Switzerland’s Health Care System from the viewpoint of the UK NHS

1. Switzerland’s Health Care System from the viewpoint of the UK NHS PanosKanavos, PhD London School of Economics Bern, 26 October 2012

2. Outline • Stylised Facts: UK • Stylised Facts: Switzerland • Indicators & Performance Measurement • A “Fair” Comparison? 2

3. Stylised Facts: UK NHS • focus on the new Health & Social Care Act, 2012 • Spending trends in light of increases in demand 3

4. Summary

5. Health care financing in an era of austerity Kanavos et al, 2011.

6. Health and Social Care Act 2010-12Progress and summary of the bill 27. March 2012 “The Bill proposes to create an independent NHS Board, promote patient choice, and to reduce NHS administration costs.” establishes an independent NHS Board to allocate resources and provide commissioning guidance increases GPs’ powers to commission services on behalf of their patients strengthens the role of the Care Quality Commission develops Monitor, the body that currently regulates NHS foundation trusts, into an economic regulator to oversee aspects of access and competition in the NHS cuts the number of health bodies to help meet the Government's commitment to cut NHS administration costs by a third, including abolishing Primary Care Trusts and Strategic Health Authorities. Source: Parliament 2012

7. Health and Social Care Act 2010-12Evolution of commissioning in the UK Implementation of Health and Social Care Act GP Commissioning groups Primary Care Trusts (PCTs) GP Fundholding Practice based commissioning 1991 1997 1998 1999 2005 2012

8. Health and Social Care Act 2010-12Key policy components of the Act Previously, clinicians negotiated service provision for their populations with the PCT. Under the Act, clinical commissioning groups (supported by the NHS Commissioning Board) will commission services directly. • Clinically led commissioning • Provider regulation • Greater voice for patients • New focus for public health • Greater accountability • Streamlined arms-length bodies Source: DoH 2012

9. Health and Social Care Act 2010-12Key policy components of the Act • Clinically led commissioning • Choice & Provider regulation • Greater voice for patients • New focus for public health • Greater accountability • Streamlined arms-length bodies Patients will be able to choose services from a broader variety of providers – including charities and independent providers – as long as they meet NHS costs. Under supervision of the Monitor agency, providers will be free to innovate to deliver services. Source: DoH 2012

10. Health and Social Care Act 2010-12Key policy components of the Act • Clinically led commissioning • Provider regulation • Greater voice for patients • New focus for public health • Greater accountability • Streamlined arms-length bodies The Act establishes new Healthwatch patient organisations locally and nationally to drive patient involvement across the NHS. Source: DoH 2012

11. Health and Social Care Act 2010-12Key policy components of the Act • Clinically led commissioning • Provider regulation • Greater voice for patients • New focus for public health • Greater accountability • Streamlined arms-length bodies The Act provides the ground work for Public Health England, a new body to drive improvements in the public’s health. Source: DoH 2012

12. Health and Social Care Act 2010-12Key policy components of the Act • Clinically led commissioning • Provider regulation • Greater voice for patients • New focus for public health • Greater accountability • Streamlined arms-length bodies The Act sets out clear roles and responsibilities, keeping Ministers’ ultimate responsibility for the NHS. It limits political micro-management and gives local authorities the responsibility for integrating local services. Source: DoH 2012

13. Health and Social Care Act 2010-12Key policy components of the Act • Clinically led commissioning • Provider regulation • Greater voice for patients • New focus for public health • Greater accountability • Streamlined arms-length bodies Abolition of some administrative bodies (incl. General Social Care Council, Office of the Healthcare Professions Adjudicator, Alcohol Education and Research Council and others). Re-establishment of NICE and the Information Centre in primary legislation. Extension of NICE’s remit to social care. Source: DoH 2012

14. 2. Stylised Facts: Swiss Health Care System 14

15. Swiss Health Care System Indicators – funding/allocation *Share in GDP: 9.9% in 2000 and 10.9% in 2005 Source: Swiss Statistics – overview: Costs, financing – Data, indicators 2010

16. Statutory Health Insurance1996 Federal Health Insurance Act • Regulated by law and supervised by the OFSP • Universal coverage • Statutory for all Swiss residents (exception for persons eligible for premium subsidies paid by the canton or commune) • Covers sickness, accidents and maternity • Competing non profit health insurances: costs are redistributed among insurers by a central fund based on a risk equalisation scheme adjusted for age, canton, gender, and recently whether the patient stayed more than 3 nights in hospital or in nursing homes. • Basic benefits package: established by the DFI/OFSP, with the support of relevant expert authorities (e.g. Swissmedic), based on whether service is effective, appropriate and cost-effective. • Complementary and supplementary health insurance also available (e.g. choice of hospital doctor, improved accommodation): usually for profit Source: Camenzind P, Squires D. The Swiss Health Care System, 2011. The Commonwealth Fund.

17. Statutory Health InsuranceWhat is covered? Patient empowerment & choice (unless enrolled under a managed care plan): • Free choice of GPs • Access without referral to specialists in a private practice What is covered? • General practitioner (GP) and specialist services (mostly all covered); • Pharmaceuticals (positive formulary), physiotherapy (if prescribed by physician), some preventive measures, some complementary medecine (as of 2012); • Mental illness (including psychotherapy, if prescribed by physician); • Costs of selected vaccinations, selected general health examinations, early detection of disease among certain risk groups; • 15% of costs of long-term inpatient care (e.g. inpatient homes, institutions for disabled and chronically ill): 2/3 being paid by OOP and the remainder by state subsidies and disability insurances. • Dental care is generally not covered Source: Camenzind P, Squires D. The Swiss Health Care System, 2011. The Commonwealth Fund.

