1. Switzerland’s Health Care System from the viewpoint of the UK NHS
Panos Kanavos, PhD
London School of Economics
Bern, 26 October 2012

2. Stylised Facts: Switzerland Indicators & Performance Measurement
Outline
Stylised Facts: UK
Stylised Facts: Switzerland
Indicators & Performance Measurement
A “Fair” Comparison? 2 2

3. focus on the new Health & Social Care Act, 2012
Stylised Facts: UK NHS
focus on the new Health & Social Care Act, 2012
Spending trends in light of increases in demand 3 3

4. Summary

5. Health care financing in an era of austerity
Kanavos et al, 2011.

6. Health and Social Care Act 2010-12 Progress and summary of the bill
27. March 2012
“The Bill proposes to create an independent NHS Board, promote patient choice, and to reduce NHS administration costs.”
establishes an independent NHS Board to allocate resources and provide commissioning guidance
increases GPs’ powers to commission services on behalf of their patients
strengthens the role of the Care Quality Commission
develops Monitor, the body that currently regulates NHS foundation trusts, into an economic regulator to oversee aspects of access and competition in the NHS
cuts the number of health bodies to help meet the Government's commitment to cut NHS administration costs by a third, including abolishing Primary Care Trusts and Strategic Health Authorities.
Source: Parliament 2012

7. Health and Social Care Act 2010-12 Evolution of commissioning in the UK
GP Commissioning groups
Primary Care Trusts (PCTs)
Implementation of Health and Social Care Act
GP Fundholding
Practice based commissioning
1997
1991
1998
2005
1999
2012

8. Health and Social Care Act 2010-12 Key policy components of the Act
Clinically led commissioning
Provider regulation
Greater voice for patients
New focus for public health
Greater accountability
Streamlined arms-length bodies
Previously, clinicians negotiated service provision for their populations with the PCT.
Under the Act, clinical commissioning groups (supported by the NHS Commissioning Board) will commission services directly.
Source: DoH 2012

9. Health and Social Care Act 2010-12 Key policy components of the Act
Clinically led commissioning
Choice & Provider regulation
Greater voice for patients
New focus for public health
Greater accountability
Streamlined arms-length bodies
Patients will be able to choose services from a broader variety of providers – including charities and independent providers – as long as they meet NHS costs.
Under supervision of the Monitor agency, providers will be free to innovate to deliver services.
Source: DoH 2012

10. Health and Social Care Act 2010-12 Key policy components of the Act
Clinically led commissioning
Provider regulation
Greater voice for patients
New focus for public health
Greater accountability
Streamlined arms-length bodies
The Act establishes new Healthwatch patient organisations locally and nationally to drive patient involvement across the NHS.
Source: DoH 2012

11. Health and Social Care Act 2010-12 Key policy components of the Act
Clinically led commissioning
Provider regulation
Greater voice for patients
New focus for public health
Greater accountability
Streamlined arms-length bodies
The Act provides the ground work for Public Health England, a new body to drive improvements in the public’s health.
Source: DoH 2012

12. Health and Social Care Act 2010-12 Key policy components of the Act
Clinically led commissioning
Provider regulation
Greater voice for patients
New focus for public health
Greater accountability
Streamlined arms-length bodies
The Act sets out clear roles and responsibilities, keeping Ministers’ ultimate responsibility for the NHS. It limits political micro-management and gives local authorities the responsibility for integrating local services.
Source: DoH 2012

13. Health and Social Care Act 2010-12 Key policy components of the Act
Clinically led commissioning
Provider regulation
Greater voice for patients
New focus for public health
Greater accountability
Streamlined arms-length bodies
Abolition of some administrative bodies (incl. General Social Care Council, Office of the Healthcare Professions Adjudicator, Alcohol Education and Research Council and others).
Re-establishment of NICE and the Information Centre in primary legislation. Extension of NICE’s remit to social care.
Source: DoH 2012

14. 2. Stylised Facts: Swiss Health Care System14 14

15. Swiss Health Care System Indicators – funding/allocation
Indicators of Health Care Costs (2010)
Costs of health care as a proportion of GDP
10.9%*
Health care budget funding
Social insurance
41.8%
Other social protection, means-tested schemes
4.5%
Private households
25.1%
State
19.0%
Health care costs by service provider
Hospitals
35.9%
Outpatient providers
30.8%
Nursing and residential facilities
17.2%
Retail sale of pharmaceuticals and therapeutic instruments
8.7%
Administrative costs and expenditure on prevention and accident provision
6.2%
Private non profit organisations
1.1%
*Share in GDP: 9.9% in 2000 and 10.9% in 2005
Source: Swiss Statistics – overview: Costs, financing – Data, indicators 2010

16. Statutory Health Insurance 1996 Federal Health Insurance Act
Regulated by law and supervised by the OFSP
Universal coverage
Statutory for all Swiss residents (exception for persons eligible for premium subsidies paid by the canton or commune)
Covers sickness, accidents and maternity
Competing non profit health insurances: costs are redistributed among insurers by a central fund based on a risk equalisation scheme adjusted for age, canton, gender, and recently whether the patient stayed more than 3 nights in hospital or in nursing homes.
Basic benefits package: established by the DFI/OFSP, with the support of relevant expert authorities (e.g. Swissmedic), based on whether service is effective, appropriate and cost-effective.
Complementary and supplementary health insurance also available (e.g. choice of hospital doctor, improved accommodation): usually for profit
Source: Camenzind P, Squires D. The Swiss Health Care System, The Commonwealth Fund.

