Abstract
Dear Editor
Re: Article by Gordon et al on interim prosthesis programme for lower limb amputees – comparison of public and private model of services
The journal is to be congratulated for publishing an article that looks at the very complex issue of cost efficiency of prosthetic treatment. There are however several issues which need to be pointed out and are relevant to the study.
The costing methodology is described, but some significant factors which relate to the real costs of labour and service provision in the public health system in NSW have not been included in this description. The costing to administrative, transport, maintenance etc has been adequately dealt with. Other costs which need to be taken into consideration include:
the superannuation component of employment which currently contributes 9% to the cost of any employee, the cost of workers compensation insurance which contribute somewhere between 5 and 10% of the cost of any employee, the costs of various types of leave, as expanded in the paragraph below, contributes another 23% the cost of obligatory non-core components of public employees including occupational, health and safety and other mandatory education, attendance at departmental meetings for smooth running of departments, attendance at further education, meetings and quality assurance projects. In general in NSW, a rough guide would be 15% of an employee's time as a junior therapist would be spent cleaning out such activity and therefore a further 15% need to added to the cost base. Finally an understanding of what the staff were engaged in when they were not making interim prosthesis is important to take into account. A full time employee receives full time pay regardless of the percentage of time they actually spend making prosthesis. If they are also engaged in other activities, then this may reduce the component wage attributable to the cost of the prosthesis, but this will have to be specified, otherwise 100% of the prosthetist's total salary should be included in the cost of the temporary prosthesis.
Excluding Saturdays and Sundays, there are generally about 260 working days in a calendar year. Any public service employee has an annual entitlement to 10 days public holiday leave, 12 rostered days off, 20 working days annual leave, between 1 and 5 days continuing education leave, 10 days for sick leave and 3 days for compassionate leave. Another 4 to 10 days of leave accrue on an annual basis for long service leave. Paid maternity leave is also available up to 14 weeks per child. Although not all employees make use of all available days off in the form of sick, family or study leave; the other types of leave are legislative requirements and entitlements. Assuming, therefore, that employees would take half of their entitled optional leave (excluding maternity leave), on average, each employee would take approx 60 of the 261 working days as leave. This would increase the hourly labour costs by roughly 23%.
In summary about 55% of the hourly rate needs to be added to the public employee costs to make up the real cost of the employee, assuming that they are at all times fully engaged in service provision.
Taking into account these figures, the real costs of the public service based prosthetic service may be up to 15% higher than that of the private service if all costs (excluding the fact that all full time prosthetists are paid full time wages regardless of what percentage of their time they spend making prosthesis) are taken into account.
Further additions to the cost base include infrastructure and equipment costs which are already built into the cost of the private prosthetist.
It is also noteworthy, that while the authors are using these incomplete costings to drive a tendering process in an attempt to decrease the hourly rate of pay for private prosthetists for the provision of interim prostheses.
Yours sincerely,
Associate Professor Friedbert Kohler
Sydney South West Area Health Service
Conjoint Associate Professor
University of New South Wales, Sydney, Australia