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Cambridge March 15, 2006 INTERNATIONAL HEALTH LEADERSHIP PROGRAMME HEALTH SYSTEM REFORM – LESSONS AND EXAMPLES Dr. Nicolaus Henke.

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Presentation on theme: "Cambridge March 15, 2006 INTERNATIONAL HEALTH LEADERSHIP PROGRAMME HEALTH SYSTEM REFORM – LESSONS AND EXAMPLES Dr. Nicolaus Henke."— Presentation transcript:

1 Cambridge March 15, 2006 INTERNATIONAL HEALTH LEADERSHIP PROGRAMME HEALTH SYSTEM REFORM – LESSONS AND EXAMPLES Dr. Nicolaus Henke

2 050913 GCC conference Systems reform breakout 1 OUR 2005/2006 EXPOSURE TO HEALTH REFORM Americas Canada U.S. Mexico Europe Germany U.K. Norway Portugal Ireland Spain Belgium Sweden Middle East and Africa Mauritania Bahrain Egypt Abu Dhabi KSA Libya Asia/ Australasia Singapore India South Korea China Japan System level and payer/ provider Payer/ provider

3 050913 GCC conference Systems reform breakout 2 Need to be specific about… -which policy / mechanisms that can unleash change - what good looks like in 5 years Large quality variations in spite of growing amount of money inflows 2 Patients starting to act as consumers and demanding better services – but are unwilling to accept resulting tax burden 3 Main elements of reform agreed at policy level – challenges in execution and engagement 4 CHALLENGES Government led systems generally unresponsive 1

4 011706 Team Update V7 3 MANY REFORM PROGRAMS ARE BASED ON SEVEN UNDERLYING IDEAS Improve public health status 1

5 011706 Team Update V7 4 MANY REFORM PROGRAMS ARE BASED ON SEVEN UNDERLYING IDEAS Improve public health status 1 Ensure financing access to care 2

6 011706 Team Update V7 5 MANY REFORM PROGRAMS ARE BASED ON SEVEN UNDERLYING IDEAS Improve public health status 1 Ensure financing access to care 2 Foster quality 3

7 011706 Team Update V7 6 MANY REFORM PROGRAMS ARE BASED ON SEVEN UNDERLYING IDEAS Improve public health status 1 Ensure financing access to care 2 Foster quality 3 Adjust capacity 4

8 011706 Team Update V7 7 MANY REFORM PROGRAMS ARE BASED ON SEVEN UNDERLYING IDEAS Improve public health status 1 Ensure financing access to care 2 Foster quality 3 Adjust capacity 4 Involve consumer 5

9 011706 Team Update V7 8 MANY REFORM PROGRAMS ARE BASED ON SEVEN UNDERLYING IDEAS Improve public health status 1 Ensure financing access to care 2 Foster quality 3 Adjust capacity 4 Involve consumer 5 Introduce competition 6

10 011706 Team Update V7 9 MANY REFORM PROGRAMS ARE BASED ON SEVEN UNDERLYING IDEAS Improve public health status 1 Ensure financing access to care 2 Foster quality 3 Adjust capacity 4 Involve consumer 5 Introduce competition 6 Adjust regulation and institutions / MOH 7

11 011706 Team Update V7 10 MANY REFORM PROGRAMS ARE BASED ON SEVEN UNDERLYING IDEAS Improve public health status 1 Ensure financing access to care 2 Foster quality 3 Adjust capacity 4 Involve consumer 5 Introduce competition 6 Adjust regulation and ministry 7

12 011706 Team Update V7 11 … AND THREE WAYS TO DRIVE THROUGH EACH BUILD AWARENESS Improve public health status 1 Ensure financing access to care 2 Foster quality 3 Adjust capacity 4 Involve consumer 5 Introduce competition 6 Adjust regulation and ministry 7

