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Behind that line lie all the capitals of the ancient state

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Title: Behind that line lie all the capitals of the ancient state


1
Lessons from the English NHS (and elsewhere)
  • Martin McKee
  • London School of Hygiene and Tropical Medicine
  • European Observatory on Health Systems and
    Policies
  • www.observatory.dk

2
Lets start at the very beginning
  • a very good place to start

What are health systems actually for?
3
Possible answers
  • The responsibility of government is to improve
    the health of the population, to respond to their
    legitimate needs, and to do so fairly
  • The responsibility of a private company is to
    increase the returns to its shareholders

4
but not only responding to what turns up
  • Assessing health needs
  • Monitoring the outcomes of health care
  • Training the next generation of health workers
  • Generating the knowledge needed for technological
    development

5
It all seems rather complicated
  • Health systems are complex social systems
  • Involving real people, with hopes, aspirations,
    and motivations
  • They involve multiple interacting elements
  • Primary, secondary, specialist care
  • They involve multiple stakeholders
  • Health, education, industry, regional development

6
If it really is so complicated
  • Surely we could simply leave it to the market
  • The invisible hand must be better at organising
    this complexity
  • No-one at the centre can possibly second guess
    all the individual decisions

7
after all, havent we learned from the 50 year
natural experiment
From Stettin in the Baltic to Trieste in the
Adriatic, an iron curtain has descended across
the Continent. Behind that line lie all the
capitals of the ancient states of Central and
Eastern Europe. Warsaw, Berlin, Prague, Vienna,
Budapest, Belgrade, Bucharest and Sofia.
8
except.
  • Markets in health care dont work so well
  • Many people who need health care dont realise it
  • Even if they do, they may be deterred from
    seeking it
  • They often dont know what they want
  • Those providing care may not realise these people
    even exist

9
Once it was so much easier
  • An individual patient went to a doctor
  • The doctor
  • made a diagnosis (probably wrong),
  • applied a treatment (probably ineffective)
  • The patient
  • died, or
  • got better

10
but now
  • A patient with arthritis, Parkinsons, heart
    failure, bronchitis, diabetes, and depression
    goes to a family doctor
  • The patient is referred to a series of medical
    specialists, nurses, other health professionals,
    all working together in a network, collaborating
    with each other
  • She receives multiple powerful and effective
    medicines, all of which are affected by her organ
    function and by the other drugs
  • She remains under continuing review for the
    remainder of her now active and fully engaged life

11
but even in the old days
  • Even when the state played a minimal role in
    health care
  • It always intervened in some areas
  • Mental health
  • Infectious disease

12
The inter-relationship of practically everything
  • A family is injured in a high speed car crash
  • They arrive at an emergency department
  • There is no paediatric service it has been
    moved into the community
  • The eye injuries cannot be treated as the
    ophthalmologists have been relocated to an
    independent treatment centre to concentrate on
    waiting lists for cataracts
  • The complex hip fracture cannot be treated,
    because the orthopaedic surgeons have been
    relocated to an independent treatment centre to
    concentrate on waiting lists for knee
    replacements
  • There is no microbiologist to speak to about the
    wound infection because the service has been
    moved 200 miles away

13
An analogy air travel
  • You want to go from Stansted to Charleroi no
    problem
  • You want to check your baggage in for a flight
    from Rome to Ljubljana via Milan forget it

14
The double agency relationship
  • The traveller
  • Knows where they want to go to
  • The airline
  • Knows how to get there
  • The travel agent
  • Knows all the different options available
  • The patient
  • Knows that she is unwell, but not why and what
    can be done
  • The doctor
  • Knows why she is ill, what must be done, but not
    who else did not seek help, or how to put in
    place the complex arrangements for help to be
    given
  • The purchaser
  • Knows what type of people are not getting care
    and what the best (evidence-based) models of care
    are, and can put them together

15
Another area where markets have problems
  • Opportunistic behaviour
  • Cream-skimming
  • Enrolment for a HMO on 6th floor of a building
    without an elevator
  • Declining to treat complex and expensive, but
    inadequately reimbursed patients
  • Concentration on conditions with high returns
  • Short-termism
  • High volume elective surgery, but no provision of
    training

