In the private sector, quality of a product is reflected in the price. But what about the quality of a public sector? How can we assess the quality of a public service given it is distributed for free? Some governments opted to adopt performance indicators that aimed at specifying the pursued quality of the service. In the English health care sector, shorter waiting times are one of the key performance indicators of the quality of health care.
The waiting time target was not just a output measure but a management performance tool used to address the chronic long waiting times of the English hospitals. The UK government created a system of strict penalties or rewards based on meeting shorter waiting time targets. Some call this system “targets and terror” as it subjected top leadership to possible public humiliation and reputational damage whilst granting highly scoring hospitals a greater autonomy and access to finance.
There is no doubt that early treatment can reduce case complexities, thus improving your condition. However, waiting time as a performance indicator tells as nothing about the quality of care itself. When we say the quality of healthcare we mean an outcome that results in better physical capabilities of patients as result of receiving the treatment. As hospital mangers are excessively focusing on waiting time target as a measurable standard set by policy makers they might neglect other more important aspects of quality; a phenomenon that is known in theory as “output distortion effect”.
Is there any evidence that waiting time policy is hitting the target and missing the point?
In my latest paper with Professor Graham Cookson, we attempt to assess the effect of waiting time on other quality outcomes that reflect the enhancement of the physical capabilities of patients rather than an output measurement (for example, admission numbers). We consider three quality outcomes; in-hospital mortality; 30-day re-admission; and, patient assessed health gains.
Although not perfectly reflecting the state of improvement in the physical status of patients, in-hospital mortality rate is one of the very widely spread indicators of healthcare. Re-admission rate within 30 days of discharge could also be deemed as an outcome indicator as it mirrors the deterioration/improvement in the health status of patients after being discharged. Our third indicator is the health gains as assessed by patients after undergoing a hip replacement operation.
Our paper shows that hospitals with shorter waiting times have significantly higher patient reported health gains given that we control for various hospital characteristics. However, there is statistical evidence that hospitals with shorter waiting times tend to have significantly higher readmission rates. This means that hospitals might tend to discharge patients prematurely in order to free up beds to meet the policy target of shorter waiting times which shows an evidence of the “output distortion” effect (Bevan and Hood, 2006). This implies that focusing on one measurable indicator of health care quality could result in deterioration in other unmeasured aspects of care quality.
Policy makers face a challenge of how to set performance standards to reflect health care quality, as there are few quality outcome indicators that are easily and reliably measured, We suggest that the focus on narrow policy targets implemented to improve quality, has actually resulted in output distortion and deteriorated in unmeasured aspect of care services.
Our paper invites policy makers to embark on designating performance management indicators that are outcome oriented and that contribute to the enhancement of physical capabilities due to receiving the healthcare services. Healthcare policy targets that would not consider hospital specifications, geographical location and patient characteristics would be short in enhancing the quality of health care systems.