re-orienting healthcare system to deliver health gain
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Re-orienting healthcare system to deliver health gain
Martin McKeeEuropean Observatory on Health Systems and PoliciesLondon School of Hygiene and Tropical Medicine
It’s great to be back… and this time, Smoke-free!
Smoke-free: good for business and good for health
• The next step• Smoke-free bars
Sunday Morning Post6th May 2007
Back to the talk:Once it was so easy
An individual patient went to a doctorThe doctor:
made a diagnosis (probably wrong),applied a treatment (probably ineffective)
The patient:died, orgot better
Health care before the 20th century
HospitalsPlaces of sanctuaryPatients “patiently waiting for death”
SurgeonsPart-time barbersJudged by speed of completing amputations
PhysiciansMasters of “watchful waiting”Judicious application of herbal remedies
NursesSisters of mercy
Type I diabetesThe first chronic disease?
Discovery of insulin changed a rapidly fatal disease of childhood into a lifelong disorderNow compatable with a normal life span, but large differences in actual attainmentHealthy survival requires co-ordination of efforts by many people and organisations
Pharmaceutical supply and distributionPrimary careSpecialist careSelf care
The same but different
DiabetesLife sustaining treatment
Insulin
MonitoringBlood sugar
ComplicationsRetinopathyNephropathyIHD
AIDSLife sustaining treatment
Anti-retrovirals
MonitoringCD4
ComplicationsPCPKaposi’s sarcomaIHD
… so now …
A patient with arthritis, Parkinsons, heart failure, bronchitis, diabetes, and depression goes to a family doctorThe patient is referred to a series of medical specialists, nurses, other health professionals, all working together in a network, collaborating with each otherShe receives multiple powerful and effective medicines, all of which are affected by her organ function and by the other drugsShe remains under continuing review for the remainder of her now active and fully engaged life
… but even in the old days
In .the face of long-term complex illness, planning was necessary …This fell to the state
Mental healthTuberculosis
Not just health: The changing world of education
… and of warfare
First question:does health care improve health?
Thomas McKeown and the role of medicine
Medical nemesisIvan Illich
Medicine is not just useless, it is actually harmfulThe concept of iatrogesesisSocial, cultural and structural ‘Hospitals have become
monuments narcissistic scientism’
Archie CochraneEffectiveness and efficiency
“All effective care should be free”"It is surely a great criticism of our profession that we have not organised a critical summary, by specialty or subspecialty, adapted periodically, of all relevant randomized controlled trials."
Florence NightingaleThe concept of avoidable mortality
Avoidable mortality
Concept developed further by Rutsteinin 1970sCauses of death at ages where death should not occurInitial examples included
diabetes under age 49, leukaemia under age 15, Asthma under age 65
What happened where medical care failed to modernise?
Death rate from avoidable mortality in UK and Russia similar in 1965, when little could be doneGap began to widen in 1970s, and has continued to do so since
0
100
200
300
400
500
600
700
1965 1975 1985 1995
Year
deat
hs/1
00,0
00
Russia United Kingdom
Age standardised death rates(0-74) from amenable causes, 1980 & 1998
0
50
100
150
200
250
300
Portug
al
United
Kingdo
mAus
triaGree
ce Italy
German
y wes
tSpa
inDen
markNeth
erlan
dsFinl
and
France
Sweden
SDR
am
enab
le c
ause
s (p
er 1
00,0
00)
1980
1998
women
Where are we now?
0 20 40 60 80 100
AustraliaSwedenCanadaFranceGreece
SpainItaly
NorwayFinlandAustriaJapan
NetherlandsGermany
New ZealandHong Kong
IrelandUK
USADenmarkPortugal
Age-standardised death rate [0-74] (per 100,000)
So health care does make a difference
Next question:How can we maximise health gain?
Living in interesting times
“People first”Concern about future costsFocus on life threatening diseases
Five maxims
1. Prevention is better than cure2. Timely investment pays off3. You can’t leave it to chance (or the
market)4. Anticipate change5. Trust but verify
1. Prevention is better than cure?
Does investment in health promotion save subsequent costs of health care?Does investment in health increase future national wealth?
