Quality and Cost International Perspectives Derek Feeley Director of Healthcare Policy and Strategy NHS Scotland

Health Care Spending per Capita in 2003 Adjusted for Differences in Cost of Living a a Source: Frogner and Anderson 2006; OECD Health Data 2005; AIHW Health Expenditure Australia 2003–04. a 2002

Percentage of Gross Domestic Product Spent on Health Care in 2003 a a a 2002 Source: Frogner and Anderson 2006; OECD Health Data 2005; AIHW Health Expenditure Australia 2003–04.

Health Care Expenditure per Capita by Source of Funding in 2003 Adjusted for Differences in Cost of Living a a a 2002 Source: Frogner and Anderson 2006; OECD Health Data 2005; AIHW Health Expenditure Australia 2003–04.

Healthy life expectancy WHO World Health Report 2006

% of total life expectancy lost to poor health (male and female) WHO Report 2006

Infant Mortality Rates 2000 Source NCHS

Quality Indicators Source OECD, Hussey et al 2004 USACanadaAusUKNZ Survival Rates Breast Cancer Kidney Transplant Process Cancer Screening Flu vaccine Waiting Elective surgery 14253

Safety: Medical Mistake, Medication Error, or Test Error in Past Two Years Percent 2005 Commonwealth Fund International Health Policy Survey

Effectiveness; Preventive Care Percent received: AUSCANNZUKUS Pap in past 3 years, age Mammogram in past 3 years, age Flu shot in past year, age Commonwealth Fund International Health Policy Survey

Timeliness; Access to Doctor When Sick or Need Medical Attention Percent AUS CAN NZ UK US 2004 Commonwealth Fund International Health Policy Survey

Patient Centered; Missed Opportunities to Engage Patient Percent saying doctor:* AUSCANNZUKUS Does NOT give you clear instructions Does NOT make goals and plans clear Does NOT tell you about treatment choices or ask your opinions * Doctor only sometimes, rarely or never 2004 Commonwealth Fund International Health Policy Survey

Efficiency ; Coordination Problems by Number of Doctors Percent 2005 Commonwealth Fund International Health Policy Survey * Either records/results did not reach doctors office in time for appointment OR doctors ordered a duplicate medical test

* Inequity counted when significant difference between income groups where p .05 and gap of >5%; for U.S. p 5%, or gap>5%. General access (4) Access because of cost (4)Coordination(9) Doctor– Patient (8)Prevention(5)Total(30) AUS CAN NZ UK US Source: Commonwealth Fund 2004 International Health Policy Survey. Equity ; Number of Measures Where Below Average Income Adults Have More Negative Experiences

Cost = Quality?

Limited to patient experience? Yes but ……..  Confirms earlier survey findings;  In line with WHO and OECD indicators which show a similar mixed story;  In line with findings at system and sub- system levels within countries.

And so…..  No discernable relationship between quality and cost;  Comparable data hard to come by;  No one country has the answer – each has scope to learn;  Social as well as clinical factors at play;

Questions and answers  Is international comparison worth the trouble? Useful in; Useful in; Raising questions Raising questions Benchmarking best practice Benchmarking best practice  Are we measuring the right things? Current OECD 15 an important 1 st step - but Current OECD 15 an important 1 st step - but Measuring what can be measured Measuring what can be measured Acute focussed Acute focussed Fail to cover all dimensions of quality Fail to cover all dimensions of quality

Policy Implications  Many of the indicators to which patients attach value require a different model of care;  New ways of delivering care will require a new quality paradigm  We need to change what we measure  We need a different mindset about the business case for quality (social as well as financial)

Shifting the balance of care  Current viewEvolving model of care  Emphasises acute careEmphasises long-term conditions  Hospital centredEmbedded in communities  Doctor dependent Team based  Episodic careContinuous care  Reactive carePreventative care  Patient as passive recipientPatient as partner  Carers undervaluedCarers supported as partners  Low techHigh tech

Implications for National health systems, quality and costs  Population health as well as healthcare  Longitudinal measures rather than episodic  Patient activation  Improved ICT required  Incentives required for; Whole system integration Whole system integration Prevention Prevention

Acknowledgement Thanks to the Commonwealth Fund for access to the data from international surveys, including; o Multinational Comparisons of Health Systems Data, 2005 (Frogner and Anderson) o The Commonwealth Fund 2005 International Health Policy Survey of Sicker Adults in Six Countries (Schoen, Osborn, Huynh, Doty, and Fenley) o The Commonwealth Fund 2004 International Health Policy Survey of Primary Care in Five Countries (Schoen and Osborn) The views expressed are my own and should not be construed as representing CMWF.

Coronary Bypass Procedures per 100,000 Population in 2003 a b a b a 2002 b 2001 Source: OECD Health Data 2005.

Spending on Physician Services per Capita in 2003 Adjusted for Differences in Cost of Living a a 2002 Source: OECD Health Data 2005; AIHW Health Expenditure Australia 2003–04.