c ham

Health care reforms and implications for the future: 

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

Lessons from international comparisons: 

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?: 

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?: 

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 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: 

The political importance of health care

Governments take a close interest in health system performance: 

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: 

Commonwealth Fund Survey 2005

Trends in health care reform: 

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): 

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: 

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): 

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): 

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: 

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: 

Chronic care model

Self care and primary care: 

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

Integration of care: 

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: 

Social and Health Model

Prevention: 

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?: 

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: 

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: 

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 : 

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): 

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: 

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