Dr Fred Hansen explores the growing issues with the NHS and examines what could be done to deal with them. He explains the need to bring the responsibility of healthcare back to the consumer and give them more control over healthcare. He picks up the issue of 'self care' and outlines why and how it could work.
Proposals to healthcare reform should be judged not on the goodness of their intentions but rather on the basis of there results – in other words: nobody washes a hired car
The focus on consumer choice within both major parties seems to respond to the core weakness of the British health system, as reported by patients (A Coulter, Picker Institute BMJ: 331, 19/11/05, pp 1199). The deplorable heritage of the NHS - its cold war bureaucracy and a paternalistic doctor-patient relationship – is the very opposite of choice. And there are many doubts whether the recently introduced patient choice between hospitals for elective surgery is the most urgent kind of choice that people are coveting. Over 500 consultants of Doctors for Reform have declared: “The NHS was conceived more than half a century ago, at a time of rationing and considerable poverty. We once believed it was the finest healthcare system in the world. Today few healthcare professionals would make that claim." Indeed Britain seems to be coping worse than other Western countries with soaring health costs and is dramatically falling behind other Western countries in such crucial things as cancer survival rates.
The intangible revolution
Quite a different issue is to predict the future of the NHS in a competitive global health market. As everybody knows, here are economies of scale, particularly in purely knowledge-based goods. This is what some experts like Roger Boothe call the intangible revolution. They maintain that the economic potential and wealth creation of the knowledge-based technology of the future is enormous. This is especially true for the health sector which in the future will produce lots of intangible products and services. But today, as a closed market, the NHS simply cannot compete with the lower prices of the much larger international markets. That’s the bad news. The good news is that the globalization of healthcare services and products is the best way to contain exploding costs everywhere. Surprisingly loss of control over health expenditures happens in very many countries, regardless of ideology and the way health care is organized – from central Europe to the United States of America.
Control over health expenditure is the main challenge
Some countries have already responded to exploding costs with incentives to save money at the origin of all health expenditures: the patient or consumer. These ideas try to encourage more responsibility by healthcare users. For example the Dutch introduced a no-claim bonus for health insurance. Switzerland introduced something similar with different choices and levels of healthcare coverage. The USA introduced medical savings accounts. Denmark is charging an extra fee for seeing a consultant and Germany introduced a general fee for seeing a GP. We certainly can learn from other countries how to achieve more.
Public confidence in health reform is dwindling
Unfortunately nothing like this is happening in Britain, except in some private insurance companies. Not surprisingly, 54% of electors don’t believe that the billions of pounds that Labor has been pouring into the NHS since 2000 will result in real improvements, and only 39% agree that it will do so. In the most recent ICM poll by the Sunday Express 35% of voters said that they think the NHS has got worse since Labor was elected as against 24% who think it has improved. 35 % think things have stayed the same. In a recent MORI poll 44% of people said they expect the NHS is getting worse, only 22% held the opposite opinion. Other surveys have suggested that the American managed care organization Kaiser Permanente was much more cost effective than the NHS run programs (BMJ 24 August 2004). The crucial difference between both was that Kaiser employed many more consultants per patient than the NHS.
The politics of choice and the Web
Although countries differ considerably, choice seems not to be as overwhelmingly important to patients as politicians often suggest. According to surveys of patient preferences, the heaviest users of primary care the elderly and the chronically ill value continuity of care higher than choice of providers. However younger patients value fast access higher than continuity. But both groups want greater personal involvement in their treatment. Ever more people are turning to the internet to get information on their condition, because it is not provided sufficiently by their doctors, surgeries and hospitals. Even among people aged 45 and over about 30% have searched the web for information about their condition. Finally choices between competing providers or hospitals seem less important to patients than fast access to specialists.