13 011706 Team Update V7 12 … AND THREE WAYS TO DRIVE THROUGH EACH BUILD AWARENESS SET INCENTIVES Improve public health status 1 Ensure financing access to care 2 Foster quality 3 Adjust capacity 4 Involve consumer 5 Introduce competition 6 Adjust regulation and ministry 7

14 011706 Team Update V7 13 … AND THREE WAYS TO DRIVE THROUGH EACH BUILD AWARENESS SET INCENTIVES MANDATED ACTIONS Improve public health status 1 Ensure financing access to care 2 Foster quality 3 Adjust capacity 4 Involve consumer 5 Introduce competition 6 Adjust regulation and ministry 7

15 011706 Team Update V7 14 Improve public health status - Examples 1 Awareness: Incentives: Mandates: - Educate public on diet, exercise, smoking, safe sex - Measure “Early Health” Differential insurance premiums based on successful lifestyle changes - Smoking ban - Vaccination campaigns - Require the use of automotive seat restraints and motorcycle helmets

16 050913 GCC conference Systems reform breakout 15 WHAT THE EARLY HEALTH INDEX COULD LOOK LIKE Single index Traffic light system ‘Nominal’ –Index –Financial Description Major indicators are scored red, yellow or green Education Vaccination Diet In vivo Dx … USChinaJapan… Example Spend by disease stage (Diabetes example) Prev- ention Diagnosis Treat- ment Comp- lication ~1% 35% 64% ~0% ‘Actual’ –DALY –Expectation of life lost –Healthy life expectancy at birth US China Japan UK … Life lost due to low investment in ‘Early Health’ 15 years 20 years 5 years 15 years

17 050913 GCC conference Systems reform breakout 16 ‘STRAW MAN’- A SMALL NUMBER OF INTERVENTIONS DRIVE ‘EARLY HEALTH’ PERFORMANCE FOR MAJOR DISEASES * Trachea/Bronchus/Lung Cancer 1 HIV/AIDS Critical ‘Early Health’ interventions PreventionScreeningDiagnosis Education In vitro diagnostics 2 Resp. cancer* Education (e.g., reduction in smoking) Genotyping (?) In vivo diagnostics In vitro diagnostics (e.g., pathology) 3 COPD 4 Measles Vaccination Physician consultation 5 Road traffic accident Education – – 6 Stomach cancer Education (e.g., reduction in smoking ?) Diet Endoscopy Genotyping (?) Endoscopy Causes of death 7 Hypertensive heart disease Education Diet Physician consultation Genotyping (?) Physician consultation 8 Tuberculosis Vaccination In vitro diagnostics (e.g., microbiology) In vivo diagnostic In vitro diagnostics (e.g., microbiology) In vivo diagnostic 9 Self inflicted Education Physician consultation 10 Ischemic Heart disease Education (e.g., reduce BP, reduce obesity, reduce cholesterol) Physician consultation In vitro diagnostics Physician consultation In vivo diagnostics (e.g., angiography)

18 011706 Team Update V7 17 Ensure financing access to care 2 - Educate about need to save - Tax incentives and employer contribution to insurance schemes - Mandated insurance or tax funded provision for all

19 Pages Hencke AI v0.1 MAURITANIA TESTS A MICRO-INSURANCE SCHEME FOR FULL PREGNANCY COVERAGE FOR $ 9 PER PREGNANCY Payment of all costs included in the services pack Respect of the standardised therapeutic procedures Regular and secured purchase of medicines and consumables Presence of qualified personnel at all instances of care Availability of all technical means necessary to administer the care needed and covered 1 2 3 4 5

20 Pages Hencke AI v0.1 19 PRELIMINARY RESULTS IN NUMBERS: ENCOURAGING PARTICIPATION IN PREVENTIVE ACTIVITIES; STRONG REDUCTION OF MORTALITY Access to care *CME: Consultation prénatale **Consultations Pré-et Post-Natale) Number consultations / woman2,61,7 Laboratory visits attendance98%31% Echography81%21% Childbirth's file made and maintained100%40% Attendance of standard pre- and postnatal consultations83%50% Maternal mortality 103747 (par 100k/par naissance ou par femme) With F-F obst. care Without F-F obst. care

