Health targets good politics, not always good policy

The National Party has made health policy a key plank of its 2023 election campaign. Front and centre of this pitch is the promise to reintroduce health targets, such as stipulating that 95 percent of emergency department patients are seen, treated or discharged within six hours. The stated purpose of health targets is to “focus the health system on improving health outcomes in five priority health areas”.

Three of the five targets – shorter stays in Emergency Departments, improved child immunisation, and faster cancer treatment – reprise those that Tony Ryall introduced in 2009, then as Minister of Health. District Health Boards were required to report quarterly on target achievement, performance was widely reported in the media, and those that fell short of target expectations braced themselves for the dreaded ministerial phone call.

Ryall’s targets were great politics. By being precise and specific, they enabled the Key government to demonstrate the delivery of key commitments. But are health targets good policy? What happened when they were implemented, and did they deliver better health outcomes?

Unlike many other proposed health policy initiatives in this election, it is easier to answer these questions because of the research carried out over the past decade. The answers are decidedly mixed. And it depends on the targets being met.

Let’s start with the positive. The child immunisation target was highly successful in lifting immunisation rates for two-year-olds in the early 2010s. The target meant that immunisation co-ordinators working for DHBs and Primary Health Organisations were proactive in identifying toddlers that had yet to be immunised, and bolstered their outreach services. This strengthened New Zealand’s herd immunity against measles, mumps and rubella. The child immunisation target also significantly reduced inequities of access to immunisation between Māori and non-Māori.

In the current environment, achieving the child immunisation target will be more challenging because of the Covid-induced backwash of increased vaccine hesitancy. National knows this, so has added a bit of salt in the form of immunisation incentive payments for GPs.

As for the Emergency Departments target, in the first year or two after Ryall introduced the targets, hospital clinicians and managers made many improvements to the flow of patients within the hospital. University of Auckland researchers estimated this saved about 700 lives in a year, a claim frequently reiterated by National’s health spokesperson, Dr Shane Reti.

However, the Shorter Stays in Emergency Departments research also showed that after one or two years, most hospitals were unable to make further process improvements, which was when clinicians and managers started gaming the target.

As our research, Gaming New Zealand’s Emergency Department Target, found they moved patients from the Emergency Departments to short-stay wards, often with the sole intention of not breaching the six-hour wait time.

Staff in multiple hospitals falsely recorded the times patients left the Emergency Department with one hospital’s management artificially inflating their hospital’s reported performance by including patients that were never seen in the Emergency Department in their figures. For Emergency Department patients that really were waiting to be admitted to wards, total waiting times (rather than reported waiting times) crept back up to pre-target levels after the first 18 months of their implementation.

This gaming behaviour points to a much deeper problem. The key driver of Emergency Department crowding is the inability to move patients to inpatient wards because of a lack of free beds.

This ‘access block’ is largely because there is often nowhere to go for inpatients who no longer need intensive treatment – they can’t return home because they need a high level of care, but there aren’t enough aged residential care places available, which is consequent to wide range of factors including the evolution of aged-residential facilities’ business models, chronic workforce shortages, and low rates of pay for those working in residential care.

This is a classic example of a highly complex system in which there are wide-ranging dependencies between health and other services. Most of the factors causing Emergency Department crowding lie well outside the walls of hospitals and afflict health systems in most high-income countries. Likewise, similar practices of ‘hitting the target and missing the point’ have been seen in other countries that have introduced such targets.

If the National Party leads the next government and reintroduces health targets, the pertinent question is not whether the targets will be met, but whether the figures can be trusted. The information on Emergency Department target achievements in the 2010s that appears in National’s policy platform can’t be taken at face value.

If targets were to be reintroduced, gaming the system could be reduced by setting up independent systems of verification, rather than relying on self-reported figures by hospitals. This would also mean employing more ‘bureaucrats’ and would fuel a culture of distrust between managers and frontline staff.

Overall, the mix of positive and negative consequences of targets really depends on the specifics of each target. The child immunisation target can’t be gamed so easily – reported levels of achievement have been more trustworthy. But the complex interdependencies, the increased pressure on frontline staff, and the likelihood of gaming is higher for the other targets of cancer waiting times, shorter wait times for first specialist assessment, and shorter wait times for surgery.

In a highly complex health sector, using targets to address wait times is like using steroids to treat a patient with eczema. The initial hit is highly effective, but the adverse effects manifest later, while the patient (ie government) becomes dependent on the increasingly artificial high that only masks the chronic condition.

Regarding National’s claims that targets will improve health outcomes, much depends on what they actually mean by these words. Improving health outcomes could mean saving lives and reducing the burden of disease and ill-health, which would be challenging to demonstrate because the research that would be needed is very costly and time-consuming.

However, if National interprets health outcomes as shorter waiting times and increased rates of immunisation then, by definition, they will succeed. That impeccable circular logic is what makes health targets such good politics, even though they are not always good policy.