Social and medical Progress
The NHS was founded in times when political and social collectivism prevailed – as were the dominant concepts of epidemic and contagious diseases. And this is reflected not only in the health bureaucracies created by Aneurin Bevan but even today in the top-down centralism of the NHS. But social and medical progress renders those collectivist concepts obsolete. Biotechnology has deconstructed the fiction of “one size fits all" medicine. The new consumerism has created a huge increase in demand for quality and choice in health services and the pharmacotherapy of the future will be much more individualized - no longer the same tablets and average dose for everybody. People are becoming even more different as we approach the genetic level of understanding diseases. And this means that, increasingly, any kind of socialized health insurance will be deeply flawed. Risks in the future will be centered in the individual and family rather than in the group or collective.
Dramatic change of disease burden
Past social progress and ongoing medical innovation have led to a fundamental transformation in the disease burden, due to changes in two major areas.
Firstly the affluent Western societies created a lifestyle which is outright unhealthy. It is to blame for the leading causes of death these days: coronary heart diseases, stroke, many different cancers, sexually transmitted diseases, asthma, diabetes and fatalities of poly-pharmacy. This lifestyle encompasses smoking, overeating, promiscuity with unprotected sex, abuse of illicit drugs like cocaine and alcohol and lack of exercise. In response, we consume vast amounts of medicines in the attempt to postpone or avoid any deterioration of health. Prudent disease prevention and health improvement through healthy lifestyles are the exception.
Secondly, globalization with mass tourism and mass immigration has introduced or brought back a host of infectious and tropical diseases to the Western societies. These include the reemergence of tuberculosis as a corollary of the HIV epidemic, diphtheria and other infectious diseases. International sex tourism also has given a booster to sexually transmitted diseases. All these factors and the masses of new immigrants with no or poor English language skills have put our Western health systems, not at least the free-for-all English NHS, under considerable pressure.
Not surprisingly, according to a survey by the think tank Reform, the productivity of the NHS has constantly declined over the last decades despite a huge increase of the NHS budget.
Since unhealthy lifestyles are to blame for much of the Western disease burden, this is where we need to look first in terms of keeping healthcare costs under control. Simple exhortation is not enough, as we have seen on the obesity epidemic for example.
So how can we achieve sustainable ways of behavior or lifestyle changes?
Setting the right incentives for consumer choice
The most promising solution would be to give patients/consumers back responsibility for their own health, and control over their own health care expenditures. Only thus we can contain the progress of chronic diseases driven by lifestyles in which peoples damage their own health. The clue is self-reliance and incentives for people to look after their own health, supported by full access to health information via the web and a viable health insurance system. Previous attempts to get people to live healthier have failed because they lacked any economic underpinning or incentives to do the right thing. But at least they may have raised awareness of the problem.
Patients value self-care high
According to surveys (Picker Institute, Oxford) most patients value preventive advice and support for self-care high. But our healthcare system does not offer any reward or incentive for combined efforts of doctors and patients to achieve this. There needs to be benefits for patients who really care about health improvement and disease prevention. Only rewards for patients who protect their health plus rewards for doctors, who are committed to health promotion with their patients, will accomplish anything. This should be the meaning of a patient-centered health care.
Health care funding needs to be linked to personal risks and lifestyle
Abandoning third-party payment systems is the truly global solution to the health care crisis. It is the way to make health care systems sustainable over the generations. It clearly implies a turn to individualized methods of raising health care funds: only this allows different patterns of individual health risks to be taken into account. It implies a competitive insurance system of staggered premiums according to different risks. Only then we might accomplish a fully patient/consumer-driven health care.
Provision of health care by private companies is not enough
The tax-funded system of health care in this country has become counterproductive. It does not give any incentive to prevent or avoid diseases. As a result not only should the provision of health care be decentralized, but also opened up to market forces, as initiated by the Tories and continued by New Labor.
However, if only the delivery of health care is privatized there remains the problem of collective or state purchasing of health services. Any kind of third party commissioning as a proxy for patients is prone to bureaucratic failures and complexity. Probably the most advanced concept, although not implemented yet, has been developed by Newt Gingrich at the Washington based Center for Health Transformation (CHT). He is attempting to abolish third-party payments in all US public healthcare provision under Medicaid and Medicare.
