Is there anything to learn from the UK? Martin Roland March 1 st 2016

The UK’s healthcare is cheap Bumping along the bottom

Yet the UK seems to do some things quite well Electronic medical records (98% vs US 84%) Computerized guideline reminders (77% vs US 47%) Case managers for chronic conditions (96% vs US 66%) Satisfaction with EMR (86% vs US 52%) Administration is a major problem (21% vs US 54%) Source: Commonwealth Fund Survey 2015

And the UK’s outcomes aren’t bad either Life expectancy at birth: 81.1 years vs 78.6 years (US) Life expectancy at 65: 19.8 years vs 19.2 years (US) Reduction in IHD mortality ( ): 67% vs 50% (US) Heart failure admissions 1 : 99 vs 366 (US) Diabetes admissions 1 : 64 vs 198 (US) Over 65% influenza immunisation 75.5% vs 66.5% (US) 1 Age-sex standardised admissions per 100,000 population Source: OECD Health at a Glance

But over here, things don’t look that rosy Health system works well, only minor changes needed UKUS %15% %16% Source: Commonwealth Fund Survey 2015

… and UK primary care physicians are getting more stressed University of Manchester. 8 th National GP Worklife Survey

So is there anything to learn from the UK? 1.Things to do 2.Things to avoid

Structure of National Health Service (England) Clinical Commissioning Groups (locality based, leadership from primary care practitioners) Primary care practices Hospitals and specialist mental healthcare providers (NHS Trusts) NHS England

So is there anything to learn from the UK? 1.Things to do 2.Things to avoid

So is there anything to learn from the UK? 1.Universal healthcare coverage, largely free at the point of delivery, FPs cover paediatrics, mental health etc. 2.Registration of 98% of the population with a primary care practice gives the basis for population responsibility (how do you combine this with patient choice?). Single electronic record. 3.Pay for performance – 12 years experience, some improvements in care, not a magic bullet, unintended consequences, due for a major overhaul 4.Hospital care is purchased by Clinical Commissioning Groups – dominated by family practitioners

Exception reporting for clinical indicators Patient refused Not clinically appropriate Newly diagnosed or recently registered Already on maximum doses of medication Roland M. NEJM 2004; 351:

So is there anything to learn from the UK? 1.Universal healthcare coverage, largely free at the point of delivery, FPs cover paediatrics, mental health etc. 2.Registration of 98% of the population with a primary care practice gives the basis for population responsibility (how do you combine this with patient choice?). Single electronic record. 3.Pay for performance – 12 years experience, some improvements in care, not a magic bullet, unintended consequences, due for a major overhaul 4.Hospital care is purchased by Clinical Commissioning Groups – dominated by family practitioners

What to avoid 1.Reorganization (re-disorganization 1 ) 2.Failure to reorganize 3.P4P incentives that are managerially rather than professionally driven 4.Thinking that culture and context aren’t important 5.Battles between payers and professionals 1 Oxman A et al. A surrealistic mega-analysis of redisorganization theories. Journal of the Royal Society of Medicine 2005; 98: 563-8