17. Statutory Health Insurance What is covered?
Patient empowerment & choice (unless enrolled under a managed care plan):
Free choice of GPs
Access without referral to specialists in a private practice
What is covered?
General practitioner (GP) and specialist services (mostly all covered);
Pharmaceuticals (positive formulary), physiotherapy (if prescribed by physician), some preventive measures, some complementary medecine (as of 2012);
Mental illness (including psychotherapy, if prescribed by physician);
Costs of selected vaccinations, selected general health examinations, early detection of disease among certain risk groups;
15% of costs of long-term inpatient care (e.g. inpatient homes, institutions for disabled and chronically ill): 2/3 being paid by OOP and the remainder by state subsidies and disability insurances.
Dental care is generally not covered
Source: Camenzind P, Squires D. The Swiss Health Care System, The Commonwealth Fund.

18. Overall health spend (per capita and as % GDP) Cost sharing Efficiency
3. Performance Measurement (also based on survey data, CMWF, )
Overall health spend (per capita and as % GDP)
Cost sharing
Efficiency
Quality
Responsiveness and access
Affordability and access
Care coordination
Relationship with doctor
Patient safety
Management of chronic disease 18 18

19. Health Spending per Capita, 2009 Adjusted for Differences in Cost of Living
Dollars
% GDP
* 2008.
Source: OECD Health Data 2011 (June 2011).

20. Health spend per capita (US$): Escalation over time
Source: OCED health data June 2012. 20 20

21. Health spend as a percent of GDP: Sustainability?
Source: OCED health data June 2012 21 21

22. Cost containment
Switzerland has among the highest expenditures per capita in the world after the US and Norway (2009)
Cost control measures
Regulated competition between insurers and providers
Inadequate risk equalisation, dual funding of hospitals by cantons and insurers, pressure on insurers to contract with certified providers
Managed care plans could reduce such problems
Pharmaceutical coverage decisions: based on effectiveness (Swissmedic) and on price (OFSP),
Efforts to reassess prices of older drugs
Price capping on generic drugs (50% less than original)
Higher co-payment for branded drugs if original drugs available (20% instead of 10%)
Flat dispensing fee for pharmacies
Health technology assessment could increase efficiency in healthcare resource allocation 22 22

23. Access and Affordability

24. Responsiveness and access: Waiting times
Switzerland UK
Access to doctor or nurse when sick or needed care
Same or next day appointment
93%*
70%
More than days
2%* 8%
Waiting times for a specialist appointment
Less than 4 weeks
82%
72%
More than 2 months 5%
19%
Waiting times for an elective surgery
More than 4 weeks
55%
59%
More than 4 months 7%
21%
* Highest score across the 11 countries included in the study
Source: Schoen C, Osborn R. The Commonwealth Fund. The Commonwealth Fund 2010 International Health Policy Survey in Eleven Countries. November 2011. 24

25. Patient cost-sharing
Patient cost sharing in the UK: approx 4.5% of total health spend
Patient cost-sharing in Switzerland: (out-of-pocket payments): approx. 30% of total health spend
Deductibles (ranging between CHF 300-2,500.- / year depending on the health plan)
Co-insurance of 10% on any costs exceeding the franchise (up to a maximum of CHF / year)
Subsidies are available at cantonal level for persons who are not able to pay partly or entirely their premiums:
Approx. 1.6% of the population are not able to cover their premiums
30% of Swiss residents benefit from these subsidies
Issues around affordability of premiums and financial burden to the population 25 25

26. Cost-Related Access Problems in the Past Year
Percent
AUS
CAN FR
GER
NETH NZ
NOR
SWE
SWIZ UK US
Did not fill prescription or skipped doses 16 15 11 14 8 12 7 9 4 30
Had a medical problem but did not visit doctor 17 10 18 6 29
Skipped test, treatment, or follow-up 19 13 31
Yes to at least one of the above 20 22 26 42
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

27. Out-of-Pocket Spending and Problems Paying Medical Bills in Past Year
More than US$1,000 in out-of-pocket costs
Serious problems paying or unable to pay medical bills
Percent
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

28. Access to Doctor or Nurse When Sick or Needed Care
Same- or next-day appointment
Waited six days or more
Percent
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

