Health System Responses to Patient’s New Role: An International Perspective Richard B. Saltman Emory University Atlanta, GA USA European Observatory on Health Systems and Policies Brussels 1

Patientmakt över vården Richard B. Saltman Fakta ISBN Häftad, 114 sidor Översättning: Stellan Wijkström Originalets titel: Patient choice and patient empowerment Utg. 01 januari 1992 Boken är tyvärr slutsåld Maktstrukturen inom sjukvårdssystemet håller på att vittra sönder. Det har börjat mullra i patientleden. Det ropas på större patientinflytande och fler valmöjligheter. Politikerna är med på noterna - till viss del. Boken analyserar begrepp som patientinflytande, patientmakt och valfrihet. Patientens ställning i Sverige och sex andra västeuropeiska länder jämförs. Kan en patient förväntas vara en upplyst konsument? Vilken sorts val är det rimligt att överlåta åt patienten? Val av vårdgivare? Val av försäkringsgivare? Val av tid och plats för icke-akuta ingrepp? Val av behandlingsform? Hur kan man förena valfrihet och patientmakt med förebyggande arbete och samordning av vårdresurser? Vilken hjälp behöver patienten för att kunna välja - och välja rätt? Bibliotek som har boken: 3

Patientmakt Over Varden This book was published in Stockholm in years ago “Patient choice” would create “patient power”: the health system would respond, and new approaches would take hold. How far did patient choice affect health system decision-making in Sweden? Have other aspects of new patient roles helped change health system decision-making? 4

This Presentation Key institutional incentives that make change difficult in health systems (advantages as well as disadvantages) Examples of patient-generated change Whether systems can respond further to patient preferences 5

Three Major Sources of Health Sector Resistance to Change 1)Provider Institutions normally prefer consistency and continuity (path dependency) 2)Physician practice patterns are difficult to change 3)Political actors tend under pressure to pull back delegated authority 6

1. Provider Institutions Need Continuity to Operate Effectively Provider institutions normally resist changes to existing services and/or their procedures: -Financial incentives -Managerial incentives -Personnel incentives -Information/knowledge incentives Established pathways are powerful 7

2. Physician Practice is Based on Clinical Evidence and Stable Routines Changing how physicians practice medicine is a complex process: - medical training - professional standards - community/patient expectations - clinical evidence (Cochrane data) - international “best practice” 8

2. Changing Physician Practice II Management literature shows that Chiefs of Service - Head Doctors – are most successful in changing physicians’ practice behavior with charts comparing that doctor to others in the same department half-life of changed behavior is only 6-12 months (unless reinforced further) 9

3. Political actors tend under pressure to pull back delegated authority Delegation of decision-making authority involves - clinical risks - social risks - political risks When stressed, political actors pull back grants of delegated authority: Example: semi-autonomous public hospitals in UK and in Spain 10

The Policymaking Dilemma How best to accommodate multiple forms of structural resistance to change? How best to balance patient preferences/interests with organizational stability? 11

Many “Management Solutions” Seek to Create Health System Change - Re-engineering/Continuous Quality Improvement (CQI) - New Public Management (NPM) - Six Sigma Lean - Value-based Purchasing 12

Many Quality of Care Solutions Donabedian (structure, process, outcome) Deming (quality circles, Theory Z) Safety routines and “never events” (operating rooms, drug dosages) 13

Many External Sources of Provider Change Professional Standards Regulatory requirements (government) Political mandates (government) Changing International Standard of Care 14

How do Patients Induce Change? Voice (constructive criticism) - complaining to medical personnel - complaining to local politicians Lateral Exit (patient choice) - choosing another doctor/facility - taking their public funding to another doctor/facility Organizing (politics) - setting up patient associations - organizing politically: Stockholm Health Care Party 15

Has Changed Patient Role Influenced Services in Other Countries: Positive Examples Drug formularies UK: - Herceptin NICE 2011 (But: January , 16 Cancer Drugs Dropped) Israel: - Avastin

Has Changed Patient Role Influenced Services in Other Countries: Positive Examples Primary Health Care: England - Evening and Saturday hours for GPs (2010) Netherlands - More home care/less nursing home care (January 2015) - Personal budgets for home care services (England also) 17

Has Changed Patient Role Influenced Services in Other Countries: Positive Examples Elective Inpatient Services: Denmark - Waiting time guarantee of 30 days (2003) England - Choice of private as well as public hospitals (2010) Netherlands - Parkinsons’ patient association/ more individualized treatment model (Bas Bloem) 18

Has Changed Patient Role Influenced Services in Other Countries: Not-So-Positive Example Elective Services: England: 200,000 patients currently on waiting lists more than 18 weeks (4 ½ months) for urgent procedures (January 2015) 3,113 elective operations cancelled in NHS in first two weeks of December 2014 (161 urgent operations) Only 83.5% of patients receive cancer treatment after 62 days with urgent referral (lowest since target introduced) 1 billion pounds extra already allocated this year to speed up services New Problem for Patients: Fiscal Austerity 19

What Changed Patient Role Typically Has Altered: Peripheral Services Primary Physician Services Home Care Services Pharmaceutical Access to some new drugs 20

What New Patient Role Typically Hasn’t Altered Core clinical routines Core financing routines Core political routines System structure/function 21

Interpretation #1 Patients have affected peripheral issues, not core issues, and this is a good thing: Stability is maintained Patient care is consistent and physician driven Patients participate but not where medical decision-making should predominate 22

Interpretation #2 Patients have been frozen out of the key decision-making processes: Physicians maintain practice control Politicians maintain regulatory control “Stasis”/path dependency pre-dominates? 23

Overall Observations The health system response in Sweden to the new patient role appears to be similar to that in other Northern European countries (Uppsala Report) Patient choice has been a useful but limited tool for patient influence and participation Additional tools may be needed to better fit health systems to patient needs/preferences 24

Can “Patient Centeredness” Help Systems Respond More Effectively? Potentially Helpful: Focusses on core clinical routines and practices Affects physician practice patterns Incorporates patient “voice” in both policy and medical process 25

Can “Patient Centeredness” Help Systems Respond More Effectively? Potential difficulties: 1) Overlapping definitions of “patient centeredness”: - “for” the patient - “with” the patient - “by” the patient 2) Same key sources of institutional resistance to change: a) institutional path dependency b) physician practice patterns c) political pullback of delegated authority 26

Should the Mix of Tools Be Strengthened Further? Beyond patient preferences Beyond patient choice (eg vardval) Beyond Patient Centeredness? 27