1. Social insurance: Present and future challenges Martin McKee European Observatory on Health Care Systems & London School of Hygiene and Tropical Medicine www.observatory.dk

2. What is social insurance? A system of risk pooling and redistribution: –From rich to poor –From young to old –From well to ill –From single to families –From men to women Based on industrial model of employment and traditional family structure

3. What is an insurer? Government agency/ Department Private company Coalition of employers and employees Quasi-independent agency … other

4. Where can you get public money for health care from? Income tax –Earned –Unearned Indirect tax – VAT Excise duties/ taxes on specified items Corporate tax Property taxes … others

5. The challenges of narrowing your tax base High employment costs Loss from informal economy Vulnerability to: –Economic cycle –Shift from earned to unearned income –Changing employment patterns –Demographic change

6. Future diversity Countries “importing” migrants to expand workforce But will a more multi-ethnic society have the same commitment to solidarity

7. The basic model Insurer PatientProvider

8. What should happen Fully informed insurer Able to express demand Provider alert to signals of change Responds immediately to changing demand Offers appropriate package

9. The challenges of delivering effective care When need is not expressed as demand Responsiveness to changing circumstances Delivering appropriate models of care Promoting effectiveness Delivering change

10. Speed of response Anticipating the consequences of: –Changing diseases –Changing expectations –Changing therapeutic opportunities –Changing family structures

11. Specifying models of care Where response requires co- ordinated efforts of a team –Shared care model to manage many chronic diseases, such as diabetes –Multi-disciplinary stroke units –Integration of acute and social care –Screening programmes

12. Which country has a breast screening programme? 20 25 30 35 40 45 1970197519801985199019952000 France Germany United Kingdom Deaths/ 100,000

13. Implementing effectiveness How do you ensure that independent professionals participate in –Life long learning –Quality assurance How do you detect poor practice? Relatives of babies who died after cardiac surgery in Bristol

14. Informing change Who pays for health services research? Who synthesises evidence? Who disseminates evidence? Who monitors changing practice?

15. The re-emergence of planning UK: National Service Frameworks –E.g. Cardiovascular disease, diabetes, mental health Germany: Disease Management Programmes –E.g. diabetes France: Regional Hospital Agencies –New cancer and AIDS centres The Netherlands: Trans-mural care networks Norway: National hospital plan

16. A new role for social insurance? Active purchasing Assess needs Specify care model Purchase care Monitor outcomes HEALTH STRATEGY