This means that the patient acquires full consumer power since he is put in control of all health expenditures on his behalf. The crucial point of a consumer-driven healthcare system will be the direct link between personal lifestyle and individual control of health expenditure with fully informed consumers.
The information point is important and the internet as well as new virtual or real health coaches hopefully can reduce the knowledge gap between health professionals and the consumers. The bridging of this gap is crucial in order to provide us with a true consumer driven health care system. My impression is that this problem of bridging the information gap is underestimated in the CHT approach which is focuses on IT implementation in the US health care system.
Markets can best address inequalities in health
Contrary to the prevailing prejudice, healthcare is not much different than other sectors where the market prevails. True, the bulk of our healthcare resources are taken up only in the last couple of years before we die. But the way to deal with this is that every consumer/patient should contribute to the necessary pool of resources to cover for these expenditures with a monthly basic contribution let us say of about Pounds 150. Upon entry into the workforce this payment should be mandatory by law.
People with healthy lifestyles will not need to spend more than this – they may spend even less. But people with risky lifestyles, like skiing or horse riding etc, will have to pay extra fees. The same of course applies to couch potatoes and people who keep smoking, boozing or overeating. However, for people with inherited diseases, permanent disabilities or for the ten percent of people who cannot afford the contribution, the government would have to step in.
Such ideas do not have to be developed from scratch, because others have already tried market-style solutions for health care.
Good examples are Denmark, Switzerland, the Netherlands and the United States, although mostly in the private sector. What they have in common is the implementation of meaningful consumer choice - with impact before any disease hits. People in some countries are encouraged to take responsibility for their future health earlier in life - all of which can be monitored by them selves or their doctors - and are rewarded with lower monthly health insurance contributions.
Evidence that the new concept will work
Evidence that a combination of activity, attitude, and good nutrition, can actually achieve a significant improvement in health and can prevent or at least postpone chronic diseases was provided by scientists at Nestlé - most of all in the area of obesity and diabetes. They have also proven that the improvement of physical health will make a huge difference in figures of mental health - showing that there is a strong connection between both. It is not at all surprising that lifestyle changes like increased physical activity and weight loss will also decrease depression and anxiety. Without treatment depression and anxiety can result in unemployment, unnecessary disability, substance abuse, inappropriate incarceration, suicide and homelessness.
The challenges for self care
The self monitoring of health parameters and introduction of personal risk management will be big challenges, but well worth it. Special bespoke software programs for consumer health control solutions need to be developed in the near future. If instead of just one third of the British population being able to maintain a normal body weight, two-thirds could do so, then the disease burden or work load for the health service could be nearly halved.
Contrary to the common belief free access to the health service without payment does not serve the patient because it is an invitation to neglect your health and leads to a general waste of resources. One example for this is that, according to a recent survey (Picker-Institute, Oxford) British patients, used to the NHS, are less inclined to get involved in health improvement than patients almost all other European countries. Another example is the millions of missed appointments with consultants, GPs and nurses in the NHS.
Public health is to be reconsidered
Fifty years of Public Health in the NHS have witnessed a complete failure to improve the health of the population at large. Apart from vaccinations in childhood and cancer screening, which are more or less established in all Western countries and not a merit of NHS-style public health, most other public health interventions to target things like cholesterol, weight and blood pressure have failed. There is poor evidence that this kind of public health interventions achieve any long-term health improvements. Admittedly, in other Western countries the results are not any better. It is therefore as true for state health interventions as for other things: market forces tend to be the stronger.
To be fair, in spite of the huge controversy over cancer screening two years ago, some benefits of the centrally planned NHS are still outstanding. Those are programs for the prevention of breast and cervical cancer in women, which should probably be maintained and developed further to other areas of prevention. But the bulk of the NHS workload is curative care for acute and chronic conditions. And for this business the future consumer and patient must have a completely different and more central role, which will impy more choices and more responsibility as well.
