To explore the attitudes of clinicians working in New Zealand publicly funded hospitals towards p... more To explore the attitudes of clinicians working in New Zealand publicly funded hospitals towards prioritizing patients for elective surgery, and their reported use of clinical priority assessment criteria (CPAC). A cross-sectional study using a postal questionnaire. The questionnaire drew on themes identified from an earlier qualitative study. Questions were closed and information was sought about perceptions of the need to prioritize patients, effective ways of doing so and the use of CPAC. New Zealand. A national sample of cardiologists, cardiac, general and orthopaedic surgeons, and registrars. Three hundred and thirty-two clinicians responded to the survey (74.1%). Respondents generally agreed that a nationally consistent method of prioritizing patients for surgery was required but felt their clinical judgement was the most effective way of prioritizing patients. Current CPAC were considered to be administrative tools and there was marked variation in their reported use. Consistent use of CPAC using the constructs provided was more likely to be reported by cardiac specialists than general or orthopaedic surgeons. Other features of the hospital system in which surgeons worked also had a major impact on access to elective surgery. Clinicians recognized the need for a nationally consistent method of prioritizing patients. Although most did not consider current CPAC were effective in achieving this, many felt there was some potential in further development of tools. However, further development is problematic in the absence of objective measures of need and ability to benefit.
Journal of Health Services Research & Policy, Jan 1, 2004
To describe the ways patients access elective surgery in New Zealand, and to understand the use o... more To describe the ways patients access elective surgery in New Zealand, and to understand the use of, and attitudes to, clinical priority assessment criteria (CPAC) in determining access to publicly funded elective surgery. A qualitative study in selected New Zealand localities. A purposive sample of general practitioners, surgeons and administrators in publicly funded hospitals were interviewed. Data were analysed by a process of thematic analysis. Sixty-five interviews were completed. General practitioners had a key role in determining which patients were seen in the public sector and, by utilising strategies to actively advocate for patients, influenced both waiting times for first assessment by surgeons and for surgery. CPAC had been developed as decision support guides with the intention that they would provide transparency and equity in determining access. However, there was variation in the way CPAC were being used both in score construction and in the influence of the score on access to surgery. The management of the hospital system also limited the extent to which CPAC could be used to prioritise patients for surgery. Variability in the use of CPAC tools meant that at the time of the study they did not provide a transparent and equitable method of determining access to surgery. This highlights the difficulties in developing and implementing CPAC and suggests that further development is difficult in the absence of evidence to identify patients who will benefit the most from surgery.
Australian and New Zealand Journal of Public Health, 2010
To identify the characteristics of New Zealanders who utilised primary healthcare services prior ... more To identify the characteristics of New Zealanders who utilised primary healthcare services prior to the implementation of the New Zealand Primary Healthcare Strategy (PHCS). This paper uses data from the 1996/97 and 2002/03 waves of the nationally representative New Zealand Health Survey to examine the relationship between individual, household and community characteristics and the utilisation of healthcare services by New Zealanders. Multivariate regression models are used to examine the correlation between particular characteristics and whether an individual visited a GP in the previous 12 months, the number of visits made to a GP in the previous 12 months, whether they reported needing to see a GP in the previous 12 months, but failed to do so, and whether they visited a secondary practitioner in the previous 12 months. Gender, age, and ethnicity are all found to be significantly related to healthcare utilisation, even when controlling for a fairly comprehensive set of characteristics. On the other hand, education, marital status, household composition, household income and community deprivation are found to be unrelated to healthcare utilisation. A strong relationship is found between employment status, health status and healthcare utilisation. We do not find any evidence of a relationship between socioeconomic status and healthcare utilisation after controlling for other measures of need. This and other findings suggest that the government subsidies in place prior to the implementation of the 2001 Primary Healthcare Strategy helped to ensure that user charges did not limit service utilisation in New Zealand for groups with lower socioeconomic status.
