As part of its election campaign health policy, the National party promised to “restore” the health targets.
These targets were a set of national performance measures, in place from July 2007 to June 30, 2020, designed to improve health services' performance (often called productivity).
They were superseded under the last Labour government by health indicators.
In order for targets to succeed, two initial baselines are required.
First, they must make good clinical sense. This requires their development to be clinically led by those with the relevant expertise. Second, they should lead to systems improvement rather than be confined to a specific clinical or diagnostic service.
Qualifiers
But even if these two baselines are met, four significant qualifiers exist.
First, targets can only apply to what can be counted, whereas much of medical treatment can’t be counted for meaningful systems improvement purposes.
This is only a relatively small part of what public hospitals do. Excluded, for example, were acute (not planned) surgery, mental health, and much of inpatient and outpatient care, including ongoing care for chronic illnesses.
General practice is fundamental to our health system but is also excluded.
Consequently, targets can’t realistically measure health or hospital system performance or productivity. When, for example, acute patient demand increases (as it has been), planned (elective) surgery decreases as a consequence.
This does not mean that performance or productivity has declined.
Second, depending on how targets are managed (monitoring management), they can incentivise perverse ‘gaming’ of the system to meet the target through coding or focusing too much on less complex and quicker surgical procedures, such as cataracts, at the expense of more complex and therefore slower procedures.
Third, their achievability depends on workforce capacity. Increasing shortages since the late 2000s would seriously hinder meeting the targets.
Fourth, achieving hospital-based targets would be made much more difficult if there was an increasing rate of acute patient demand, leading to bed shortages and a slowdown of non-acute surgery.
If combined with increasing workforce shortages, target achievement would be trapped in a tightening vice.
Targets backstory
Targets began when Labour’s Pete Hodgson was health minister, focusing on elective surgery access. However, National’s Tony Ryall significantly expanded these to six when he assumed the portfolio in late 2008.
Three of these targets were useful but not necessarily system improvements – better help for smokers to quit, more heart and diabetes checks, and raising healthy kids.
They did contribute to better outcomes, but it was difficult to differentiate between these specific targets and other measures.
Another target – increased immunisations – was successful as an illness prevention measure. However, achieving this has become a greater challenge because of increased activism arising out of the covid-19 response by the small but strident anti-vaccination movement.
The other three targets are the ones that attract the most prominence and controversy. One is improved access to planned (elective) treatment, mainly surgery.
The objective was that, following a general practitioner referral to a public hospital and the consequential first specialist assessment, a patient would be put on a waiting list to be treated within four months.
Another was faster cancer treatment. That is, 90% of patients who are graded with a high suspicion of cancer should first be seen within 14 days. Then, subject to diagnosis, they should have their treatment within 62 days of receipt of their referral.
Finally, there were shorter stays in emergency departments. This is often called the six-hour target. That is, 95% of patients should be either discharged or admitted into the main hospital within six hours.
The experience of the last three targets, in particular, was mixed. The objectives were good, and some outcomes were positive. Of the three, the six-hour target was the most significant in terms of systems improvement.
There was a high level of emergency medicine clinical leadership in its design.
Further, it was not just about what happened in emergency departments. It required a hospital-wide response because the key challenge was not patients who could be discharged but rather those requiring hospital admission. This meant that bed-blocking had to be addressed.
Unfortunately, there was perverse gaming. The then-National-led government erred in hyping up the targets by asserting that they were a measure of productivity improvement.
This monitoring narrative increasingly incentivised gaming within district health boards (managerially rather than clinically driven) in order to appear to meet the target.
This was compounded by the impact on public hospitals trapped in the vice of (a) acute demand rising at a greater rate than population growth and (b) increasing and entrenched workforce shortages.
These hospital-based targets could not be met because the workforce's capacity to achieve them was increasingly compromised by this tightening vice.
When the Labour-led coalition government took office in 2017, it was accused of abandoning targets. Not so. Health minister David Clark continued with them but ceased the misleading productivity narrative.
This was the right response, but the messaging was poor, thereby reinforcing the accusation.
From targets to indicators
The new government did, however, start work on developing ‘health indicators’ as an alternative to the targets. In principle, this was a positive move.
There are now 12 health indicators that are designed to be neither carrot nor stick (some are still in development). They are:
- Percentage of children who have all their age-appropriate schedule vaccinations by two years.
- Ambulatory (outpatient) sensitive hospitalisations for children under five (rate of hospital admissions for children for an illness that might have been prevented or better managed in the community).
- Percentage of under-25-year-olds able to access specialist mental health services within three weeks of referral.
- Access to primary mental health and addiction services.
- Ambulatory (outpatient) sensitive hospitalisations for adults aged 45 to 64 (rate of hospital admissions for an illness that might have been prevented or better managed in the community).
- Participation in the National Bowel Screening Programme.
- Acute hospital bed-day rate (number of days spent in hospital for unplanned care, including emergencies).
- Access to planned care (people who had surgery or care that was planned in advance, as a percentage of the agreed number of events in the delivery plan).
- Percentage of people who say they can get primary care from a general practitioner or nurse when they need it.
- Percentage of people who say they felt involved in their own care and treatment with their GP or nurse.
- Annual surplus or deficit at financial year end (net surplus or deficit as a percentage of total revenue).
- The variance between planned budget and year-end actuals (budget versus actuals variance as a percentage of budget).
The first 10 of these indicators are a big improvement on the former targets. Their scope is wider, including going beyond what can be counted.
However, there are glaring omissions – addressing workforce shortages and enhancing health professional engagement – where most expertise for systems improvement resides.
Further, accessing cancer treatment is inexplicably omitted.
Unfortunately, the robustness of the indicators is undermined by the final two. These are about the quality and management of funding.
They are as much about government accountability as anything else. Furthermore, nationally aggregated data under the centralised health restructuring makes them meaningless as an indicator.
National’s health targets
National’s election manifesto declared there would be five major health targets:
- Shorter stays in the emergency department (the six-hour target).
- Faster cancer treatment – 85% of patients to receive cancer management within 31 days of the decision to treat.
- Improved immunisation – 95% of two-year-olds receiving their full age-appropriate immunisations.
- Shorter wait times for first specialist assessment – a meaningful reduction in the number of people waiting more than four months to see a specialist.
- Shorter wait times for surgery – a meaningful reduction in the number of people waiting more than four months for surgery.
The laudability of these objectives is not in doubt. But, learning from the experience of National’s previous targets, their utility rests and falls on the workforce capacity and the monitoring narrative.
As new health minister Shane Reti contemplates this, he would do well to consider blending them in with the first 10 existing health indicators.
He might also wish to consider changing the name ‘targets’ to ‘indicators’ because, in reality, that is actually what they are.