21 050913 GCC conference Systems reform breakout 20 Ensure quality in a devolved system 1. Set standards 3. Monitor and provide information 4. Assess, audit and enforce 5. Enable choice and competition through stronger payer function Levers Strengthen national registration process, credentialing and accreditation mechanisms Strengthen peer review and ongoing validation Introduce rigorous privileging at the provider level Use multiple levers to increase information available to patients Prioritise key indicators to measure outcomes and adherence to best practice Provide real-time standardised information through clear data protocols Make information freely available to commissioners, public and providers Build GP capabilities to monitor provider performance and analyse data Make investigation and enforcement for quality failures faster and more effective Strengthen consequence management for poor performers Extend choice and patient ownership of care decisions (e.g., treatments) Strengthen payer skills, resources and systems to improve quality Leverage payer purchasing power through joint commissioning (e.g., consortia) Standardise care pathways and adherence to high quality care through commissioning Strengthen existing quality incentives in contracts Create competitive commissioning market 2. Provide incentives Provide financial incentives for high quality care to primary and secondary care providers Build quality indicators into Payment by Results Foster quality 3

22 050913 GCC conference Systems reform breakout 21 DETAILED STANDARDS FOR CARE – FOR EXAMPLE JCAHO AND CMS *JCAHO implementation with July 2004 discharges **CMS and JCAHO changing to 120 minutes with July 2004 discharges Source:JACHO; CMS; interviews; team analysis CMS JCAHO Acute MI Aspirin at arrival Aspirin prescribed at discharge ACE inhibitor for left ventricular systolic dysfunction Adult smoking cessation advice/counseling Beta blocker prescribed at discharge Beta blocker at arrival Mean time to thrombolysis Thrombolytic agent received with 30 minutes of hospital arrival Mean time to PCI PCI received within 120 minutes of hospital arrival Inpatient mortality * *,** Heart failure Discharge instructions Left ventricular function assessment ACE inhibitor for left ventricular systolic dysfunction Adult smoking cessation advice/counseling Pneumonia Initial antibiotic received within 4 hours of hospital arrival Initial antibiotic received within 8 hours of arrival Antibiotic timing (Mean) Initial antibiotic selection for community acquired pneumonia (CAP) in immunocompetent patients Blood cultures performed with 24 hours prior to or after hospital arrival Blood culture performed before first antibiotic received in hospital Influenza vaccination Pneumococcal screening and/or vaccination Adult smoking cessation advice/counseling Oxygenation assessment * * * Surgical infection prevention Prophylactic antibiotic received with 1 hour prior to surgical incision Prophylactic antibiotic selection for surgical patients Prophylactic antibiotics discontinued within 24 hours after surgery end time * “I foresee JCAHO and CMS merging toward a common standard. We need leadership from a federal entity to ensure we don’t have disparate standard.” – JCAHO Associate Director of Oryx “JCAHO and CMS have plans to work together to expand standards into areas like pain management, children’s asthma, and ICV care. We have no qualms about taking on metrics other organizations like Leapfrog have developed.” – JCAHO Associate Director of Oryx