Doctors for Reform
Recently Doctors for Reform rejected the current tax-based healthcare system in Britain. As Dr Christopher Lees, one of the founders admitted the group was disappointed by the Wanless Report’s conclusion that taxation was the best way to fund healthcare. Doctors for Reform are looking increasingly to health care systems in continental Europe, one of the favorite candidates being Switzerland which has implemented the most advanced market based health-reform - it combines mandatory social insurance with individual discounts for people who stick to a healthy lifestyle and take up less health care resources. In the Swiss system employers no longer contribute to health insurance for their employees.
According to Doctors for Reform taxation-funded healthcare can never meet demand and compulsory insurance in Europe works much better. “The NHS as we know it has had its day", said the founder of the group, the oncologist Professor Karol Sikora. He added, tax finance is simply no longer fair because people with a healthy lifestyle have to subsidize people, who knowingly damage their health in a variety of ways. Indeed the NHS provides incentives not to bother about one’s health and even to remain ill in order to get the most out of the NHS. It is another example of the welfare state that actually encourages people to the opposite of what it seeks to achieve. James Bartholomew has looked into this in his book “The Welfare State we are in".
Getting away from centrally planned and politically driven NHS, Doctors for Reform maintain, would provide more flexibility, freedom of choice and more competition for excellent health care. Putting power into patient’s hands would mean more choices. And the patients in the UK seem to agree. In the already quoted ICM poll 52 % of respondents agreed that Britain should move towards a European style system “where everyone takes out health insurance and the Government tops up payments for people who can’t afford the premiums".
How can we implement this new concept of consumer driven health care?
Inevitably, any reform of NHS financing must be gradual. But once it is under way, it could serve as a template for other countries and give Britain an advantage for the export of ideas and services to bigger markets in Europe and abroad with the possibility to employing millions of people. This means the huge present workforce of the NHS 1.3 million do not have to expect redundancy.
Many pundits expect the healthcare sector in the developed countries to grow faster than others and an increasing part of this expansion of the health market will come from private, out of the pocket payments. Even in the UK, with hero behemoth NHS, a growing part of the electorate is willing to spend more for their health out of their pocket. In the ICM poll 41 % were open to charging patients for some NHS services. These people will purchase Top-Up fees for primary care and medication.
And that’s what the market should offer them in the areas of self management of disease prevention and chronic conditions. The introduction of electronic health records, given interoperability, will foster the use of personal software modules for disease prevention and for the control of chronic ailments. There are many other new developments such as the digital directories, online services for directing consumers to the right health provider and so on.
Ten guiding principles for a patient driven health care:
1) Devolution of decisions
2) Create full price transparency for consumers
3) Develop individual health risk management tools
4) Create a genuine health insurance market
5) Create comprehensive IT support
6) Give every patient his own electronic health care record
7) Abandon third-party payments
8) Enable early access to orphan drugs
9) Manage heath care market as national asset
10) Pay for outcome instead of performance
Self care and individual risk management tools
In order to prepare for this change we need to establish a think-tank exclusively dedicated to market based health reform with a focus on individual health risk management. The main purpose would be to develop concepts for self care and risk management for every major preventable disease and also for the management of chronic conditions. These modern software modules will include modern technologies for the monitoring of body functions taking patients beyond mere good intentions. If the patient can see on his or her laptop what difference they can make in terms of health and disease, this is much more rewarding and motivating. However the most sustainable incentive will be financial. Healthy people will be able to save in their health care accounts for their future (already many millions of Americans save into Medical Savings Accounts).
How to build the SelfCare think tank
Sponsors for a self care think tank could come from in the existing health care industry, e.g. pharmaceutical, NHS and insurance companies, HMOs or PFI consortia. The main remit would be to develop and design multiple software modules for coaching and personal health management including health promotion, disease prevention and disease management. Most of those software modules would be protected by intellectual property rights and form the basis for software products destined to be marketed for private purchase and consumption. This means the sponsors of SelfCare could benefit in the form of ownership of certain disease-specific modules or software products which would grant them a return on their investment.