Preventive medications such as statins are used to reduce cardiovascular risk. There is some evid... more Preventive medications such as statins are used to reduce cardiovascular risk. There is some evidence to suggest that people of lower socioeconomic position are less likely to be prescribed statins. In New Zealand, Maori have higher rates of cardiovascular disease. This study aimed to investigate statin utilisation by socioeconomic position and ethnicity in a region of New Zealand. This was a cross-sectional study in which data were collected on all prescriptions dispensed from all pharmacies in one city during 2005/6. Linkage with national datasets provided information on patients' age, gender and ethnicity. Socioeconomic position was identified using the New Zealand Index of Socioeconomic Deprivation 2006. Statin use increased with age until around 75 years. Below age 65 years, those in the most deprived socioeconomic areas were most likely to receive statins. In the 55-64 age group, 22.3% of the most deprived population received a statin prescription (compared with 17.5% of t...
Journal of health services research & policy, 2002
New Zealand's health care sector has undergone almost continual restructuring since the early... more New Zealand's health care sector has undergone almost continual restructuring since the early 1980s. In the latest set of reforms, 21 district health boards (DHBs) have been established with responsibility for promoting health, purchasing services for their populations and delivering publicly owned health services. Boards will be governed by a mix of elected and appointed members, will be responsible for arranging the delivery of primary and community health services, and will own and run public hospitals and related facilities. We clarify the differences and continuities between earlier reforms and the 2000/01 structures, as well as the current reforms' potential strengths and weaknesses. The paper discusses whether the DHB model was the only feasible option for restructuring and whether the dynamics of the new system may lead to further changes, particularly on the purchaser side of the system. Given that DHBs face potential conflict between their purchasing and provision ...
Journal of health services research & policy, Jan 11, 2014
The financial sustainability of publicly funded health care systems is a challenge to policymaker... more The financial sustainability of publicly funded health care systems is a challenge to policymakers in many countries as health care absorbs an ever increasing share of both national wealth and government spending. New technology, aging populations and increasing public expectations of the health care system are often cited as reasons why health care systems need ever increasing funding as well as reasons why universal and comprehensive public systems are unsustainable. However, increases in health care spending are not usually linked to corresponding increases in need for care within populations. Attempts to promote financial sustainability of systems such as limiting the range of services is covered or the groups of population covered may compromise their political sustainability as some groups are left to seek private cover for some or all services. In this paper, an alternative view of financial sustainability is presented which identifies the failure of planning and management o...
To describe the clinical and demographic characteristics of patients referred by general practiti... more To describe the clinical and demographic characteristics of patients referred by general practitioners (GPs) to both public and private sectors for non-urgent surgical assessment. During 2004, a cohort of 1420 adult patients with the potential to benefit from elective surgery was recruited into the study by their GPs. GPs recorded patient demographics and reasons for referral. 345 out of 828 eligible GPs (42%) agreed to participate in the study and submitted data on 1603 referrals, 2.4 referrals per reporting week. After excluding ACC cases, data on 1420 referrals were analysed. Forty-two percent of those referred were male and 69% were European New Zealanders. The mean age was 55 years. The largest number of referrals were made to general surgery (37%), followed by orthopaedics (19%), gynaecology (12%), and plastic surgery (10%). The modal level of urgency was "routine" and in 24% of cases cancer was a possibility. The GP felt surgery was needed in 47% of cases, while in ...
