OPINION: Charlie’s story – measuring what makes a difference

16 June 2014

Free prescriptions and more time … primary health nurse practitioner ROSEMARY MINTO argues for what could most help patients like Charlie*.

I saw Charlie last week: a fifty-two-year-old Māori man with diabetes, stage two renal failure, and obesity.

Before meeting Charlie, I presumed he was there to get his prescriptions, which he hadn’t had for five months. However, that wasn’t at the top of his priority list. Charlie’s blood sugars are poorly controlled and have been for months, and his renal function is declining, neither of which Charlie can “feel”, so it doesn’t impact on his daily functioning. Higher on Charlie’s mind is the fact that he can’t maintain an erection and as yet hadn’t figured out how to bring this up in a consultation – he is too ‘whakama’ (shy).

Charlie often can’t afford to get all his prescriptions at once, so he makes a random choice as to which ones he takes, and besides, he doesn’t feel too much different off them. He is employed in a low paying job working six days a week and can’t afford to take days off sick or to visit the doctor/nurse because he has dependants at home relying on the wage. He and his family have already been evicted twice from homes for not meeting rent this year, and as he says, who can budget something with nothing?

So hearing that children up to age thirteen will get free consultations in the recent budget is a nice surprise, and may help Charlie’s family, but actually, the bigger picture seems to have been missed in making this decision. The barriers that matter to Charlie and providers who see high needs patients are that he can’t afford his prescriptions and he may not understand the implications of not taking them. The quality programme outcomes – set to help measure the effectiveness of the New Zealand healthcare system and providers’ care – seem to miss the point when it comes to identifying and managing the impact of social inequities in New Zealand.

Extracting pertinent information from a patient and developing a shared management plan in a 15 minute consultation often seems impossible when seeing people with high needs; and Charlie will not divulge “private” information to strangers. Building a relationship, trust, and increasing health and life literacy skills takes time, especially if consultations are sporadic. Whanaungatanga (attaining and maintaining relationships) funding does not feature in contracts.

Time costs money and contractual pressures to reach targets and get measurement data into the system risks dehumanising and distracting providers’ from their primary objective: to help people.

Unfortunately, Government policies and quality programmes demand outcomes that are not always centred on meaningful outcomes for patients, or what the person considers important (Patient Reported Outcome Measures – PROM). Instead, they recognise outputs and measure surrogate markers that don’t always measure “health” in an individual.

The pressure is on for providers to get the data in, despite the data not making an iota of difference to long-term patient outcomes and certainly not reflecting the hours of staff time spent gathering that information. Charlie’s world-view won’t change if he does or doesn’t have his cholesterol checked. His view won’t change until providers have the time and ability to assist Charlie to understand the implications on his health of a poor test result. Measuring what he thinks matters makes far more sense to me.

So what do I want to see in future policy and budgets? I want to see health professionals measuring outcomes that research proves make a difference and that the patient considers important, too. A time when measuring a person’s understanding of the importance of lower blood sugars will prove I have done my job instead of justmeasuring an average blood sugar.

Lowering the price of prescriptions would be one of the most effective ways to help people to stay out of hospital. I see no point in free health care if people cannot afford the medicines they are prescribed – and they don’t understand the implications of not taking them.

 

* not real name