29. After-Hours Care and Emergency Room Use
Difficulty getting after-hours care without going to the emergency room
Used emergency room in past two years
Percent
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

30. Waited Less Than a Month to See Specialist
Percent
Base: Saw or needed to see a specialist in the past two years.
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

31. Care Coordination and Care Transitions

32. Coordination Problems in the Past Two Years
Percent
AUS
CAN FR
GER
NETH NZ
NOR
SWE
SWIZ UK US
Test results/ records not available at appointment and/or duplicate tests ordered 19 25 20 16 18 15 22 11 13 27
Providers failed to share important information with each other 12 14 23 10 7 17
Specialist did not have information about medical history and/or regular doctor not informed about specialist care 37 35 9 6
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

33. Experienced Coordination Gaps in Past Two Years
Percent
* Test results/records not available at time of appointment, doctors ordered test that had already been done, providers failed to share important information with each other, specialist did not have information about medical history, and/or regular doctor not informed about specialist care.
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

34. Gaps in Hospital or Surgery Discharge in Past Two Years
Percent did NOT
AUS
CAN FR
GER
NETH NZ
NOR
SWE
SWIZ UK US
Receive instructions about symptoms and when to seek further care 16 33 23 22 17 29 27 13 11 7
Know who to contact for questions about condition or treatment 12 20 9 10 5 6
Receive written plan for care after discharge 30 26 44 31 46 28 19
Have arrange-ments made for follow-up visits 47 38 36 32
Receive clear instructions about what medicines to be taking 15 14
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

35. Patient Safety (medical errors)

36. Medical, Medication, or Lab Test Errors in Past Two Years
Percent reported:
AUS
CAN FR
GER
NETH NZ
NOR
SWE
SWIZ UK US
Wrong medication or dose 4 5 6 8 7 2
Medical mistake in treatment 10 11 13 17
Incorrect diagnostic/ lab test results* 3
Delays in abnormal test results* 9
Any medical, medication, or lab errors 19 21 16 20 22 25
Q1705; q1710; q1730
* Base: Had blood test, x-rays, or other tests in past two years.
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

37. Pharmacist or Doctor Did Not Review and Discuss Prescriptions in Past Year
Percent
Base: Taking two or more prescriptions.
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

38. Doctor–Patient Relationship and Patient Activation

39. Doctor–Patient Relationship and Communication
Percent reported regular doctor always/often:
AUS
CAN FR
GER
NETH NZ
NOR
SWE
SWIZ UK US
Spends enough time with you 85 77 82 86 87 71 70 88 81
Encourages you to ask questions and explains things in a way that is easy to understand 69 59 53 64 54 67 31 41
Always/often to both 66 50 61 52 65 27 37 73 72
Q1705; q1710; q1730
Base: Has a regular doctor/place of care.
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

40. Shared Decision-Making with Specialists
Percent reporting positive shared decision-making experiences with specialists*
Q1705; q1710; q1730
* Reported specialist always/often: 1) Gives opportunities to ask questions about recommended treatment; 2) Tells you about treatment choices; and 3) Involves you as much as you want in decisions about your care.
Base: Seen specialist in past two years.
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

41. Managing Chronic Conditions

42. Patient Engagement in Care Management for Chronic Condition
Percent reported professional in past year has:
AUS
CAN FR
GER
NETH NZ
NOR
SWE
SWIZ UK US
Discussed your main goals/ priorities 63 67 42 59 62 51 36 81 78 76
Helped make treatment plan you could carry out in daily life 61 53 49 52 58 41 40 74 80 71
Given clear instructions on symptoms and when to seek care 66 56 64 44 84 75
Yes to all three 48 30 45 23 22 69
Q1705; q1710; q1730
Base: Has chronic condition.
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

43. Between Doctor Visits, Has a Health Care Professional Who . . .
You can easily call to ask a question or get advice
Contacts you to see how things are going
Percent
Base: Has chronic condition.
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

44. Blood Pressure Under Control Last Time Checked Has Heart Disease, Hypertension, and/or Diabetes
Percent yes, under control
Q1705; q1710; q1730
Base: Has heart disease, hypertension, and/or diabetes and blood pressure checked in past year.
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

45. 4. A Fair Comparison? Cross-Cutting Themes and Implications
Room for improvement in all countries
Improving care coordination and system integration
Engaging patients in care and self-management
Using information better and in a cleverer way
Efforts to make health care system more patient-centric, encourage choice and improve access
Further competition needed to increase efficiency and improve performance (both UK and Switzerland)
Better purchasing
More competition in insurance markets and fewer barriers
From a quality of care perspective, no single health system model stands out
U.K. and Switzerland very often lead but have very different systems
Very high co-payments in Switzerland & frequent calls for more affordable health insurance premia
UK and Switzerland lead on perceived quality indicators