Cheap, Convenient, and Quality Healthcare—Pick Any Two

Many years ago, when my hospital still had a photography and printing department, it had a sign on the wall listing the three desirable properties for their work: FAST, CHEAP, QUALITY, and invited customers to pick which two they wanted. The implications were clear—high-quality work done quickly was not going to be cheap, cheap but high-quality work was going to take time, while people wanting work done quickly and cheaply were going to have to compromise on quality. This rule, which is sometimes known as the ‘iron triangle’, applies to healthcare as much as printing. I work in a publicly funded health system and those who control the funding and planning of our services often seem to think that they can defy the rule and deliver all three. Politicians promise more convenient and better services but are unwilling to raise taxes to pay for them. Reducing waiting times in our overcrowded emergency departments (faster treatment) is a government target (https://www.dpmc.govt.nz/our-programmes/government-targets) but this can only be achieved by either increasing funding to employ more staff or by reducing the time spent with each patient (compromising quality). Another government target is to cut waiting lists by out-sourcing elective surgery to private hospitals. This will have to be paid for by diverting funds from the public service and since most private specialists also work in the public system, there will also be fewer specialists left to do the more challenging cases in public hospitals (https://nzmj.org.nz/journal/vol-138-no-1614/health-minister-brown-wants-to-fix-the-system-but-risks-breaking-it-further). On top of this, public hospitals in New Zealand are often left to manage unexpected complications after private surgery (https://doi.org/10.1016/j.healthpol.2020.12.008). The scheme may deliver convenient and quality care for some patients, but it will not be cheap. Of course, we should always strive to provide faster, cost-effective, and better healthcare, and occasionally there are developments that break the rule. Conservative treatment of primary spontaneous pneumothoraxes is one example: not inserting a chest tube and managing patients at home saves money, is more convenient, and delivers a higher quality of care for most patients with fewer adverse events and a lower risk of recurrence. However, we only know this because of a high-quality trial that took time to complete and needed substantial research funding (http://www.nejm.org/doi/10.1056/NEJMoa1910775). Politicians who look to save money by cutting research budgets should be made aware of the long-term consequences in terms of quality and cost-effectiveness. There are also times when we may only get one, or even none, of the desired attributes. Here I am thinking of some of the computer systems that I am required to use, or the overenthusiastic IT projects that promise to solve all of our problems but end in failure. Usually, we find that these projects have tried to do too much at once (too fast), underestimated the costs (too cheap), or had insufficient expertise (poor quality) (https://www.otago.ac.nz/press/books/dangerous-enthusiasms-e-government-computer-failure-and-information-system-development). Readers of Respirology will work in many different health systems, but regardless of how your system operates, I think that you will find that the rule applies. Healthcare that is cheap, convenient, and high quality—which two would you pick? The author declares no conflicts of interest.