Health reform lacks objective assessment

Hey there, time traveller!
This article was published 13/11/2017 (369 days ago), so information in it may no longer be current.

One would never start a weight-loss program without stepping on a scale, first to set a baseline and then to monitor progress with regular weigh-ins. Options to staring down at hard reality between your toes are to wear black, suck in your gut or choose friends who assert you are losing weight.

But numbers do not lie. Without objective measures of performance, dieting becomes a delusion. Yet this is exactly what the Manitoba government seems to be asking citizens to accept when it comes to its program of fiscal retrenchment and health-care "reform." Accountability is much more than counting pennies… we need to know the results of both restraint and spending.

For example, I would like to know how the redesign of the emergency system in the province improves care. From what I can surmise, fewer emergency rooms may increase transit time, possibly contributing to higher morbidity and mortality. Offsetting this may be better equipped and staffed ERs as well as a better paramedic system. Without a baseline and regular monitoring, how will we will know the net impact of this fiscal experiment?

As citizens, we have fragmentary and selective information on the performance of our health-care system, often published by governments, institutes and think tanks pushing a perspective. Yet masses of information exist in the administrative files of government. In principle, it is possible to extract selected data to offer Manitobans an improved understanding of public sector performance.

This state of ignorance applies to all spheres of government activity, not just health. Further, the Manitoba government is not alone. Most jurisdictions fail to measure public sector performance properly. It seems all governments resist measuring their performance in delivering goods and services.

Robert Kaplan and David Norton’s seminal Harvard Business Review article in 1992 originated the idea of a balanced scorecard that moved beyond using profit as the sole measure of corporate success. For them, the four pillars of business success encompassed financial results (including profit), customer perspectives, measures of efficiency in internal business operations, and measures of innovation and learning.

If we apply the Kaplan/Norton view to health-care, how might this look?

The financial perspective is the easiest and includes the costs of various procedures, including the time costs imposed on patients and the value of lowering the incidence of illness.

The customer perspective requires followup with patients and caregivers, which the health-care system rarely does. I took my car in for winterizing last week and received a satisfaction survey by email in three days. No one has contacted me for my opinion about any interaction I have had with the health-care system… ever.

Measures of internal efficiency relate to operations. I had a little insight into this as I told my family physician about my hip replacement… he was unaware. Inter-agency communication in the health system remains fragmentary. I had the fanciful notion the system of electronic medical records would have data on all my interactions with the health-care system.

Finally, where is the Manitoba health system in terms of the state-of-the-art compared with other provinces and countries? I imagine it may be "OK", but — and this is the issue — we just do not know.

So how do we proceed to give citizens information on the performance of government? In addition to monitoring patient experience through regular surveys, government must implement on two fronts.

First, the guardians of public-sector performance data need to be independent. Statistics Canada has the aura of independence when it releases performance data such as the unemployment rate. However, the potential for politically interfering in one of the world’s premier statistical agencies became apparent when the Harper government cancelled the long form for the census.

To assure independence, the performance measurement system must reside outside any government department in a special operating agency that reports to the legislature. An alternative is to assign this role to the auditor general, which reports equally to the government and the opposition.

Second, as I have said, much of the performance data we need already exists. For example, the Canadian Institute for Health Information releases a vast array of information on the performance of the Canadian health system. However, extracting and understanding a relevant subset of performance measures is beyond the capacity of most citizens.

To create that essential subset, government must engage with technical experts, those delivering services and users from across the political spectrum.

For public services, the balanced scorecard means both selecting the measures that capture the essence of public sector performance and creating transparency in the presentation and interpretation of that information.

Accountability under the current provincial government seems to mean restraint without accountability. This is no better than the previous government that practised spending without accountability. It is time citizens demand government invest in and maintain a robust and independent system of performance measurement and accountability.

Gregory Mason is an associate professor in the department of economics of the University of Manitoba.