16
Reaching out to those in need
  • Doctors tend to gather where the climate is
    healthy... and where the patients can pay for
    their services
  • Ivan Illich
  • "the availability of good medical care tends to
    vary inversely with the need for it in the
    population served."
  • Julian Tudor Hart

17
And another specifying the product
  • Uncertainty
  • What single diagnosis for a patient with multiple
    pathology
  • Clinical thresholds
  • Data manipulation
  • DRG creep

18
Looking to the future
  • To respond effectively we need to take a long
    time perspective and engage in sustained
    investment to meet future needs
  • We must increase dramatically our ability to
    forecast the needs for these resources
  • We must incorporate flexibility to adapt to
    changing circumstances

19
Changing circumstancesKnown knowns and unknown
unknowns
  • there are known knowns there are things we
    know we know. We also know there are known
    unknowns that is to say we know there are some
    things we do not know. But there are also unknown
    unknowns, the ones we dont know we dont know.
    And if one looks throughout the history of our
    country and other free countries, it is the
    latter category that tend to be the difficult
    ones.

20
So in the end it is an empirical question
  • Markets beat planning where the conditions for a
    market exist
  • Less certain whether this applies in health care
  • Which gets the best results?
  • Planned services
  • Unplanned services (free market)

21
Type I diabetesThen and now
  • Discovery of insulin changed a rapidly fatal
    disease of childhood into a lifelong disorder
  • Now compatable with a normal life span, but large
    differences in actual attainment
  • Healthy survival requires co-ordination of
    efforts by many people and organisations
  • Pharmaceutical supply and distribution
  • Primary care
  • Specialist care
  • Self care

22
Value for money?
US health expenditure 15 of GNP Swedish health
expenditure 9 of GNP
23
Cheap, convenient, and deadly
  • Some Hospitals Call 911 to Save Their Patients
  • A 44 year old man underwent thoracic surgery in a
    small specialist hospital in Texas
  • He developed respiratory problems
  • There was no medical care on site
  • The nurses called 911 to get help from a nearby
    full service hospital
  • He died
  • New York Times, 2 April 2007

24
Preventing deaths from cervical cancer more may
not be better
  • Number of cervical smears in a lifetime
  • Germany 50
  • Finland - 7

5
4
Germany
3
2
Finland
1
0
1990
2000
25
Avoidable mortality
  • Idea goes back to Florence Nightingale
  • Concept developed in 1970s
  • List of causes of death at particular ages where
    death should not occur
  • Examples include
  • diabetes under age 49,
  • leukaemia under age 15,
  • Asthma under age 65

26
Change in avoidable mortality 1998-2003
27
Still, maybe the private sector gives better
value?
  • In Australia, after adjusting for case-mix,
    public hospitals are more efficient than
    privately operated ones
  • Perhaps because private hospitals treat patients
    more intensively
  • Systematic review of 149 comparisons of US
    for-profit and not-for profit hospitals
  • 88 found not-for-profit better cost, outcomes,
    access
  • 43 found no difference
  • 18 found for-profit better

28
and not just in health care more market
successes
  • Break up of UK telephone directory enquiry
    service
  • Millions spent on marketing by new operators
  • Recouped by much high charges
  • Quality of service appalling
  • Customer confusion
  • Collapse in demand
  • 118118 (market leader) abandoning product
  • A complete disaster

29
The English experience
  • Recognition that the UK was lagging behind
    similar countries
  • Low cancer survival
  • Long waiting lists
  • Concern about future affordability of health
    system
  • Ageing population
  • New technology

30
Projections of future expenditure on UK NHS under
three scenarios

50 bn
Fully engaged major commitment to health
improvement
Source Wanless Report
31
So what happened?
  • Wanless recommended sustained investment in
    health promotion and health care capacity over a
    10 year period
  • Gordon Brown wanted results quicker (the tyranny
    of the electoral cycle)
  • Rapid increase in expenditure
  • Limited scope to increase supply
  • Price inflation

32
Drive to increase capacity
  • Patients sent to France, Germany, Belgium for
    surgery
  • Private finance initiative to pay for new
    hospitals
  • Independent Sector Treatment Centres for elective
    surgery