23 050913 GCC conference Systems reform breakout 22 METRICS USED BY CMS/Premier Demonstration Project * Heart Attack (Acute Myocardial Infarction or AMI) Aspirin at arrival Aspirin at discharge ACE Inhibitor for Left Ventricular Systolic Dysfunction Beta Blocker at arrival Beta Blocker at discharge Thrombolytic received within 30 minutes of hospital arrival PCI received within 120 minutes of hospital arrival Smoking cessation advice/counselling Inpatient mortality rate Coronary Artery Bypass Graft (CABG) Aspirin at discharge CABG using internal mammary artery Prophylactic antibiotic 1 h prior to surgical incision Prophylactic antibiotic selection for surgical patients Prophylactic antibiotics discontinued within 24 hours after surgery Inpatient mortality rate Post operative haemorrhage or haematoma Post operative physiologic and metabolic derangement Heart FailureHeart Failure (HF) Assessment of Left Ventricular Function ACE Inhibitor for Left Ventricular Systolic Dysfunction Detailed discharge instructions Adult smoking cessation advice/counselling *3 year pilot at consortium of nonprofit health systems including 270 hospitals and treating 400,000 patients in the 5 conditions Source: CMS/Premier Demonstration Project; WSJ, 4 May 2005; CMS Press Release 3 May 2005 Hip and Knee replacement Prophylactic antibiotic 1 h prior to surgical incision Prophylactic antibiotic selection for surgical patients Prophylactic antibiotics discontinued within 24 hours after surgery Post operative haemorrhage or haematoma Post operative physiologic and metabolic derangement Readmissions 30 days post discharge Community Acquired Pneumonia (CAP) Oxygenation Assessment Initial Antibiotic Antibiotic timing Pneumococcal screening / vaccination Blood culture performed first antibiotic received in hospital Smoking cessation advice/counselling Influenza screening / vaccination 9093 8690 6476 8591 7080 AMICABGHFHip & Knee CAP Median quality scores improvements – year 1

24 050913 GCC conference Systems reform breakout 23 DIFFERENCES IN QUALITY BETWEEN PUBLICLY REPORTING AND NON-PUBLICLY REPORTING PLANS Measure * Public reporters, %Non-public reporters, % Difference, % 19.8 9.0 4.5 9.7 7.4 13.6 7.6 10.5 3.5 5.5 3.1 Adolescent immunisation status (combo 1) Beta-blocker treatment after heart attack Check-ups after delivery Childhood immunisation status (combo 1) Cholesterol management – Control (LDL <130) Cholesterol management – Screening Comprehensive diabetes care – Eye exams Comprehensive diabetes care – HbA1c testing Comprehensive diabetes care – Lipid control (LDL <130) Comprehensive diabetes care – Lipid profile Timeliness of prenatal care *Selected averages for commercial (non-Medicare/Medicaid) providers Source:NCQA – The State of Health Care Quality, 2004

25 050913 GCC conference Systems reform breakout 24 USE OF INFORMATION TO DRIVE QUALITY Reduction in mortality rates since data began to be published by a private company Mortality rate for open heart procedures in children under 1 % Individual hospital trusts A B C D E F Source: Aylin et al. British Medical Journal, October 2004 U.K. EXAMPLE

26 050913 GCC conference Systems reform breakout 25 QUALITY MANAGEMENT IN PRIMARY CARE – NETHERLANDS Physicians take part in 6–12 peer reviews per year Peer reviews Treatment guidelines About 70 guidelines have been developed Quality monitoring Statistical analysis of treatment processes and outcomes Video recordings of physician- patient interaction Practice visits Goal is mainly to evaluate management processes About 40% of all general practitioners take part Key facts Measures to ensure quality History of quality initiatives Initiatives to introduce peer reviews and treatment guidelines Dekker reforms introduce competition and focus on quality Law passed to enforce annual quality reviews 1970s 1980s/90s 1996 IMPROVE QUALITY

27 050913 GCC conference Systems reform breakout 26 CHRONIC DISEASE MANAGEMENT SHOWS POTENTIAL EXAMPLE Source: PCT interviews; North Bradford PCT Performance Report, Sept. 2004; CDM Compendium, DH, 2004 Example: North Bradford PCT Diabetes GPs Respiratory GPs Frequent flyers GPs Primary care center Nurse support Emergency admissions 25% 38%-73%15%-70% 45% 90% 40%-50% Average length of stay Results Approach Region’s patients stratified by risk group, creating 4-5 pools, e.g., –Diabetes –Respiratory –Frequent hospital use GPs merged into primary care groups of up to 10, with 2 each trained on 1 disease (e.g., diabetes), networked with local specialist (to handle escalated cases), and given 24/7 nurse support Each patient assigned exclusively to GP/nurse, located at the primary care center System designed to reduce complications and time spent in the hospital

