someone’s diagnosis, investigation or treatment, we really like to blame a health practitioner or two. In the Herald today, just such a diagnostic disaster is blamed on the DHB as Ron Paterson asks them to apologise for poor service. This is pretty unfair of Mr. Paterson as it is clear from this unfortunate young lady’s story that the problem is much deeper than faulty DHB systems.

The patient, a woman in her mid-20s referred to in the report as Mrs A, suffered pain and hearing loss in her right ear in 2005.

She was referred to an ear, nose and throat specialist but was not seen due to her “routine priority”.

When her symptoms worsened in late 2006, a “semi-urgent” MRI brain scan was recommended.

However, in May 2007, a board radiologist advised her she did not qualify for an MRI.

“Although your referral was wait-listed for a publicly funded examination, it is now apparent that the demand for more urgent examinations means that in effect your requested examination will not get done,” the radiologist said.

Almost 18 months later, when Mrs A suffered balance problems — including a number of falls and a tendency to drift to the right — she was referred for an urgent scan.

The MRI revealed a 4cm slow-growing benign tumour.

Now I’m betting most people would like to blame the hapless radiologist for this. But he was simply following protocol.

Some might try to blame the GP for not being more forceful or urgent in his referrals. But the GP can only write down the things that he finds. Routine exaggeration of patient’s symptoms quickly gets picked up by the hospital resulting in a potential “cry wolf” dilemma as the hospital assumes the GP is exaggerating.

Mr Paterson blames the DHB for this. But they are working within the financial constraints they have. If the government has paid for 2000 MRI scans, they can’t go ahead and do 2500.

Some may try to blame Tony Ryall and National for not providing sufficient funding. But the government also has to work within some sort of financial constraint. The bulk of new money in the budget seems to be heading into the health system – and it is still not enough.

The real problem here, the elephant in the room as it were, is that state provision of health will always suffer system wide failures like this because it is state health. Ron Paterson dimly senses this when he talks about service provision being determined “by post code”. This is partially an artifact from Labour’s formation of DHB’s with semi-autonomous powers to determine their own priorities. Restricted budgets are reallocated to different areas according to the priorities of the board members in each DHB. Consequently, a patient in Hamilton may wait three times longer for a effort ECG (Treadmill test) than the same patient would wait in Auckland. Clearly MRIs are in short supply in Nelson but a man with a prostate problem will wait only half as long for a urology appointment.

All of these are but symptoms of rationing.

Access to health care is determine primarily by money. Health care is an expensive thing to provide. Had this young lady had medical insurance or independent means, she would have had an ENT consult within one or two weeks, an MRI the following week and an operation the week after that. Her hearing might have been preserved and the operation would certainly have been less extensive. But the state is unable to provide a service at this level simply because, while people are willing to spend large amounts of money on their own, or their family’s, health, they are less willing to do so for strangers via taxation. Worse, the state has no idea about individual needs, only the average need of a population. Consequently, even with large increases in expenditure, the state will inevitably purchase too few services in certain areas and too many in others. People like Mrs. A will still fall through the gaps.

Perhaps the most pervasive problem in a resource-contrained system is that of dismissiveness. Referrals for investigations of minor symptoms are actively discouraged to free up resources for those with major, alarming symptoms. Unfortunately, this dismissal of minor symptoms is not an acceptable clinical method. Just because 99% of people with such symptoms have trivial problems does not means that we do not have an ethical obligation to ensure that the patient is not exhibiting early symptoms of something serious. Even if we cannot perform extensive diagnostic tests at the drop of a hat, we should be able to react quickly at any alarming sign of progression, even if the progression is from minor to somewhat less minor symptoms. Sadly, the overall approach in state medicine is to dismiss all minor symptoms until the become major ones. The inevitable consequence of this is that the cost of fixing the problem increases exponentially, both in dollar terms and in terms of trauma to the patient and reduced treatment success rates.

State health systems fail individuals precisely because they are state health systems.


Related posts:

  1. Dying to Get In
  2. A Question of Dying
  3. Lying on Wait

One Response to “System Failure”

  • Private systems fail too, just for different reasons. (Before you say money directed at those without would fix this, isn’t that the essence of a state system?!)

    As all systems fail, really, wouldn’t the relevant question be not spotting individual cases of failure but asking which does better overall?

    (I’m not saying it’s not worthy to point out cases of failure that might be looked at how to improve a system.)