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

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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

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300

Portug

al

United

Kingdo

mAus

triaGree

ce Italy

German

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inDen

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and

France

Sweden

SDR

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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

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20-24 25-29 30-34 35-39 40-44 45-49

deat

hs /

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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