28 050913 GCC conference Systems reform breakout 27 CHRONIC DISEASE MANAGEMENT AND PRO-ACTIVE CASE MANAGEMENT Constant weight checks More healthy nutrition Best practice medication Disease Congestive heart failure (CHF) 1 Disease management interventions GPsNurseO/P Effects on existing treatment structures Daily blood sugar checks Expert patient programme Best practice medication Diabetes 2 Best practice medication Expert patient programme Peak flow monitoring Asthma 3 COPD 4 CHD/ Hypertension 5 Monitoring risk profile Behaviour modification Best practice medication High risk / older people / Frequent flyers 6 A&E Emergency Admissions LOS Best practice medication Expert patient programme Peak flow monitoring Identification of patients Allocation of case manager Regular monitoring and review Pro-active assessment and treatment Best practice medication 25%45% 40-90%30% 38-73%90% 20%70% ??% 15-70%40-50% Source: McKinsey analysis; Chronic disease management compendium, DH, 2004

29 011706 Team Update V7 28 Adjust capacity - examples 4 Specialised players in US and UK Home monitoring to support chronic disease management Intermediate care in U.S. Regional emergency care planning in England

30 050913 GCC conference Systems reform breakout 29 Increasing case load Number of heart surgeries Lower costs US$000 43 27 THIU.S. average - 37% Higher quality – better survival rate, % 82 92 THI 5 year U.S. average 1 year SPECIALISATION IN HEART SURGERY – USA Source: Texas Heart Institute 137 THIU.S. average 10,500 IMPROVE QUALITY

31 050913 GCC conference Systems reform breakout 30 SYSTEM PATIENT FLOW (REGION WITH 3 MILLION PEOPLE) Blue light ambulance Emergency care Community care (incl GPs) Paramedic Social care Acute Care “A&E” ITU CCU Inpatient care Diagnostics Outpatients Intermediate care Elective care 24x7 service Telephone service Patient Source:Team analysis Key thrusts Triage early Avoid inappropriate hospitalisation Provide scheduled care where possible

32 050913 GCC conference Systems reform breakout 31 UTILIZATION CHANGES * Based on 5-year projections ** Based on national targets for diagnostics Source:Team analysis -20- 30% Activity redistribution to other Services (e.g. ECS) Activity redistribution to self care Underlying Activity Growth ALOS reduction (partially due to transfer to Intermediate care; likely to be less than full 30% identified in initiatives, as simpler cases will have been transferred out) 16% -84% 0% A+E 16% -36% -8% Inpatient spells 16% -60% -10% Outpatient Episodes 117%* * -44% 0% Diagnostic Episodes Activity Productivity

33 050913 GCC conference Systems reform breakout 32 IMPACT ON SITES Acute care Emergency care Community care Diagnostics Intermediate care Elective care *22 community hospitals, 12 of which are non-Trust sites. Many of these currently provide (sub)-residential care **Highly preliminary Source: Team analysis Sustainable System (5yrs+) 5-7 3-4 20 Co-located with Acute care/Emergency care 17-22 100-200 Current 3 Co-located with acute 22* 390 9 6 Interim System (2-3yrs)** 6-18 22 300-350 7-8 5-6

