|Implemented in this survey?|
In May 2009, six months after a change of government, the incoming Minister of Health announced a revised set of health targets as an indication of key government priorities in health. The revised list reflects a shift in emphasis towards performance indicators focusing on hospitals and specialist care, and away from population health goals.
In August 2007, the Ministry of Health announced a list of ten headline national health targets. The purpose of the list was to give the Ministry and District Health Boards a sharper strategic focus. The original targets emphasised population health objectives, including increased immunisation rates, addressing risk factors for diabetes, and reducing tobacco-related harm. Other targets focused on service improvement (reducing cancer waiting times, improving elective services, improving adolescent oral health utilisation, diabetes services and mental health services) and reducing ambulatory sensitive hospitalisation. Six months after a change to a center-right government after November 2008 elections, the incoming Minister of Health published a revised list of six targets. Five of these targets focused on similar areas to the 2007 list (immunisation; elective surgery, cancer waiting times, smoking and diabetes services), although some had different performance indicators, and the diabetes target was expanded to cover cardiovascular services. A new target for shorter stays in emergency departments was added (Tenbensel, 2009), and five target areas were dropped (oral health, ambulatory sensitive hospitalisation, mental health, nutrition/physical activity/obesity, and a target relating to the Ministry of Health's proportion of health spending.
A significant feature of the health target revision is that it was directly undertaken by the Minister of Health, not the Ministry. The original list was formulated by the Ministry as a way of sharpening its strategic focus, and that of District Health Boards. The revised list indicates changes in the new government's priorities with a reduced emphasis on population health and a greater emphasis on politically salient hospital services and specialist waiting times. The performance indicators also reflect a shift towards measures that the Ministry and DHBs have more direct control over. For example, the smoking target has changed from increasing the proportion of 14-15 year olds who have never smoked, to better advice and support services for hospitalised smokers.
The Minister of Health has also linked the targets more closely to political and electoral accountability, claiming that the new targets "are more focused on the areas the public are more
concerned about" (Palmer, 2009). According to the Minister, the old target regarding ambulatory sensitive admissions was 'a very difficult concept' and the new emergency department target was easier
to understand (Palmer, 2009).
Finally, the removal of the target relating to risk factors of obesity and diabetes reflects the incoming government's approach to these issues, which emphasises a lesser role of government in managing and monitoring risk factors and health behaviours, and a greater emphasis on personal responsibility in obesity prevention. According to the new Minister of Health, "changing attitudes towards food and exercise require information and support rather than top-down government instruction" (Johnson, 2009). Within diabetes prevention policy, the focus has shifted away from nutrition and towards physical activity.
|Degree of Innovation||traditional||innovative|
|Degree of Controversy||consensual||highly controversial|
|Structural or Systemic Impact||marginal||fundamental|
|Public Visibility||very low||very high|
The refocusing of targets towards hospital services, and towards performance indicators that DHBs have more leverage over represents an incremental shift towards a tighter regime of performance management in these substantive areas of health policy. It is unlikely however, that this will translate into any significant systemic impact. While awareness of the targets is high amongst those working in the health sector, public visibility is very low.
|Implemented in this survey?|
The change of health policy targets have been welcomed by some health sector groups including the New Zealand Medical Association which commented that "the minister's expectations are more realistic and more focused" (Yeats, 2009). Other groups representing health providers, such as Primary Health Organisations New Zealand, support the new targets because it reduces their members' reporting requirements. The Association of Salaried Medical Specialists commented specifically on the elective surgery target, stating that it was "a laudable objective but it's going to be a challenge" (Palmer, 2009). Criticism has come from opposition political parties, and stakeholder groups particularly those groups concerned with the deleted target areas of obesity, diabetes and mental health.
|Minister of Health||very supportive||strongly opposed|
|New Zealand Medical Association||very supportive||strongly opposed|
|National Maori PHO Coalition||very supportive||strongly opposed|
|Primary Health Organisations New Zealand||very supportive||strongly opposed|
|Association of Salaried Medical Specialists||very supportive||strongly opposed|
|New Zealand Nurses Organisation||very supportive||strongly opposed|
|Public health groups||very supportive||strongly opposed|
|Mental health interests||very supportive||strongly opposed|
|Labour Party||very supportive||strongly opposed|
|Green Party||very supportive||strongly opposed|
|Minister of Health||very strong||none|
|New Zealand Medical Association||very strong||none|
|National Maori PHO Coalition||very strong||none|
|Primary Health Organisations New Zealand||very strong||none|
|Association of Salaried Medical Specialists||very strong||none|
|New Zealand Nurses Organisation||very strong||none|
|Public health groups||very strong||none|
|Mental health interests||very strong||none|
|Labour Party||very strong||none|
|Green Party||very strong||none|
DHB reporting on targets was based on the 2007 list of targets until March 2009. As some of the targets (e.g. immunisation) are similar or the same as the 2007 targets, they will be subject to ongoing monitoring.
The Ministry of Health has produced quarterly and annual reports on target performance. In general, DHB-level indicators of broader population health and prevention showed either marginal change or no improvement. As of March 2009, there had been no significant change in the immunisation coverage across the country.
However, there has been more movement on the targets that are more directly related to those services provided by DHBs. The 2007 elective services target, for instance, showed significant performance improvement. Performance regarding the target for reducing cancer waiting times has fluctuated and varied between parts of the country, with problems concentrated in the central region around Wellington. This most likely is a reflection of workforce shortages. Performance against the mental health targets has also varied widely, with urban DHBs meeting them, but many rural DHBs falling well short.
Overall, this pattern of performance indicates that DHBs have more leverage over service targets than those targets relating to public health and prevention.
Although the substance of the targets has changed, there are, as yet, no indications of a move to a 'hard target' regime associated with rewards and sanctions based on DHB and Ministry of Health performance. The Minister has hinted that more explicit rewards and sanctions may be applied, particularly around hospital related service targets, but as yet there is no move towards the English NHS style of target regime.
Progress against the three hospital-related targets will be closely monitored as meeting these targets is likely to become a key plank in the National Party's campaign for re-election in 2011. Each of these targets raises some implementation issues and challenges. Implications of the emergency department target have been canvassed in another report ( Tenbensel, 2009). The new target for elective surgery may run into workforce capacity problems (and must be seen in conjunction with the new policy allowing DHBs to engage in contracting out of elective surgery to private providers).
Apart from the immunisation target, the targets associated with health prevention are more focused on measuring service activities, and will be easier for DHBs to influence.
|Quality of Health Care Services||marginal||fundamental|
|Level of Equity||system less equitable||system more equitable|
|Cost Efficiency||very low||very high|
The revised set of targets is designed to focus DHB attention on increased access (to elective services and cancer services) and timeliness of care (emergency department waiting time) and as such are intended to increase quality. If quality encompasses timely access, then focused attention and achievement of targets may lead to improved quality. However, it is also possible that such focused attention may shift access problems to other parts of the health service such that the targets may have implications for quality elsewhere in the system. Success in meeting the elective services target will largely depend on workforce capacity. The effect on equity is difficult to predict, but one possible consequence is that patients who are harder to treat may be disadvantaged as DHBs concentrate on 'low hanging fruit' in order to meet targets. The broader funding environment suggests that hospitals will be asked to do more (in order to meet the targets) with little increased funding, but the targets themselves cannot be considered a direct intervention to improve cost-efficiency.
Process Stages: Policy Paper
Tim Tenbensel, CHSRP