33
Going abroad cheaper and faster
The first nine patients sent to France by the
English NHS
Comparing prices
34
Building new hospitals
  • Public Private Partnerships
  • Nothing new
  • All hospitals (except in the USSR) have always
    involved some public-private involvement
  • New model involves private sector designing,
    building, and operating facility on behalf of
    state body
  • PFI in UK most widely applied model

35
Suggested benefits
  • Private sector intrinsically better at managing
    projects than public sector
  • If so, why leave public sector with even more
    complex task of managing the PPP?
  • Most important removes funding from public
    sector borrowing requirement, so allowing Finance
    minister to achieve his Golden Rule of no net
    borrowing over economic cycle
  • Except that this no longer applies as PSBR has
    been redefined

36
and also
  • More likely to complete on time
  • Except time from project conception to completion
    may be longer
  • Transfers risk to private sector
  • Except, risk comparator pseudo-scientific
    mumbo-jumbo
  • Official from United Kingdom National Audit
    Office

37
In practice
  • Higher cost (in some cases unaffordable)
  • Favours new build over refurbishment
  • Longer, costly, and more complex procurement
  • Inflexibility
  • Lack of real evidence due to secrecy
  • Problems with quality

38
The cost of private provision
  • High costs of preparing tenders, involving very
    extensive legal specifications to cover all
    foreseeable events
  • High costs of preparing tenders, with losing
    contractors passing costs on in next bid
  • Cost of borrowing higher for private consortium
    than government
  • Governments have AAA status
  • PFI bonds typically BBB (just above junk status)

39
Flexibility The hospital of the past
Medical
Medical
Medical
Medical
Paediatrics
Pathology
Maternity
Surgery
Surgery
Theatres
ICU
Geriatrics
Radiology
Outpatients
Geriatrics
A E
40
The hospital of the future?
Medical Assessment
Major trauma
Minor Injury
Primary Care
Paediatrics
Children
Imaging
Pathology
Imaging
Specialist Imaging
Pathology
Imaging
Diagnostics
Pathology
Theatres
Ambulatory care
Intermediate care rehab
Medium
High Dependency
Maternity
Theatres
Imaging
ICU
Source Edwards McKee
41
The bed issue
n
Too few
contracted
Beds
Too many
requirements
0
Now 30 years
Now
42
and populations change
  • Need for reconfiguration of hospital services in
    many places
  • Take an area served by 3 hospitals, which now
    needs only 2
  • One is a PFI hospital
  • If it closes, the health authority still has to
    pay as if it was open
  • Already a problem with PFI schools

43
Higher quality?
  • Bishop Auckland Hospital
  • Generator and core electrical systems had to be
    redesigned immediately after opening
  • Norfolk Norwich Hospital
  • Negative pressure rooms were not properly
    operational for 2 years
  • No ventilation in the kitchens so staff work in
    30 C temperatures (with 44 C being recorded)
  • Hereford Hospital
  • Boiler house opened with no water treatment plant
  • Doors too heavy for the opening restraints
  • Seacroft Hospital, Leeds
  • Mental health facility found to have breached
    every section of the fire safety code

44
But we should look beyond Europe too
  • La Trobe Regional Hospital, Melbourne, Australia
  • Built by a private company to replace older
    public hospitals, having entered into a
    confidential contract with the government of
    Victoria to provide hospital services for 20
    years.
  • In 1999 the hospital lost AUS6 million and was
    projecting ongoing losses.
  • The Victoria health minister reported that the
    scale of losses was such that the hospital could
    no longer guarantee its standard of care.
  • In 2000 the company was released from its
    contract in return for an agreement to drop legal
    action against the government.
  • It sold the facility to the government for
    AUS6.6 million (about half of what it was valued
    at) and made an additional payment of AUS1
    million.

45
Dead but not buried?
46
ISTCsHow are they performing?
  • Paid 11 above NHS rates plus a further subsidy
    to cover bidding costs
  • Compliance with contracts uncertain but estimated
    that only about 70 of contracted work being done
  • Data were so variable and incomplete as to render
    any attempt at commenting on trends and
    comparisons between schemes and with any external
    benchmarks futile
  • increasing evidence that they are unable to
    manage complications

47
In summaryModernising the English NHS
  • Creative destruction
  • McKinsey Co
  • We had to destroy the village to save it
  • Peter Arnett quoting unnamed US Army officer in
    Vietnam
  • Modernisation
  • or The Great Leap Forward
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