34 050913 GCC conference Systems reform breakout 33 *Stroke: 4 days acute, then rehab, Joint replacement 2 days acute then rehab, fractured neck of femur 2 days acute then rehabilitation in intermediate care Source:Hospital bed utilisation in the NHS, Kaiser Permanente and the US Medicare programme. Ham et al. BMJ 2003;327:1257-60, Bedfordshire and Hertfordshire SHA NHS OBDs per 100’000 population >65 yrs, 000s Stroke Joint Replace- ment Fractured neck of femur Total ALOS in NHS, days ALOS in Kaiser, days OBDs with Kaiser ALOS, 000s OBDs saved per 100’000 population >65yrs,000s Total OBDs, 000s Current ALOS, days Best practice ALOS, days OBDs if applied best practice, 000s OBDs save, 000s Comparison Kaiser—NHS Benchmarking Beds and Herts SHA (1.5m population) 22.3 27 4.26 3.5 18.8 55.5 17.7 ~4* 12.5 33.0 8.2 12 4.3 2.9 5.3 38.3 13.5 ~4 11.3 27.0 8.4 27 4.9 1.5 6.9 34.0 20 ~2 3.4 31.6 30.7 12.5 91.6 38.9 34.0 Current LOS range, days0–3930–225 0–515 Kaiser comparison suggests there is much scope to reduce LOS in hospitals 38.9 INCREASE CAPACITY STEPDOWN SERVICES CAN SUBSTANTIALLY REDUCE LENGTH OF STAY IN ACUTE CENTRES Top 3 conditions account for 40% of potential shift from acute sector to intermediate Extrapolates to 3m bed days in England

35 011706 Team Update V7 34 Involve consumer 5 Urban sickness funds in China Differentiate offering to consumer segments Consumer information in Norway

36 050913 GCC conference Systems reform breakout 35 Increasing rights and expectations Growing demand for efficient, convenient, andpersonalized services (from and beyond health care) Greater clarity of treatment outcomes More power to challenge health-care professionals Larger influence of advocacy groups Increasing and changing health-care needs Aging population Increased prevalence and burden of disease Greater focus on wellness and prevention Broader definition of disease Increasing responsibilities Rolling back of health- care systems (increased rationing and co-payment) Requirement for active decision making Product innovation from insurers/providers Advanced technology and more information Better access to health information More treatment options Advancing medical and information technology Growing innovation in private sector FOUR MAIN DRIVERS OF CONSUMERISM

37 050913 GCC conference Systems reform breakout 36 GOVERNMENT RESPONDING TO SOCIAL PRESSURE *Police definition Source:Ministry of Public Security statistics; People’s Daily Government launched “Harmonious Society” campaign, November 2004 –Intended to “enable all people to share the social wealth created in reform and development” –Includes increased investments in healthcare and other social infrastructure In healthcare, is seeking to increase “Basic Urban” insurance cover from 130 to ~450 MM Is also piloting rural insurance scheme, though at very low coverage levels 10 50 96 9 40 95 25 32 0102 58 2003 45 11 98 12 9400 15 19939799 “Mass incidents”* in China Thousands Government needs to improve healthcare to address foreign investors’: Concerns about lost productivity Concerns about having to pick up the slack Government increasingly concerned by violent protests

38 050913 GCC conference Systems reform breakout 37 Lives 2003 Basis of industry growth projections Most insurance products have high deductibles and co-pays, leading to continued suppressed demand Insurance coverage ILLUSTRATIVE Rural scheme or out of pocket Without private insurance Low, very cost-sensitive demand Other Rural scheme with U.S.$75 deductible, 80% co-pays Private cover to reduce out-of- pocket expense Coastal rural Urban scheme deductible 10% average salary (U.S.$700/yr in Shanghai); Co-pay ~40% (outpatient), 10-20% (inpatient), depending on region and service Mass market ~25MM Private insurance Urban Scheme Premium MULTI-TIER CONSUMER MARKET IS EMERGING *Projection assumes premium and coastal urban segments grow at private insurance premium CAGR (13% 2003-2010); all Premium have Urban Basic insurance; Government achieves goal of insuring 450 MM urban population; Chinese population grows to ~1,380 MM Source: MOH 2003 National Health Services Survey; Asian Demographics; literature survey; team analysis Lives 2015 ~100MM ~105MM~350MM ~15MM~50MM ~1,150MM~900MM

