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

4 May 2007 ACHSE NSW State Conference 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

4 May 2007 ACHSE NSW State Conference 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?

4 May 2007 ACHSE NSW State Conference 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

4 May 2007 ACHSE NSW State Conference 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

4 May 2007 ACHSE NSW State Conference The political importance of health care Which issue is the most important in your decision on how to vote? NHS Education Law and order Tax and public services Economy 27% 18% 14% 11% 10% ICM Guardian 22 March 2005

4 May 2007 ACHSE NSW State Conference 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 years

4 May 2007 ACHSE NSW State Conference Commonwealth Fund Survey 2005 Percentage of sicker adults saying fundamental changes in health care system are needed Australia Canada NZ UK US Germany

4 May 2007 ACHSE NSW State Conference 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

4 May 2007 ACHSE NSW State Conference 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

4 May 2007 ACHSE NSW State Conference 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

4 May 2007 ACHSE NSW State Conference 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

4 May 2007 ACHSE NSW State Conference 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

4 May 2007 ACHSE NSW State Conference 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

4 May 2007 ACHSE NSW State Conference Chronic care model

4 May 2007 ACHSE NSW State Conference 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

4 May 2007 ACHSE NSW State Conference

4 May 2007 ACHSE NSW State Conference 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

4 May 2007 ACHSE NSW State Conference Social and Health Model

4 May 2007 ACHSE NSW State Conference 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

4 May 2007 ACHSE NSW State Conference 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

4 May 2007 ACHSE NSW State Conference 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?

4 May 2007 ACHSE NSW State Conference 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’

4 May 2007 ACHSE NSW State Conference 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

4 May 2007 ACHSE NSW State Conference 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

4 May 2007 ACHSE NSW State Conference Thank you