(to pay for health and social care, among other things)
Prevention is better than cureProjections of future expenditure on UK NHS under three scenarios
Fully engaged = major commitment to health improvementSource: Wanless Report
} €50 bn
Ageing populations
Costs of care increase with proximity to death, not chronological age
It is expensive to die, not to grow oldClear evidence for compression of morbidity
Tomorrow’s 80 year olds will be much fitter than today’s
Investment in health –investment in wealth creation
2. Timely investment pays off?The health production function
Human capitalthe right mix of skilled workers
Physical capital Appropriate facilities Effective drugs and technology
Intellectual capitalResearch and developmentImplementation of evidence
Social capitalNetworks and connectionsTrust
Money is not enoughMoney is only useful if there is something to buy
Doctors can’t be trained overnightHospitals don’t come in flat packs
UK reforms increased funding very rapidly
Predictable resultCost inflation
RadiologyOutpatients
MedicalMedical
Medical Medical
Surgery Surgery
Theatres ICU
Paeds Geriatrics
GeriatricsMaternity Pathology
A& E
Physical capital:The hospital of the past
Imaging
Intermediatecare & rehab
Diagnostics
ICU
Paediatrics
Maternity
Minor Injury
PrimaryCare
MedicalAssessment
Major trauma
ChildrenImaging Imaging Specialist
Imaging
Pathology
Pathology
Pathology
Theatres
TheatresAmbulatory care
Imaging
Medium
HighDependency
The hospital of the future?
Source: Edwards & McKee
Human capital:Trained staff
“OK, we’ll vote. How many say the heart has four chambers?”
… and patients
Social capital: the case of magnet hospitals
39 hospitals defined prospectively as providing a good nursing environment;matched with 195 controls with similar characteristics in other areas;after adjustment for severity; magnet hospitals had a 4.6% lower mortality rateboard certification, technology etc.. not relevant
Aiken et al., 1994
The inter-relationship of practically everything
A family is injured in a high speed car crashThey arrive at an emergency department
There is no paediatric service – it has been moved into the communityThe eye injuries cannot be treated as the ophthalmologists have been relocated to an independent treatment centre to concentrate on waiting lists for cataractsThe complex hip fracture cannot be treated, because the orthopaedic surgeons have been relocated to an independent treatment centre to concentrate on waiting lists for keen replacementsThere is no microbiologist to speak to about the wound infection because the service has been moved 200 miles away
3. You can’t leave it to chance?
Surely we could simply leave it to the marketThe invisible hand must be better at organising this complexityNo-one at the centre can possibly second guess all the individual decisions
… except….
Markets in health care don’t work so well
Many people who need health care don’t realise itEven if they do, they may be deterred from seeking itThey often don’t know what they wantThose providing care may not realise these people even exist
Reaching out to those in need
‘[Doctors] tend to gather where the climate is healthy... and where the patients can pay for their services’
Ivan Illich"the availability of good medical care tends to vary inversely with the need for it in the population served."
Julian Tudor Hart
Opportunistic behaviourCream-skimming
Enrolment for a HMO on 6th floor of a building without an elevatorDeclining to treat complex and expensive, but inadequately reimbursed patientsConcentration on conditions with high returns
Short-termismHigh volume elective surgery, but no provision of training
The test: mortality from diabetes
0
5
10
15
20
25
30
20-24 25-29 30-34 35-39 40-44 45-49
deat
hs /
100,
000
US black, m
US white, f
US white, m
US black, f
Sweden, m
Sweden, f
Diabetes mellitus
4. Anticipate change
Changing settings and changing roles
Don’t fossilise the system:(one of the) critical flaws in British hospital procurement
Now Now + 30 years
Beds
0
n
requirements
contractedToo few
Too many
But avoid permanent revolution
“Creative destruction”The view from 10 Downing
Street
“We had to destroy the village to save it”
Peter Arnett quoting unnamed US Army officer in Vietnam
5. Trust but verify
Evidence may be context specific
Trauma centresSave lives in US but not UKBut profile of injuries very different
Evercare (a chronic disease management package)
Reduces admissions in US but not in UKBut many elements already in place in UK
Assess needs
Specify care model
Monitor outcome
Purchase care
Health strategy
A schematic model
In summaryGood health doesn’t arise by chanceIt helps to have a plan and some idea of how you will achieve itDon’t wait for diseases to become life threatening
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