39 050913 GCC conference Systems reform breakout 38 1,319.0 Cost of treatment80% Co-payExcluded services 96.6 DeductibleReimbursement MEDICAL EXPENSE EXAMPLE: BROKEN FINGER RMB (US$1 = 8.3 RMB)

40 050913 GCC conference Systems reform breakout 39 Sources: 1,500 telephone interviews evenly distributed in Germany, U.K., Italy in March 2001; McKinsey analysis Desire for health-care proactivity “Anxious Seeker” 14% “Receiver” 17% “Proactive” 21% Psychological burden of health concerns High LowHigh Low “Depender” 14% “Avoider” 18% “Stoic” 16% While distinct segments exist, patient behavior varies widely within each segment WE SEE SIX DISTINCT ATTITUDINAL SEGMENTS WHICH ARE GOOD PREDICTORS AND PROXIES FOR BEHAVIOUR

41 40

42 41 INVOLVE CONSUMER TO DRIVE HOSPITAL QUALITY How it works Free choice of hospital (since January 2001) Patients free to call toll free number or visit website to find shortest waiting times and book treatment (since May 2003) Hospital outcome ratings and rankings of service level by hospital on internet (since September 2003) Patient is guaranteed treatment within a certain time period by law Source:www.sykehusvalg.net; McKinsey

43 011706 Team Update V7 42 Introduce competition 6 Leads to new ideas and new dynamics (better services, more efficient medical cost management) Example: Germany, U.S. May impede chronic disease management and add overhead cost Drives through improvements in efficiency and quality of care as well as responsiveness to patient needs Examples: Foundation Trusts in England, regional budgets and contracting (e.g., Norway, Italy, Germany) Need to make the choosing process meaningful and data transparent to avoid competition on meaningless parameters – in reality choice does not mean patients choosing hospitals, but doctors choosing doctors with very limited factual information Hypotheses based on experiences so far Competition between payors Contestabilty for hospitals and doctors Building blocks Regulatory framework critical for overall success, two key roles –Consumer protection / quality watchdog –Financial, governance and market rules and behaviours of players Independent regulation

44 050913 GCC conference Systems reform breakout 43 NHS IN ENGLAND IS BUYING IN DIAGNOSTIC AND SURGERY CAPACITY FROM THE PRIVATE SECTOR INCREASE CAPACITY

45 050913 GCC conference Systems reform breakout 44 SETTING UP OF FOUNDATION TRUSTS IN ENGLAND New freedoms bestowed on hospitals Potential ways of improving services Able to borrow money on capital markets No more directives from DH (previously over one per day) Full profit and loss accountability Able to develop strategic partnerships Able to develop new services Companies with P&L, in charge of revenues and costs Investment in new facilities Innovating to develop patient services Focus on efficiency and cost effectiveness – keeping the savings

46 050913 GCC conference Systems reform breakout 45 Policy Regulation Role Payors Although hospitals can be public sector, increasing trend to operational independence of hospitals Public and private insurers SingaporeGermany United Kingdom Norway Country Private & public hospitals; private physicians Ministry of Health Professional organisations Public hospitals Dept. of Health Primary Care Trusts Healthcare Commission; SHAs Public hospitals Ministry of Health National Board of Health Private & public hospitals; private physicians Ministry of Health Qatar and Abu Dhabi have already moved functions from ministries to authorities; the UAE federal government is following Service provision Adjust regulation and institutions / MOH 7