Journal of Health Services Research & Policy, 2004
To explore factors potentially influencing equitable access to elective surgery in New Zealand by... more To explore factors potentially influencing equitable access to elective surgery in New Zealand by describing clinicians' perceptions of equity and the factors they consider when prioritising patients for elective surgery. A qualitative study in selected New Zealand localities. A purposive sample of 49 general practitioners, specialists and registrars were interviewed. Data were analysed thematically. General practitioners described unequal opportunities for patients to access primary and secondary care and, in particular, private sector elective surgery. They felt that socio-economically disadvantaged patients were less able to advocate for themselves and were more vulnerable to being lost to the elective surgical booking system as well as being less able to access private care. Both GPs and secondary care clinicians described situations where they would personally advocate for individual patients to improve their access. Advocacy was related to clinicians' perceptions of the 'value' that patients would receive from the surgery and patients' needs for public sector funding. The structure of the health system contributes to inequities in access to elective care in New Zealand. Subjective decision making by clinicians has the potential to advantage or disadvantage patients through the weighting clinicians place on socio-demographic factors when making rationing decisions. Review of the potential structural barriers to equitable access, further public debate and guidance for clinicians on the relative importance of socio-demographic factors in deciding access to rationed services are required for allocation of services to be fair.
To explore the attitudes of clinicians working in New Zealand publicly funded hospitals towards p... more To explore the attitudes of clinicians working in New Zealand publicly funded hospitals towards prioritizing patients for elective surgery, and their reported use of clinical priority assessment criteria (CPAC). A cross-sectional study using a postal questionnaire. The questionnaire drew on themes identified from an earlier qualitative study. Questions were closed and information was sought about perceptions of the need to prioritize patients, effective ways of doing so and the use of CPAC. New Zealand. A national sample of cardiologists, cardiac, general and orthopaedic surgeons, and registrars. Three hundred and thirty-two clinicians responded to the survey (74.1%). Respondents generally agreed that a nationally consistent method of prioritizing patients for surgery was required but felt their clinical judgement was the most effective way of prioritizing patients. Current CPAC were considered to be administrative tools and there was marked variation in their reported use. Consistent use of CPAC using the constructs provided was more likely to be reported by cardiac specialists than general or orthopaedic surgeons. Other features of the hospital system in which surgeons worked also had a major impact on access to elective surgery. Clinicians recognized the need for a nationally consistent method of prioritizing patients. Although most did not consider current CPAC were effective in achieving this, many felt there was some potential in further development of tools. However, further development is problematic in the absence of objective measures of need and ability to benefit.
International Journal of Technology Assessment in Health Care, 2013
The aim of this study was to gather qualitative and quantitative data on criteria considered by h... more The aim of this study was to gather qualitative and quantitative data on criteria considered by healthcare decision makers. Using snowball sampling and an online questionnaire with forty-three criteria organized into ten clusters, decision makers were invited by an international task force to report which criteria they consider when making decisions on healthcare interventions in their context. Respondents reported whether each criterion is "currently considered," "should be considered," and its relative weight (scale 0-5). Differences in proportions of respondents were explored with inferential statistics across levels of decision (micro, meso, macro), decision maker perspectives, and world regions. A total of 140 decision makers (1/3 clinical, 2/3 policy) from 23 countries in five continents completed the survey. The most relevant criteria (top ranked for "Currently considered," "Should be considered," and weights) were Clinical efficacy/effectiveness, Safety, Quality of evidence, Disease severity, and Impact on healthcare costs. Organizational and skill requirements were frequently considered but had relatively low weights. For almost all criteria, a higher proportion of decision makers reported that they "Should be…
With demand for health services continuing to grow as populations age and new technologies emerge... more With demand for health services continuing to grow as populations age and new technologies emerge to meet health needs, healthcare policy-makers are under constant pressure to set priorities, ie, to make choices about the health services that can and cannot be funded within available resources. In a recent paper, Smith et al apply an influential policy studies framework – Kingdon’s multiple streams approach (MSA) – to explore the factors that explain why one health service delivery organization adopted a formal priority setting framework (in the form of programme budgeting and marginal analysis [PBMA]) to assist it in making priority setting decisions. MSA is a theory of agenda-setting, ie, how it is that different issues do or do not reach a decision-making point. In this paper, I reflect on the use of the MSA framework to explore priority setting processes and how the framework might be applied to similar cases in future.
