Health care reforms and implications for the future

1. Health care reforms and implications for the future Chris Ham University of Birmingham England

2. Lessons from international comparisons • High spending countries like the US do not have the best performance e.g. health outcomes • Countries with mainly public financing have better equity of access to care • Speed of access and responsiveness are related to spending and capacity • Quality and safety are increasingly important everywhere following the IOM 2001 report

3. The ideal system? • Swedish or Japanese health outcomes • UK primary care • French style patient choice • German levels of access to doctors and hospitals • US levels of hospital efficiency (in the best performing organisations) • UK work on quality and safety?

4. The worst system? • US levels of expenditure (c.16% GDP) • US inequities in access to health care (45 million not covered) • UK waiting times for treatment - historically • French and German inefficiencies in delivery e.g. duplication of services • Health outcomes that are worsening as in the former Soviet Union

5. Health care is politically and economically important • Health care accounts for an average of 8.9% of a country’s national income in OECD countries • 73% of health care spending typically comes from taxes or compulsory social insurance • Finance ministries everywhere are concerned to contain costs and get value for money

6. The political importance of health care

7. Governments take a close interest in health system performance • Political success depends on bringing about improvements in health care • Commonwealth Fund surveys show high proportion of people (the public and doctors) believe fundamental reform is needed • Most countries have undertaken health care reform in last 20-30 years

8. Commonwealth Fund Survey 2005

9. Trends in health care reform • Major changes to financing methods are unusual • Reforms have focused more on the delivery of care • Cost containment, efficiency and responsiveness, and quality and safety have been key themes

10. Cost containment (1970s onwards) • Prospective global budgets for hospitals • Controls over hospital building and medical equipment • Limits on doctors’ fees and incomes • Restrictions on medical education and training numbers • These policies generally worked

11. Efficiency and responsiveness (1980s onwards) – the big bang • Market-like mechanisms: splitting purchaser and provider roles • Management reforms: involving clinicians in leadership and drawing on private sector expertise • Budgetary incentives: DRGs and pay for performance • These policies have had mixed impact

12. Quality and safety (2000 onwards) • Measuring clinical outcomes and publishing the results • Setting standards and inspecting providers against these standards • Creating new agencies to oversee quality and safety • These policies are a work in progress

13. The high performing health care system (OECD, 2004) • Focus more on prevention • Improve speed of access to care • Eliminate ancillary or luxury services • Manage demand better • Promote health technology assessment • Use incentives to reward quality and efficiency • Invest in IT

14. The future challenge: chronic diseases • Health care systems need to reorient to respond to the increasing prevalence of chronic diseases • Wagner’s Chronic Care Model is a good organising framework • Key principles are a focus on prevention, together with self care, primary care and service integration

15. Chronic care model

16. Self care and primary care • Most care is self care and patients, carers and families need support to be effective • Health care systems everywhere must to do more to recognise this • Consistently high standards of primary care are a fundamental building block • Team working based on registration and continuity of care hold the key

18. Integration of care • There are excellent models of integration in the US non-system • Kaiser Permanente, Group Health Co-operative, and Health Partners are all examples • These organisations have much to teach systems like the UK and Australia • The NHS has a partnership with Kaiser to adapt its approach

19. Social and Health Model

20. Prevention • Population wide interventions can be effective e.g. on smoking • Individual interventions can be effective e.g. use of statins to control cholesterol • Governments are wary of being seen as part of a nanny state • The costs of unhealthy choices may be unaffordable, and yet the science of behaviour change is weak

21. Are we over-medicalising health problems? • Every second a patient is prescribed a course of statins • Every minute 380 patients are prescribed a heart drug • Every hour 50 inpatients receive hospital treatment for CHD • Every day 250 patients undergo a heart bypass or angioplasty

22. Community action • The Chronic Care Model emphasises community action on prevention • The Wanless report in the UK advocated that the public needed to be ‘fully engaged’ • If community action falls short of full engagement, will publicly funded systems be sustainable? • Do we need a new contract with citizens that relates rights to responsibilities?

23. Big bang reform • Top down change led by government often falls short of its promise • Bottom up reform that engages clinical teams needs more emphasis • Kaiser Permanente achieves this and aligns objectives and incentives at all levels • Kaiser’s philosophy is that improvement is best achieved ‘through commitment and not compliance’

24. In summary • Prevention and health improvement need more than rhetorical support • Rising to the challenge of chronic diseases is a universal priority • Self care, primary care and service integration need increased focus • Acute hospitals remain hugely important but no longer at the heart of the system

25. In summary (2) • The experience of Kaiser and other integrated systems (like the VA) repays careful study • Successful systems in future will overcome the professional and organisational silos • These systems will find ways of aligning objectives and incentives, using the commitment of clinical teams to drive improvement

26. Thank you c.j.ham@bham.ac.uk