Three pillars of a successful national healthcare system
Countries across the world are striving to improve their national Healthcare systems. Can we learn some best practices from such endeavors to make the Healthcare a universal success? In my previous blog I was arguing that the success of the national healthcare system does not directly depend on financing models: public, private or the mix of both. The important factor is that citizens are included in the process of decisions in regard to the scope and quality of services they receive.
Healthcare system does not exist in a social vacuum, but is functioning in coherence with other national socio-political institutions. The more value the individual life means for the nation, the more efforts the government undertakes to protect this life. Therefore one can notice without any high-brow scholar studies the correlation between the level of democratic maturity and the quality of life and medicine in the country.
Thus France, Belgium, Germany, UK, Netherlands, Sweden, Switzerland and other developed European countries have a life expectancies within the range of 80-87. Countries like Eritrea, Ethiopia, Tadzhikistan and Russia have life expectancy within the range of 60-69.
But the mature healthcare systems of the developed world are also not on the same level. Thus United States, one of the biggest spender on healthcare in the World (17% of GDP), is underperforming compared to the European countries such as France, Germany, the Netherlands, Norway, Sweden, Switzerland, the United Kingdom. More than 27% of Americans think that they need to fundamentally change their Healthcare system compared to 4% population of UK or 5% of the Dutch people. The mortality ratio amenable to healthcare is also higher in the US (96 deaths per 100.000 population) compared to EU countries such as France (55 deaths per 100.000 population, Sweden 61, Norway 64 or Netherlands 66 deaths per 100.000 citizens .
The UK is leading the Commonwealth fund 2014 survey scoring high for the quality of care, efficiency and low cost at the point of service, with Switzerland coming an overall second and Sweden as the third. Patients, from their side, are having a slightly different view, according to the 2014 Euro Health Consumer Index survey, giving preferences to Netherlands, Switzerland and Norway.
The UK and Norway have public system predominantly funded through general taxation and earmarked taxes. The Netherlands and Switzerland have a strong emphasis on individual contributions and direct citizens’ payments.
What those countries with seemingly different approaches to the healthcare management have nevertheless in common? The underlying aspect that unites them all is the strong public impact on the quality and distribution of Healthcare services. Despite the fact that the direct patient’s experience is still not yet regularly captured by the professional medical community (only 1% of GPs in France, 7% in Norway and 15% in Switzerland are routinely receiving and reviewing patient satisfaction and experience data), there are other channels citizen can use to express their opinion on the services they receive. Such channels are:
- Local decision makers.
Decisions regarding citizens’ healthcare could be taken centrally, e.g., as in the US or locally, e.g., as in Switzerland. The closer the gap between citizens and healthcare decision makers, the more adjustable is the system to the needs of its constituents.
26 Swiss cantons are largely responsible for the provision of health care operated by private insurance companies primarily on a regional basis. Similar to states, cantons are sovereign in all matters, including health care.
In Sweden county councils’ expenditures on healthcare amount to nearly 72 percent, 8 percent to municipalities, leaving only to about 2 percent to the central governments (Statistics Sweden, 2014).
Local governmental organizations are often much more receptive to citizens aspirations and complaints. After all, patients are part of their electorate. They may very well be their neighbors or people they meet in the local pub. The important factor: one can directly look into the eyes of those authorities and ask tough questions.
Countries with the centralized governmental health management nevertheless tend to delegate responsibilities to local authorities to avoid monopoly and to balance their own power. Thus UK has established Healthwatch, a national body to promote patient interests in each locality. The local Healthwatches support people’s complaints, reporting their concerns to Healthwatch England, which can then recommend actions to the Care Quality Commission. In addition, local NHS bodies, including general practices, hospital trusts and commissioning groups, are expected to support their own patient engagement groups and initiatives. Norway, where the government has an overall responsibility of providing care, municipalities are playing a strong role in care delivery, especially in the area of primary care.
On the contrary, when the gap between the consumers (e.g., patients) and the service delivery providers such as centralized government organizations or large Health Insurance funds is huge and the relationships are depersonalized, the chasm is often filled by bureaucracy and the voices of citizens are doused. In this case, the authorities are lured to protect their own interests vs. the interests of their constituents.
