Citizen involvement and health system reform Josep Figueras European Health Forum Gastein 5 th October 2005

Are health system reforms increasing citizen involvement? What are the available strategies? Do they make a difference in the outcome (including responsiveness) of the health services?

Citizen involvement / Strategies Informing the public / benchmarking Assessing public views / priorities Advocacy (patient & consumer) groups Formal representation (purchaser & providers) Patients rights legislation Increasing choice (insurer & provider) Participation in clinical decision making Adapted from den Exter in Figueras et al (2005)

Citizen involvement / Strategies Voice and Exit Informing the public / benchmarking Assessing public views / priorities Advocacy (patient & consumer) groups Formal representation (purchaser & providers) Patients rights legislation Increasing choice (insurer & provider) Participation in clinical decision making Adapted from den Exter in Figueras et al (2005)

Citizen involvement / Strategies Voice and Exit Informing the public / benchmarking Assessing public views / priorities Advocacy (patient & consumer) groups Formal representation (purchaser & providers) Patients rights legislation Increasing choice (insurer & provider) Participation in clinical decision making Adapted from den Exter in Figueras et al (2005)

Citizen involvement / Strategies Public / Citizen / Patient Informing the public / benchmarking Assessing public views / priorities Advocacy (patient & consumer) groups Formal representation (purchaser & providers) Patients rights legislation Increasing choice (insurer & provider) Participation in clinical decision making Adapted from den Exter in Figueras et al (2005)

Citizen involvement / Strategies Areas of involvement Informing the public / benchmarking Assessing public views / priorities Advocacy (patient & consumer) groups Formal representation (purchaser & providers) Patients rights legislation Increasing choice (insurer & provider) Participation in clinical decision making Adapted from den Exter in Figueras et al (2005)

Satisfaction with the health care system Sources: (A) Pescosolido et al. 1985; (B) Blendon et al. 1990, # Blendon et al. 1991; (C) Blendon et al. 1995; (D), (F) (G) (H) Eurobarometer, Mossialos, Figueras et al. 2004, (E) & (I) Blendon et al ; (J) OECD 2005; (K) Harris poll 2004 In Busse et al. (2005)

Overall levels of responsiveness WHO Survey Source: Valentine et al (2003)

Stockholm network 2004

Formal representation HTA / Setting the benefit package –E.g. Germany: federal joint committee; UK NICE Insurers / purchasers –In all SHI: representation in sickness funds boards Primary care and hospital providers –E.g. Patient forums in NHS trusts in the UK Whose representatives? Dominance of medical & managerial elites?

Patients rights Statutory establishment of packages of care Patient charters /laws: access, treatment coverage –E.g. guarantees on waiting times and opting out Complaints mechanisms Ombudsperson Backed by legal / financial sanctions?

Thomson and Dixon, EuroObserver 2004

Opportunities for choice Source: Coulter & Jenkinson (2005) Score: 1 (very bad) 2 (bad), 3 (moderate), 4 (good) 5 (very good)

Levels of choice WHO Survey Source: Valentine et al (2003)

Reforms to increase choice Choice of sickness funds in SHI countries –Belgium, Switzerland, Germany, The Netherlands Choice of hospital providers in NHS type systems in UK, Northern and Mediterranean countries Sufficient information / benchmarking? Trade offs with equity and efficiency? –Inverse participation law (R. Klein)

Increasing number and range of strategies Impact on health sytems Involving patients has contributed to changes in the provision of services accross a range of settings but the effects of this process on the quality and effectiveness of services is unknown. Crawford et al Citizen involvement Concluding points

Voice mechanisms have a limted impact However key role of accountability, legal and financial sanctions in increasing impact Exit (choice) strategies have larger impact, but equity and efficiency trade offs Citizen involvement Concluding points