Doctors and healthcare reform

In the past, doctors probably felt they had a significant influence over their immediate work environment. However, this is changing, and, as Perkins et al. report in this issue of the Journal, there is a low level of congruence between the personal goals of individual medical specialists and organisational goals.¹ Importantly, the medical specialists are less enthusiastic about their work since the introduction of healthcare system changes that involved resource restrictions and splitting the roles of purchasers and providers (although Perkins et al. did not control for other variables, such as salaries and promotion).

While Perkins et al. did not address differences in responses in relation to individual specialists' organisational roles, they did find that specialists in the United Kingdom reported a greater influence on management than their Australian and New Zealand counterparts; this may reflect the greater role for United Kingdom specialists as clinical managers. The study sample in New South Wales (whence the Australian sample was drawn) consisted mainly of visiting medical staff from one Area Health Service, and previous research has shown that visiting specialists identify less with an organisation than physicians who have adopted a managerial role, such as divisional directors.²

Of interest, in terms of health service reform, New South Wales was in a period of relative health policy stability at the time of the survey; nevertheless, the specialists reported decreased enthusiasm for their work.

Perkins et al. show that medical specialists would like to influence the "management" of their healthcare organisations, but they have been unsuccessful at this, either because management is unwilling to be influenced, or the attempts at influence are ineffective. At the hospital level, attempts to ensure a greater clinician role in management may involve, as Perkins et al. and their respondents point out, a heavy but rewarding workload.

Any policy alternative to managed care must address the need to improve technical efficiency and value for money (technical and allocative efficiency) in the healthcare sector. The key way to address hospital technical efficiency issues is through casemix funding, paying hospitals on the basis of benchmark performance rather than on the basis of history or political influence. Increasing value for money relies on changing the behaviours of providers through funding and education strategies. The 1997 Budget strategy of limiting additions to the Medicare Schedule to cost-effective interventions is a step in the right direction. Providers will also need assistance in implementing best-practice approaches to care -- this can be done through the introduction of local guidelines to influence behaviour.

Local guidelines should not be seen as idiosyncratic approaches based on the conventional wisdom of local providers, but rather should be based on the best available evidence,^3,4 building on nationally established guidelines where these exist.⁵ Local guidelines can be supplemented by care paths or clinical pathways to reduce provider variation and lower costs. Care paths also have the benefit of defining appropriate practice and providing a framework for evaluation.

The alternative to managed care thus requires a twofold approach:

• Improve the technical efficiency of healthcare provision; and

• Encourage and provide incentives for the adoption of local guidelines to influence practice patterns, to ensure effective and efficient care.

Unfortunately, local strategies for behaviour change seem to have had limited success.^6,7 Even when professional organisations support guidelines for cost-effective care, such guidelines cannot always be implemented, for reasons such as the strongly held beliefs of individual doctors in maintaining their own professional autonomy.⁸ However, local norms can influence practice,⁹ through peer pressure and systematic quality assessment processes. In addition, information given to doctors about resource consumption for specific conditions seems to play a part in reducing hospital costs,¹⁰ by, for instance, providing feedback to referring physicians about the costs and benefits of ordering particular diagnostic tests.

For healthcare providers collectively, it would probably be more politically attractive to be able to influence their own destiny rather than have it determined without their professional involvement. A corollary to this is that the medical profession (and the other health professions) must be given the opportunity to engage in the reform process.

To diminish the sense of alienation identified by Perkins et al., the medical profession needs to recognise the legitimacy of funders' and purchasers' concerns about cost increases and value for money. We need to develop strategies that respond to these needs in ways that do not undermine professional values or lead to alienation and loss of morale.

Stephen J Duckett
Professor of Health Policy; Dean, Faculty of Health Sciences
La Trobe University, Melbourne, VIC.

1. Perkins RJ, Petrie KJ, Alley PG, et al. Health services reform: the perceptions of medical specialists in Australia (New South Wales), the United Kindom and New Zealand. Med J Aust 1997; 167: 201-204.
2. Abernethy MA, Stoelwinder JU. Goal orientations and the use of budgeting information: A comparison between physicians and non-physicians in public teaching hospitals. In: Butler JRG, Doessel DP, editors. Proceedings of the Eighth Australian Conference of Health Economists. Sydney: Australian Studies in Health Services Administration, 1987: 67-92.
3. Grimshaw J, Freemantle N, Wallace S, et al. Developing and implementing clinical practice guidelines. Qual Health Care 1995; 4: 55-64.
4. Eccles M, Clapp Z, Grimshaw J, et al. Developing valid guidelines: methodological and procedural issues from the North of England evidence-based guideline development project. Qual Health Care 1996; 5: 44-50.
5. Smallwood RA, Lapsley HM. Clinical practice guidelines: to what end? Med J Aust 1997; 166: 592-595.
6. Eisenberg JM. Doctors' decisions and the cost of medical care. Ann Arbor: Health Administration Press, 1986.
7. Mittman BS, Siu AL. Changing provider behavior: Applying research on outcomes and effectiveness in health care. In: Shortell SM, Reinhardt UE, editors. Improving health policy and management: nine critical research issues for the 1990s. Ann Arbor: Health Administration Press, 1992: 195-226.
8. Rappolt SG. Clinical guidelines and the fate of medical autonomy in Ontario. Soc Sci Med 1997; 44: 977-987.
9. Westert GP. Variation in use of hospital care: an empirical and theoretical analysis of differences in the duration of hospital stay. Assen/Maastricht: Van Gorcum, 1992.
10. Conrad D, Wickizer T, Maynard C, et al. Managing care, incentives and information: An exploratory look inside the "Black Box" of hospital efficiency. Health Serv Res 1996; 31: 235-259.