To explore the attitudes of clinicians working in New Zealand publicly funded hospitals towards p... more To explore the attitudes of clinicians working in New Zealand publicly funded hospitals towards prioritizing patients for elective surgery, and their reported use of clinical priority assessment criteria (CPAC). A cross-sectional study using a postal questionnaire. The questionnaire drew on themes identified from an earlier qualitative study. Questions were closed and information was sought about perceptions of the need to prioritize patients, effective ways of doing so and the use of CPAC. New Zealand. A national sample of cardiologists, cardiac, general and orthopaedic surgeons, and registrars. Three hundred and thirty-two clinicians responded to the survey (74.1%). Respondents generally agreed that a nationally consistent method of prioritizing patients for surgery was required but felt their clinical judgement was the most effective way of prioritizing patients. Current CPAC were considered to be administrative tools and there was marked variation in their reported use. Consistent use of CPAC using the constructs provided was more likely to be reported by cardiac specialists than general or orthopaedic surgeons. Other features of the hospital system in which surgeons worked also had a major impact on access to elective surgery. Clinicians recognized the need for a nationally consistent method of prioritizing patients. Although most did not consider current CPAC were effective in achieving this, many felt there was some potential in further development of tools. However, further development is problematic in the absence of objective measures of need and ability to benefit.
Journal of Health Services Research & Policy, Jan 1, 2004
To describe the ways patients access elective surgery in New Zealand, and to understand the use o... more To describe the ways patients access elective surgery in New Zealand, and to understand the use of, and attitudes to, clinical priority assessment criteria (CPAC) in determining access to publicly funded elective surgery. A qualitative study in selected New Zealand localities. A purposive sample of general practitioners, surgeons and administrators in publicly funded hospitals were interviewed. Data were analysed by a process of thematic analysis. Sixty-five interviews were completed. General practitioners had a key role in determining which patients were seen in the public sector and, by utilising strategies to actively advocate for patients, influenced both waiting times for first assessment by surgeons and for surgery. CPAC had been developed as decision support guides with the intention that they would provide transparency and equity in determining access. However, there was variation in the way CPAC were being used both in score construction and in the influence of the score on access to surgery. The management of the hospital system also limited the extent to which CPAC could be used to prioritise patients for surgery. Variability in the use of CPAC tools meant that at the time of the study they did not provide a transparent and equitable method of determining access to surgery. This highlights the difficulties in developing and implementing CPAC and suggests that further development is difficult in the absence of evidence to identify patients who will benefit the most from surgery.
Australian and New Zealand Journal of Public Health, 2010
To identify the characteristics of New Zealanders who utilised primary healthcare services prior ... more To identify the characteristics of New Zealanders who utilised primary healthcare services prior to the implementation of the New Zealand Primary Healthcare Strategy (PHCS). This paper uses data from the 1996/97 and 2002/03 waves of the nationally representative New Zealand Health Survey to examine the relationship between individual, household and community characteristics and the utilisation of healthcare services by New Zealanders. Multivariate regression models are used to examine the correlation between particular characteristics and whether an individual visited a GP in the previous 12 months, the number of visits made to a GP in the previous 12 months, whether they reported needing to see a GP in the previous 12 months, but failed to do so, and whether they visited a secondary practitioner in the previous 12 months. Gender, age, and ethnicity are all found to be significantly related to healthcare utilisation, even when controlling for a fairly comprehensive set of characteristics. On the other hand, education, marital status, household composition, household income and community deprivation are found to be unrelated to healthcare utilisation. A strong relationship is found between employment status, health status and healthcare utilisation. We do not find any evidence of a relationship between socioeconomic status and healthcare utilisation after controlling for other measures of need. This and other findings suggest that the government subsidies in place prior to the implementation of the 2001 Primary Healthcare Strategy helped to ensure that user charges did not limit service utilisation in New Zealand for groups with lower socioeconomic status.
