In 2006, 12% of the New Zealand population was 65 years or older. By the late 2040s, this will double to 25%.1 It is well known that healthcare costs in the last year of life are up to six to 12 times more than for other years.2 In terms of healthcare expenditure, this means we’ll have more aged people with greater healthcare needs, whilst proportionally fewer younger people will be contributing to the economy.
New health technologies are also becoming increasingly expensive. These combined pressures are predicted to result in an increase in the proportion of GDP spent on healthcare by 50% (from 6.2% in 2002 to 9.2% in 2051).3
There will always be a treatment that may be expensive relative to its efficacy, but which could potentially extend the period of medical dependence or delay death. Whilst no-one wants to halt technological advances, it is inevitable that there will be complex conversations about when and where technology is best deployed, and how to prioritise access. Increasingly, doctors will face challenges about whether they are spending too much for too little gain, and this may leave them exposed to unhappy patients. A key part of the debate on allocating finite resources involves balancing the rights of an individual with the “common good” of the wider community. At present, particularly with a captive media, it is easy for an individual’s needs to gain ascendancy over the needs of wider society. We need to question this tendency to give the individual moral ascendancy in an environment of increasing resource constraint.
An unacceptable consequence of unconstrained health expectations could be the ability to perform more expensive interventions on fewer individuals. So with increasingly unaffordable technology and the baby boomer cohort approaching old age, how do we balance tensions between individual desires and the common good?
Doctors are trained to do the best for the patient “in front of us now”. However, this cannot be at the expense of the patient we have just seen, or those we are about to see. Although making decisions based on common good is difficult for individual doctors, we cannot side-step these issues. Where public resources are limited, the National Ethics Advisory Committee considers it a health professional’s responsibility to determine, on nationally consistent, fair, and open grounds, which patients should be given priority to services.4
MCNZ ethical principles also state that the care of the patient is the number one priority, with an obligation to provide the best standards of service possible, but within the resources available.5 To a certain extent, the law also assists doctors who have to make prioritisation decisions. In New Zealand, patients’ rights are enshrined in the HDC Code of Health and Disability Services Consumers’ Rights Regulation 1996 (the Code).6 While the Code protects certain rights, it does not guarantee access to healthcare. Clause 3 stipulates that providers will not be in breach of the Code if they have taken reasonable steps in the circumstances to give effect to the rights in the Code. Relevant circumstances include the provider’s resource constraints.
In New Zealand, healthcare spending is largely devolved to 23 District Health Boards (DHBs). Each DHB must provide care for the entire community on a population-based funding model. Inevitably, senior medical staff become involved in purchasing decisions, helping to allocate resources according to community health and disability needs. Demand frequently exceeds these resources, as attested by the column inches dedicated to community angst around access issues. Despite the requirement to complete health needs assessments in the New Zealand Public Health and Disability Act 2000, DHB health planning often lacks wide-ranging analyses of community healthcare needs in relation to specific interventions. So decisions on access to care can appear to be arbitrary.
There are, however, successful examples of DHB level needs assessment analysis processes. Nationally, the prioritisation of elective surgery, or Clinical Priority Assessment Criteria (CPAC) system, is a good example of a successful prioritisation process.
Developed to assess patients’ relative priority for surgery, it is designed to ensure those with the greatest need and ability to benefit are treated first. Patients are scored on a range of criteria and then ranked according to results.
The relative “value” of healthcare can also be compared using the Quality Adjusted Life Year (QALY). This unit measure weighs up the quality and quantity of life, following a procedure, against the actual cost. Although not a perfect outcome measure, when used in processes such as programme budgeting and marginal analysis, the use of QALYs and other such measures offers a structure and methodology around planning and funding decisions.
In the future, doctors will need to grapple with systems like these that aim to increase transparency in decision-making. As the effects of the changing demographic situation translates into an increase in numbers in consulting rooms, there will be many more patients with unmet expectations because of the issues around limited access to scarcer healthcare resources. As this demand for services rises, patients may increasingly see doctors as the “gatekeeper” to healthcare and we will have to give more thought to how these issues affect patient relationships. Communication with patients who have expectations about their healthcare will become a fundamental skill.
Conversations around managing expectations are already commonplace in elective surgery. However, the use of managers’ letters to explain why an elective surgical service is not available is testament to the fact that we find these conversations difficult.
This reluctance for face-to-face communication may stem from doctors’ fears of the risk of complaints from disgruntled patients over prioritisation decisions. Experience with the CPAC system suggests that patients will usually support a prioritisation system if they are informed about resources, believe thresholds are reasonable, and understand alternative care options.
It’s clear we need to improve the way we discuss issues and manage patient expectations around healthcare resources. If patients believe a doctor has denied them access to care, the likelihood of complaints will rise. Worse still, patients may lose trust in their practitioner and the wider healthcare system.
The author, Emma Westwood, is a freelance writer in New Zealand, and was speaking to Dr Denys Court and Dr Brendon Gray of MPS.
References
1. Statistics New Zealand, National Population Projections: 2006 (base) – 2061: Commentary.
2. Gray and Seshamani, Age, Proximity to Death and Future Demands on the National Health Service (2002). Presentation at HERC (Health Economics Research Centre) Conference.
3. Ministry of Health, Population Ageing and Health Expenditure: New Zealand 2002–2051, Wellington (2004).
4. National Ethics Advisory Committee.
5. Medical Council of New Zealand, Good Medical Practice: A Guide for Doctors (June 2008).
6. The Health and Disability Commissioner, The HDC Code of Health and Disability Services Consumers’ Rights Regulation, (July 1996).