18. 3. Performance Measurement (also based on survey data, CMWF, 2010-2011) • Overall health spend (per capita and as % GDP) • Cost sharing • Efficiency • Quality • Responsiveness and access • Affordability and access • Care coordination • Relationship with doctor • Patient safety • Management of chronic disease 18

19. Health Spending per Capita, 2009Adjusted for Differences in Cost of Living Dollars % GDP * 2008. Source: OECD Health Data 2011 (June 2011).

20. Health spend per capita (US$): Escalation over time Source: OCED health data June 2012. 20

21. Health spend as a percent of GDP: Sustainability? Source: OCED health data June 2012 21

22. Cost containment • Switzerland has among the highest expenditures per capita in the world after the US and Norway (2009) • Cost control measures • Regulated competition between insurers and providers • Inadequate risk equalisation, dual funding of hospitals by cantons and insurers, pressure on insurers to contract with certified providers • Managed care plans could reduce such problems • Pharmaceutical coverage decisions: based on effectiveness (Swissmedic) and on price (OFSP), • Efforts to reassess prices of older drugs • Price capping on generic drugs (50% less than original) • Higher co-payment for branded drugs if original drugs available (20% instead of 10%) • Flat dispensing fee for pharmacies • Health technology assessment could increase efficiency in healthcare resource allocation 22

23. Access and Affordability

24. Responsiveness and access: Waiting times * Highest score across the 11 countries included in the study Source: Schoen C, Osborn R. The Commonwealth Fund. The Commonwealth Fund 2010 International Health Policy Survey in Eleven Countries. November 2011.

25. Patient cost-sharing • Patient cost sharing in the UK: approx 4.5% of total health spend • Patient cost-sharing in Switzerland: (out-of-pocket payments): approx. 30% of total health spend • Deductibles (ranging between CHF 300-2,500.- / year depending on the health plan) • Co-insurance of 10% on any costs exceeding the franchise (up to a maximum of CHF 700.- / year) • Subsidies are available at cantonal level for persons who are not able to pay partly or entirely their premiums: • Approx. 1.6% of the population are not able to cover their premiums • 30% of Swiss residents benefit from these subsidies • Issues around affordability of premiums and financial burden to the population 25

26. Cost-Related Access Problems in the Past Year Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

27. Out-of-Pocket Spending and Problems Paying Medical Bills in Past Year More than US$1,000 in out-of-pocket costs Serious problems paying or unable to pay medical bills Percent Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

28. Access to Doctor or Nurse When Sick or Needed Care Same- or next-day appointment Waited six days or more Percent Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

29. After-Hours Care and Emergency Room Use Difficulty getting after-hours care without going to the emergency room Used emergency room in past two years Percent Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

30. Waited Less Than a Month to See Specialist Percent Base: Saw or needed to see a specialist in the past two years. Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

31. Care Coordination and Care Transitions

32. Coordination Problems in the Past Two Years Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

33. Experienced Coordination Gaps in Past Two Years Percent * Test results/records not available at time of appointment, doctors ordered test that had already been done, providers failed to share important information with each other, specialist did not have information about medical history, and/or regular doctor not informed about specialist care. Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

34. Gaps in Hospital or Surgery Discharge in Past Two Years Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

35. Patient Safety (medical errors)

36. Medical, Medication, or Lab Test Errors in Past Two Years * Base: Had blood test, x-rays, or other tests in past two years. Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

37. Pharmacist or Doctor Did Not Review and Discuss Prescriptions in Past Year Percent Base: Taking two or more prescriptions. Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

38. Doctor–Patient Relationship and Patient Activation

39. Doctor–Patient Relationship and Communication Base: Has a regular doctor/place of care. Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

40. Shared Decision-Making with Specialists Percent reporting positive shared decision-making experiences with specialists* * Reported specialist always/often: 1) Gives opportunities to ask questions about recommended treatment; 2) Tells you about treatment choices; and 3) Involves you as much as you want in decisions about your care. Base: Seen specialist in past two years. Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

41. Managing Chronic Conditions

42. Patient Engagement in Care Management for Chronic Condition Base: Has chronic condition. Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

43. Between Doctor Visits, Has a Health Care Professional Who . . . You can easily call to ask a question or get advice Contacts you to see how things are going Percent Base: Has chronic condition. Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

44. Blood Pressure Under Control Last Time CheckedHas Heart Disease, Hypertension, and/or Diabetes Percent yes, under control Base: Has heart disease, hypertension, and/or diabetes and blood pressure checked in past year. Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

45. 4. A Fair Comparison?Cross-Cutting Themes and Implications • Room for improvement in all countries • Improving care coordination and system integration • Engaging patients in care and self-management • Using information better and in a cleverer way • Efforts to make health care system more patient-centric, encourage choice and improve access • Further competition needed to increase efficiency and improve performance (both UK and Switzerland) • Better purchasing • More competition in insurance markets and fewer barriers • From a quality of care perspective, no single health system model stands out • U.K. and Switzerland very often lead but have very different systems • Very high co-payments in Switzerland & frequent calls for more affordable health insurance premia • UK and Switzerland lead on perceived quality indicators