Preventive medications such as statins are used to reduce cardiovascular risk. There is some evid... more Preventive medications such as statins are used to reduce cardiovascular risk. There is some evidence to suggest that people of lower socioeconomic position are less likely to be prescribed statins. In New Zealand, Maori have higher rates of cardiovascular disease. This study aimed to investigate statin utilisation by socioeconomic position and ethnicity in a region of New Zealand. This was a cross-sectional study in which data were collected on all prescriptions dispensed from all pharmacies in one city during 2005/6. Linkage with national datasets provided information on patients' age, gender and ethnicity. Socioeconomic position was identified using the New Zealand Index of Socioeconomic Deprivation 2006. Statin use increased with age until around 75 years. Below age 65 years, those in the most deprived socioeconomic areas were most likely to receive statins. In the 55-64 age group, 22.3% of the most deprived population received a statin prescription (compared with 17.5% of t...
Journal of health services research & policy, 2002
New Zealand's health care sector has undergone almost continual restructuring since the early... more New Zealand's health care sector has undergone almost continual restructuring since the early 1980s. In the latest set of reforms, 21 district health boards (DHBs) have been established with responsibility for promoting health, purchasing services for their populations and delivering publicly owned health services. Boards will be governed by a mix of elected and appointed members, will be responsible for arranging the delivery of primary and community health services, and will own and run public hospitals and related facilities. We clarify the differences and continuities between earlier reforms and the 2000/01 structures, as well as the current reforms' potential strengths and weaknesses. The paper discusses whether the DHB model was the only feasible option for restructuring and whether the dynamics of the new system may lead to further changes, particularly on the purchaser side of the system. Given that DHBs face potential conflict between their purchasing and provision ...
Journal of health services research & policy, Jan 11, 2014
The financial sustainability of publicly funded health care systems is a challenge to policymaker... more The financial sustainability of publicly funded health care systems is a challenge to policymakers in many countries as health care absorbs an ever increasing share of both national wealth and government spending. New technology, aging populations and increasing public expectations of the health care system are often cited as reasons why health care systems need ever increasing funding as well as reasons why universal and comprehensive public systems are unsustainable. However, increases in health care spending are not usually linked to corresponding increases in need for care within populations. Attempts to promote financial sustainability of systems such as limiting the range of services is covered or the groups of population covered may compromise their political sustainability as some groups are left to seek private cover for some or all services. In this paper, an alternative view of financial sustainability is presented which identifies the failure of planning and management o...
To describe the clinical and demographic characteristics of patients referred by general practiti... more To describe the clinical and demographic characteristics of patients referred by general practitioners (GPs) to both public and private sectors for non-urgent surgical assessment. During 2004, a cohort of 1420 adult patients with the potential to benefit from elective surgery was recruited into the study by their GPs. GPs recorded patient demographics and reasons for referral. 345 out of 828 eligible GPs (42%) agreed to participate in the study and submitted data on 1603 referrals, 2.4 referrals per reporting week. After excluding ACC cases, data on 1420 referrals were analysed. Forty-two percent of those referred were male and 69% were European New Zealanders. The mean age was 55 years. The largest number of referrals were made to general surgery (37%), followed by orthopaedics (19%), gynaecology (12%), and plastic surgery (10%). The modal level of urgency was "routine" and in 24% of cases cancer was a possibility. The GP felt surgery was needed in 47% of cases, while in ...
