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Performance dimensions for a reformed health care system

Criticism Number 7

It is important to accurately define the things you are talking about, particularly the goals or objectives - what Samuel calls "performance dimensions". Samuel uses words, which only distort the health care situation and his arguments are consequently not based on a context, which is real.

Performance dimensions

Samuel sets out a number of "performance dimensions" for his model. There is nothing wrong with the goals or criteria by which the model is to be measured, but there are problems in the way some are defined. This may result in distorted arguments, in misapplication and in dysfunction.

When the track record of the market and of government process are examined there must be considerable doubt that a health care market system could attain the desired objectives.

Access: - In Australia the prime concern about access relates to the bush and to aboriginal communities. Here local culture is based on cooperation and on interpersonal relationships. Not only are there cultural problems but problems of distance, community size, and communication. Distance makes strict oversight impractical. Systems developed locally and supported by a wider integrated service would be more appropriate. Samuel's competitive proposal is not congruent with community perspectives. Many developing countries have similar problems.

In urban communities the main problem of access for basic care is the failure to fund the public hospital system and to attract health care professionals. It would be cheaper to fund this system and restructure it to meet the community's objectives than to squander money on a complicated competitive system and profits for shareholders.

CLICK HERE -- for more about providing services to the bush.

Equity: - In the US marketplace there is gross inequity and vast numbers are denied care. Horror stories abound. The market targets those who have money and has little interest in philanthropy. Samuel plans to overcome this problem by using contracts based on market forces. Contracts are not a substitute for a commitment to human values. My personal experience is that contracts for providing care are regularly abused. The US experience reveals the same patterns of misuse.

CLICK HERE -- for more about the problems of equity, the market and contracts

Efficiency:- Samuel describes technical, allocative and dynamic efficiency and this is clearly one of the major objectives of his model. Cost effectiveness and efficiency are clearly desirable.

Of concern is the way in which health care corporations have used the rhetoric of efficiency to justify denying care, the disruption of the working environment and the provision of substandard care. The pressures generated by competitive market pressures encourage this sort of rationalisation.

Equally worrying has been the imposition of efficiency by the boardroom, without regard to the individuality and particular problems of patient care. The corporate model of efficiency is very different to that which is required in health and aged care.

CLICK HERE -- to explore the issue of efficiency in health care.

Samuel again misdefines his three types of efficiency in Macmedicine terms. He talks of costs, what people value highly and demand. He is promoting a system for the allocation of scarce resources and the taxpayer is footing the bill. By his emphasis on what the community values and what it demands he skews the whole debate. Corporate marketing for the benefit of shareholders readily generates valued services and demand. We are talking about "need", something measurable and defined. This is threatening to corporate interests as it restricts what they consider "legitimate business opportunities". The model falls down because it misspecifies what publicly funded health care is all about.

CLICK HERE -- for more about the market, valued products and demand

Quality: - Presumably Samuel is referring to care rather than economic performance when he talks about quality. There is nothing wrong with aspiring towards high quality care. It is an "idea" which we all understand. Samuel follows corporate practice in referring to "objectives for service quality". Here its use is more problematical. Presumably if he has an objective then it is something which can be measured else there is no way of evaluating the effectiveness of his model and its attainment of that objective. If this were so then it would be better to use the correct words "standard" or "criteria" instead of "quality". These words require the defining of more exact specifications before proceeding. Health care is as far as possible a scientific discipline and accuracy is desirable.

It is also better to use the word "care" rather than "services". Care has a precise meaning understood by the community and by all of the health care professions. Using the word "services" distorts the discussion and the arguments by placing the physical health and mental well being of the community in the same paradigm as our plumbing and electricity.

In the health care marketplace the word quality and all the associative meanings that accompany it have been misused for corporate purposes. Quality care has very different meanings in the boardroom, in marketing and in the hospital bed. A lot of confusion, misrepresentation and misery might have been avoided by the use of more clearly defined words. Experience in the market shows that there can be little confidence that acceptable standards are being met when this service is provided by corporations in a competitive marketplace and monitored by government organisations. However poor their standards corporations all claim to provide "quality care".

CLICK HERE -- for information about the way the marketplace has misused quality and the way in which regulatory bodies have failed to address "quality" issues.

Accountability: - Accountability is clearly a desirable goal. The problem is that in the health care marketplace it is extremely difficult to implement. Health care corporations have not held their managers accountable for anything other than profit. Those responsible for holding corporations accountable to the community have failed to do so. Instead this buzzword has replaced social responsibility and social control by the community.

Samuel makes it difficult to enforce accountability in his model by holding people responsible for quality of services rather than standards of care. Furthermore the people who are to be held accountable are the managers. This who have identified with practices which bribed and coerced doctors into misusing and defrauding their patients in order to increase profits. A brave new world!

CLICK HERE -- for information describing what managers were held accountable for and how bodies accountability to citizens failed them.

CLICK HERE -- to proceed to the next criticism - Number 8

CLICK HERE -- to proceed to the next section of Samuel's speech

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This page created April 2000 by Michael Wynne