Could it be the reason why the US Healthcare reforms driven by the government in combination with huge conglomerates such as Medicare and Medicaid have more challenges and less success than their European counterparts? The latter have a stronger orientation to pushing the decisions towards local authorities that are more receptive to public control.
- Direct financial involvement of citizens
The US spend twice as much money per capita on healthcare as the average developed country. Nevertheless the life expectancies in the country (79 years) is lower than in the majority of the developed countries in the world. The key to the successful care therefore is not the the amount of spending, but in its intelligent distribution.
The Dutch and the Swiss healthcare systems can be viewed as an interesting example of the citizen’s “quality control” over healthcare services through the direct involvement in financial mechanisms. After both countries decided to erase the barriers between private and public insurances, citizens were obliged to buy the “basic package” of the minimum health insurance deal that covers all ‘essential healthcare’ set by the government. The logic was the following: if you pay directly, you know what you should get. Dutch and Swiss consumers are keenly aware of the costs of their health insurance as well as of services they are guaranteed to receive. Contrary to that, health services covered by large health insurance funds or through payroll taxes are much less transparent and utterly depersonalized. One is contributing to the pool, not always being sure what one can fish out of it.
If you pay you can choose a supplier or a vendor. Competition is always a strong mechanism to leverage quality and accessibility of care. Dutch patients can switch between 40 private small health insurance houses all over the country. Switzerland has a similar approach with a 100 small private insurance companies to manage care. All of them are competing on price and quality, struggling to keep premiums low and quality high for fear of losing customers and profits.
We like places where everybody knows us and welcomes with a smile, therefore we normally prefer our small local bakery to the large supermarket. If we do not like the price and quality of muffins in our bakery we are going to another one around the corner. Why can’t we transfer this model to the healthcare?
3. Patient-oriented information technology.
There is a clear correlation between the advancement of healthcare and acceptance of ICT. The UK was one of the first countries to embark on the large-scale national eHealth Project. By 2013, nearly half the population of England had a Summary Care Record. Electronic transfers (from general practices to pharmacies) are widely used for prescriptions and for the storage and distribution of digital images (e.g., scans, X-rays). The Choose and Book system provides patients with the online choice of hospital where they prefer to be treated. Through MyNHS Portal patients can monitor the performance of hospitals and GPs in their area, providing direct comments and recommendations.
Sweden is another country that uses ICT extensively to enhance care of its citizens. The 1177 services in Sweden are providing a 24 hours access to medical staff to advise patients on recommended treatments. Additionally, there is a collaborative initiative between all county councils and regions to provide online information about pharmaceuticals, medical conditions, and pathways for seeking care, known as 1177.se.
The spread of wearable devices empowered by consumer mobile applications generated “mHealth” – a collection of electronic options of providing care. Not only mHealth gave way to new citizens services like online booking, remote diagnostics, patient monitoring and online rehabilitation, it also generated independent channels for citizens to express their opinion on the level of services they were receiving as well as on the their governments’ efforts to improve such services.
Yet the majority of medical systems were not interconnected, thus preventing data sharing between physicians and patients. Interoperability seemed to be an insurmountable barrier for the eHealth success.
The evolution of the Cloud technologies was a big step forward. They allowed patients and physicians to communicate with each other remotely, sharing data from Electronic Medical Records (EMR) and Personal Health Records (PHR). Systems such as Microsoft HealthVault® originally launched in 2007 in the USA is available now world-wide. Such systems help individuals to collect, manage and share their medical and wellness information. Some of the examples include common clinical types (medication prescriptions, allergies, etc.), demographics, health state measurements (blood glucose, blood pressure, etc.), fitness level (e.g., measured by heart rate and blood pressure) and the commensurate arrangements (exercise sessions) as well as unstructured information (such as scanned images and other documents). HealthVault is available on the Web as well as from mobile and tablet appstore by Microsoft and other providers. Other IT vendors such as Apple with Health Kit or Samsung with SAMI are catching up.
Are the above three pillars sufficient to make the healthcare system more patient-oriented and successful? Apparently not, but they are indispensable to start with.