Journal of Health Services Research & Policy, 2004
To explore factors potentially influencing equitable access to elective surgery in New Zealand by... more To explore factors potentially influencing equitable access to elective surgery in New Zealand by describing clinicians' perceptions of equity and the factors they consider when prioritising patients for elective surgery. A qualitative study in selected New Zealand localities. A purposive sample of 49 general practitioners, specialists and registrars were interviewed. Data were analysed thematically. General practitioners described unequal opportunities for patients to access primary and secondary care and, in particular, private sector elective surgery. They felt that socio-economically disadvantaged patients were less able to advocate for themselves and were more vulnerable to being lost to the elective surgical booking system as well as being less able to access private care. Both GPs and secondary care clinicians described situations where they would personally advocate for individual patients to improve their access. Advocacy was related to clinicians' perceptions of the 'value' that patients would receive from the surgery and patients' needs for public sector funding. The structure of the health system contributes to inequities in access to elective care in New Zealand. Subjective decision making by clinicians has the potential to advantage or disadvantage patients through the weighting clinicians place on socio-demographic factors when making rationing decisions. Review of the potential structural barriers to equitable access, further public debate and guidance for clinicians on the relative importance of socio-demographic factors in deciding access to rationed services are required for allocation of services to be fair.
To explore the attitudes of clinicians working in New Zealand publicly funded hospitals towards p... more To explore the attitudes of clinicians working in New Zealand publicly funded hospitals towards prioritizing patients for elective surgery, and their reported use of clinical priority assessment criteria (CPAC). A cross-sectional study using a postal questionnaire. The questionnaire drew on themes identified from an earlier qualitative study. Questions were closed and information was sought about perceptions of the need to prioritize patients, effective ways of doing so and the use of CPAC. New Zealand. A national sample of cardiologists, cardiac, general and orthopaedic surgeons, and registrars. Three hundred and thirty-two clinicians responded to the survey (74.1%). Respondents generally agreed that a nationally consistent method of prioritizing patients for surgery was required but felt their clinical judgement was the most effective way of prioritizing patients. Current CPAC were considered to be administrative tools and there was marked variation in their reported use. Consistent use of CPAC using the constructs provided was more likely to be reported by cardiac specialists than general or orthopaedic surgeons. Other features of the hospital system in which surgeons worked also had a major impact on access to elective surgery. Clinicians recognized the need for a nationally consistent method of prioritizing patients. Although most did not consider current CPAC were effective in achieving this, many felt there was some potential in further development of tools. However, further development is problematic in the absence of objective measures of need and ability to benefit.
International Journal of Technology Assessment in Health Care, 2013
The aim of this study was to gather qualitative and quantitative data on criteria considered by h... more The aim of this study was to gather qualitative and quantitative data on criteria considered by healthcare decision makers. Using snowball sampling and an online questionnaire with forty-three criteria organized into ten clusters, decision makers were invited by an international task force to report which criteria they consider when making decisions on healthcare interventions in their context. Respondents reported whether each criterion is "currently considered," "should be considered," and its relative weight (scale 0-5). Differences in proportions of respondents were explored with inferential statistics across levels of decision (micro, meso, macro), decision maker perspectives, and world regions. A total of 140 decision makers (1/3 clinical, 2/3 policy) from 23 countries in five continents completed the survey. The most relevant criteria (top ranked for "Currently considered," "Should be considered," and weights) were Clinical efficacy/effectiveness, Safety, Quality of evidence, Disease severity, and Impact on healthcare costs. Organizational and skill requirements were frequently considered but had relatively low weights. For almost all criteria, a higher proportion of decision makers reported that they "Should be…
With demand for health services continuing to grow as populations age and new technologies emerge... more With demand for health services continuing to grow as populations age and new technologies emerge to meet health needs, healthcare policy-makers are under constant pressure to set priorities, ie, to make choices about the health services that can and cannot be funded within available resources. In a recent paper, Smith et al apply an influential policy studies framework – Kingdon’s multiple streams approach (MSA) – to explore the factors that explain why one health service delivery organization adopted a formal priority setting framework (in the form of programme budgeting and marginal analysis [PBMA]) to assist it in making priority setting decisions. MSA is a theory of agenda-setting, ie, how it is that different issues do or do not reach a decision-making point. In this paper, I reflect on the use of the MSA framework to explore priority setting processes and how the framework might be applied to similar cases in future.
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Papers by Jackie Cumming
Volume 5 - Issue 8 by Jackie Cumming