47 050913 GCC conference Systems reform breakout 46 2 ROLES: ECONOMIC REGULATION AND CONSUMER PROTECTION TO REGULATE EX-STATE RUN INDUSTRIES (UK EXAMPLE) *Reflects network/distribution segment of market vs. other market segments (e.g., broadcasting, gas metering) Source:Interviews with regulators Economic regulation Consumer protection Healthcare Housing Gas & electricity* Commu- nication* MailFTsNon-FTsIS Set conditions for market entry and exit Monitor and disclose financial performance n/a Manage financial in- stability n/a Achieve sustainable profits for providers n/a Manage competition Ensure affordable end- user pricing n/a Set quality standards Monitor quality n/a Encourage choice and innovation Promote safety of public Manage externalities (e.g., environmental impact) n/a WaterRail Government Economic regulator Quality and safety regulator(s)

48 050913 GCC conference Systems reform breakout 47 SHOULD MINISTRY AND HEALTH SERVICE BE SEPARATE? Source:Team analysis Minister of Health Standards and quality (CMO) Primary Care Strategy and Policy co-ord DH Finance DH IT policy and standards DH HR policy and standardds DH communications Secondary Care Social Care & Public Health Other Care (Drugs, Mental health, Dental) Cancer Diabetes … Investigations & Inquiries NHS communications Health Service Executive SHAs Provider development NHS Finance, Strategy & Planning NHS IT implementation NHS workforce Planning and capability development DRAFT

49 050913 GCC conference Systems reform breakout 48 DRAWING IT TOGETHER – EXAMPLE OF A DIAGNOSTIC IssueAction System appears to be accumulating debt System unable to make most effective use of resources Fix Patient Treatment at the Expense of the State Fix Health Insurance Organisation Rationalise services 2. Fix financing Poor exposed to health shocks as a result of high level of out of pocket spend Launch package Shift OOP spending into pools Subsidise poor/ fund for non-risk events (i.e., primary care, ?old age?) 1. Increase pooling Poor responsiveness of system, notably hospitals, to patient needs –Centrally driven – hospitals have little flexibility on staff & budget Fix clinic/ hospital management through increased autonomy and building capabilities –Devolve (some) resource flexibility (staff, budget) Focus on defined basic package 3. Improve service delivery While physical access is not an issue, service, drug & quality staff availability is Increase incentives to work in rural areas (clinicians & management) Reform takleef (existing allocation mechanism) 4. Improve access for the poor/ rural 94% of nurses have only secondary level of education Medical schools are expanding imperilling standards Weakest doctors are allocated to positions with least oversight/ training Step up post-high school nurse training Increase oversight/ training for rural doctors 5. Increase levels of education MoHP currently sprawls across all roles Suboptimal performance Institute independent quality assessment/ accreditation Simplify organisational structure 6. Refocus organisations

50 050913 GCC conference Systems reform breakout 49 EXAMPLE OF A PROGRAM – ENGLAND 1999-2008 Steps 1) Create capacity 1999-2004 Set targets Abandon 4 regional HQ and health authorities, create 28 SHAs and 300 PCTs under Triple nominal spend over 10 years to meet targets 2) Create plural market 2004-2008 Aggressive new access targets Choice Plurality of supply (FT, ISTC) Incentives – PBR, Consultant contract, GP contract

51 050913 GCC conference Systems reform breakout 50 Mar-00 Sep-00 Mar-01 Sep-01 Mar-02 Sep-02 Mar-03 Sep-03 Mar-04 Sep-04 Sep-05 Mar-05 WAITING TIMES Inpatient waiting times in England (March 00 – September 05) Number of patients waiting for admission > 6 months > 9 months > 12 months > 15 months

52 050913 GCC conference Systems reform breakout 51 KEY OBSERVATIONS AND TAKEAWAYS Seven ideas underlying most system reforms Incentives matter, including how payers pay and how provider contestability is enabled Information matters Balance of mandates vs incentives vs information is important Involving the consumer will be critical Sequencing and capability building is one of the biggest challenges Success may be driven by –A very clear view of what system success looks like in 3-5 years (results) –Focus on executing on 2-3 key policies to get there, and evolving them over time


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