How to manage healthcare systems when the pursestrings are tight
is not hitting news headlines as much as last year. However, the question of how to reduce healthcare costs in a difficult economic climate still seems to be grabbing headlines across the world.
First came the news that Donald Berwick , founder of the Institute for Healthcare Improvement and pioneer of EBM, was appointed by President Obama as the Head of the Centers for Medicare & Medicaid Services (CMS), which delivers America’s piecemeal state healthcare system. Berwick has a proven track record in putting EBM into practice and improving the quality of patient care. He has long been an admirer of the UK’s NHS, saying that, “The decision is not whether or not we will ration care - the decision is whether we will ration with our eyes open.”. Unsurprisingly, his appointment has been criticised by Republicans, who fear that he might actually do something about America’s spiralling healthcare costs. His appointment will hopefully bring accountability and some transparency (and hopefully some EBM) to America’s industry- and private sector-dominated health systems.
Germany has a national health insurance system largely funded through employers’ contributions, but now spends more on health care as a proportion of GDP than any country apart from the USA and Switzerland. Health reforms were pushed through last week which resulted in capping of employer's contributions, but also allowed Germany's health insurance providers to demand unlimited top-up fees from individuals. In short, Germany has chosen reduced coverage of healthcare rather than evidence-based reductions in costs.
Recently, development aid for health has increased substantially, from $5.6bn in 1990 to $21.8bn in 2007. With increases in spending by the poorer countries themselves, a BMJ article calls for greater rationalization of health spending, based on local needs and demands, and not the demands of international stakeholders and NGOs. The authors give the example of Rwanda where earmarking of funds for HIV/AIDS and target-setting led to just $1m for the integrated management of childhood illnesses, compared to $47m for HIV/AIDS, grossly disproportionate in a country with a 3% infection rate." This meant that "physicians employed by NGOs to deliver HIV/AIDS services are paid almost 6 times as much as physicians paid by the state, making it impossible to keep well qualified health personnel in the public sector."
Disdain for externally-set targets is shared by the UK’s coalition government, which has been quick to criticize Labour’s targets as it sets out its health reform stall. The two main aspects seem to be more power to GPs to commission services that are more aligned with patient needs and and independent sector providers will be encouraged to compete for patients. The problem is that in order to cut costs and improve services, there is going to have to be some measurement. And so the Health Secretary, Andrew Lansley has given us some political waffle to get our teeth into, saying that he wants to move from national targets to a "set of national outcome goals". New metrics and standards of healthcare are currently being designed and the first set of new standards is due by April 2011. The plan is for the new NHS commissioning board to use them to hold GP groups to account. Good evaluation using good measurement tools (yet again, evidence-based healthcare) are essential for any such plans to work.
EBM-the best way to cut the cost?
Across government, but particularly across the NHS, a fear of impending cost-cutting is dominating both news and journals. The NHS Confederation, which independently represents all organisations within the NHS, reckons that the health service will be facing “real-terms reduction of between £8bn and 10bn over the three years after 2011” .
The budget for the NHS in England in 2010-11 is forecast to be just under £110bn, so the predicted shortfall between rising costs (due to an ageing population and increasing cost of treatments) and the budget is substantial. The Office for Health Economics to compare what we can do with £8-10 billion for a population of 25 million: (1) provide family health or mental health services for 1 year, (2) provide cancer treatment for 2 years, (3) provide care for normal births for 27 years, or (4) provide prescriptions for 1.6 years.
As the new Chancellor, George Osborne calls for a public consultation about where cuts should be made in public services, there are already several theories of where we should save in healthcare. At a conference of the British Medical Association this week, the GP leader advised reducing the “bureaucracy tied to the NHS market, management consultants, patient surveys and management tiers. He also called the role of NHS Direct into question. I blogged about the cost of healthcare consulting a few weeks ago, quoting the £600 million that is spent annually on consulting rather than on treating patients. Using the above Office of Health Economics data, we see that this money could have paid for family health or mental health for 1 month or for normal baby deliveries for 2 years. As a practising doctor, I can say that this kind of comparative cost data about treatments is hard to come by, so it must be even harder for patients and the general public to find out where their money is being spent. This situation is the same across other government departments. If George Osborne wants a proper engagement with the public, this kind of data is needed.
This week’s BMJ editorials include two salutary examples of where money is being wasted in the current NHS. Firstly the case of swine flu and the massive stockpiles of Tamiflu and vaccines, which have made drug companies US$7-10 billion cannot show more clearly what happens when evidence is not part of health policy. Add to that the issue of conflict of interest and the amount of money wasted (or swindled) goes up exponentially. Secondly, the idea of “risk sharing” which provided interferon to multiple sclerosis patients, despite NICE recommendations that it was an ineffective treatment. Risk sharing meant that drug companies and government work together to provide disease modifying treatments within the NHS under the conditions of a large study. “If the drugs were more effective than the NICE predictions, and so achieved cost effectiveness, then all would be well. If not, there would need to be a financial reckoning—payback from the drug industry to the Department of Health or reduced drug costs—to achieve "affordability" post hoc.” The results now show that interferon does no good, but are the drug companies keeping their side of the bargain? Of course not.
The good news is that there is one methodology that exists in order to evaluate treatments and healthcare in general. That methodology is EBM and it needs to be tied more closely with health policy if we are to have any chance of reducing the wastage in the NHS.
Reflecting on electing
Today, as people queue at polling booths around the country, I wonder how much they will be influenced by the health policies of the main political parties. You would hope that it has a big bearing on people’s voting choices as the NHS is the UK’s biggest employer with a 1.5 million-strong workforce responsible for the health of 60 million people. Both the Lancet and the BMJ have tried to tease out what the different parties are offering over the last couple of weeks.
A Lancet editorial looks at how the three main parties fare in achieving aims of “better services”, “fairer services”, “protecting health” and “advancing health”. It concludes that the Conservatives and Liberal Democrats lead over Labour in terms of “fairer services” but Labour is likely to deliver better services and is ahead in terms of global health policy. There are many similarities between the health manifestos of the three main parties but the more you analyse, the less detail you find, particularly regarding how the NHS will be funded in difficult economic times and how limited resources will be allocated. This vagueness is there in the manifestos of the smaller parties as well.
There have been many calls to bring evidence to the realm of policy making, but it is difficult to find objective evidence-based statements in the policy documents of three major parties. This lack of evidence means that voter decisions are less likely to be based on facts, and are more likely to be influenced by political spin. For example, it is impossible to escape the political football that is cancer care, kicked from Labour to Conservatives throughout this election campaign, but data about how services will be funded, or how the burden of cancer compares with burden of other diseases in the UK is lacking. There is little or no mention of cost-effectiveness of drugs. This information is available in the public domain, but it is barely ever quoted, and, as far as I can tell, evidence-based medicine is not mentioned in any of the manifestos. Instead we get politicised promises of “an appointment within a week” by Labour versus “access to more cancer drugs” under Conservatives. You can only be an informed voter if there is good quality information from all the political parties.