Health care reforms and implications for the future

Health care reforms and implications for the future

Chris Ham

University of Birmingham

England

4 May 2007 ACHSE NSW State Conference

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


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?


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


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


The political importance of health care

Which issue is the most important in your decision on how to vote?

NHS

Education

Law and order

Tax and public services

Economy

27%

18%

14%

11%

10%

ICM Guardian 22 March 2005


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


Commonwealth Fund Survey 2005

Percentage of sicker adults saying fundamental changes in health care system are needed

Australia

Canada

NZ

UK

US

Germany

48

61

52

52

44

54


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


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


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


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


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


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


Chronic care model

i

i Wagner EH. Chronic disease management: What will it take to improve care for chronicillness? Effective Clinical Practice. 1998;1:2-4.


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


Health care professionals may only interact with people with achronic disease for a few hours a year…

the rest of the time patients care for themselves…


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


Social and Health Model

Self Management

Disease Management

Case Management

Higher risk patients. Disease specific

interventions; early diagnosis

70-80% of Individuals Health promotion; diet;

exercise

Individuals with highly complex conditions/needs

Improving care for the chronically ill; Diversion from acute care

Health view Social Care view

Supporting more individuals at home with higher level of needs; diversion from permanent

residential and nursing home care

Support to carers; high quality home care

services

Valuing People; investment in

voluntary sector;

preventative services

The Right Service for Individuals

Level 1

Level 2

Level 3


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


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


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?


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’


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


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


Thank you

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Documents

Health care reforms and implications for the future