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

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

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

Summary

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

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

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

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

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

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

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

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

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

2. Stylised Facts: Swiss Health Care System 14 14

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

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 http://www.eda.admin.ch/eda/en/home/topics/intorg/un/unge/gepri/manins/inshea.html Source: Camenzind P, Squires D. The Swiss Health Care System, 2011. The Commonwealth Fund.

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 http://www.eda.admin.ch/eda/en/home/topics/intorg/un/unge/gepri/manins/inshea.html Source: Camenzind P, Squires D. The Swiss Health Care System, 2011. The Commonwealth Fund.

Overall health spend (per capita and as % GDP) Cost sharing Efficiency 3. Performance Measurement (also based on survey data, CMWF, 2010-2011) 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

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

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

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

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

Access and Affordability

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

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 700.- / 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

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.

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.

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.

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.

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.

Care Coordination and Care Transitions

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.

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.

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.

Patient Safety (medical errors)

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.

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.

Doctor–Patient Relationship and Patient Activation

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.

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.

Managing Chronic Conditions

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.

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.

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.

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