New Zealand Rehabilitation Association, Inc.

I have recently finished a series of ‘regional workshops' for students undertaking a distance-taught paper on Rehabilitation Principles. In these regional workshops we discussed, among other things, the influence of health funding structures on the provision of rehabilitation. This is a topic that many health professionals would prefer not to think about - clinicians would just like to do the job of helping people get better after injury or illness and leave the squabbling over money up to the bean counters and policy makers.

Unfortunately, life (and clinical work) is not so simple. To state the blindingly obvious, simple matters such as whether someone's rehabilitation is covered by ACC or the Ministry of Health (MOH) has a significant impact the types of services that are available to them and the types of adaptive equipment they might be able to have. This inequity between ACC and MOH funding is complex and not fixed by simply throwing more money at the DHB providers. These two health systems are governed by significantly different public policies and have totally different income streams. Total expenditure on health care via the MOH system also is many times greater than that via ACC. Very broadly speaking - and don't quote me on this - MOH expenditure accounts for approximate 7% of NZ's Gross Domestic Product (GDP) while ACC accounts for approximately one and bit percent of GDP. So, if we were to plump up the funding for patients in the MOH system to match that available to those in the ACC system, New Zealanders would have to be happy with greater taxation for health expenditure (or perhaps with spending less on something else... road? education?).

Now personally, I tend to be socially leaning when it comes to taxation and think that the private insurance system of the US system provides a good example of what can go terribly wrong (certainly for older adults and people with chronic health conditions) when health funding is driven by a dogma of individual responsibility. However, all I point out here is that more money is perhaps not the answer to New Zealand's health funding inequities.

This leads on to the issue of making more of the health dollar that we have - getting more bang for your buck. A key solution here is introducing incentives in the health system to achieve better health outcomes for the money spent rather than merely funding clinicians to provide more services. Monitoring of key performance indicators in the health sector is one part of this. Of course, the effectiveness of this to improve the health status of the nation is only as good as performance targets that are set, and, on this note, the previous government's targets for the DHBs has recently come under fire from Minister of Health, Tony Ryall. Ryall has culled the total number of targets for the DHBs achieve from ten to six, arguing this on the grounds that: 1) too many performance targets is overly complicated - presumably the argument here is that this just ends up confusing the providers about priorities, and b) regardless of how worthy a health cause might be, a performance target that is difficult to influence or report on has no use as a means of influencing health provider behaviour. To this end, Ryall has scrapped DHB targets related to nutrition, obesity and physical activity.

This is clearly going be a controversial move from the perspective of the opposition government and some advocacy groups, but the one issue I would like to comment on is the nature of the remaining six performance targets. All of these remaining targets still emphasis service provision rather than health outcomes: shorter lengths of stay in Emergency Departments (ED), quicker access to elective surgery and cancer treatment, immunisation rates, screening for risk of heart disease and diabetes etc. It is assumed in this system however that the quick ED stay was effective, that the elective surgery and cancer treatment resolved the heath problem, and that the screening and assessment programme improve the wellness of the population as a whole. A hypothetical 83 year old Mrs Jones could be admitted to elective surgery for a total hip joint replacement, but if there is no funding for Mrs Jones to receive an extended period of post-surgery rehabilitation to address her frailty and falls risk at home, the surgery is of questionable value in the long term.  However, under the current system, the DHB can tick the box that surgery was provided - a job well done!  In fact, if Mrs Jones was to fall at home, break her new hip, and end up in ED, the DHB could then also record this as a new event, giving themselves another tick for how fast they can process Mrs Jones through to the hospital wards, and no doubt on to a rest home.

Rehabilitation suffers under funding systems that emphasis acute care service provision. Key performance indicators for DHBs should reflect improvements in functional outcomes rather than simply hospital throughput. Ultimately, what you pay for is what you get.