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Compare and contrast two health care systems_ Which country will

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									Nana A.O. Akuffo- 012169964
Patrick Vivathanakul Chew - 010772148

Compare and contrast two health care systems, Which country will you
rather be ill in and why?

Abstract: -

We are going to compare and contrast the NHS and the South African health care system.
The NHS system is a publicly funded system, which is provided through taxation. It caters for
the whole population. The South African system is both publicly and privately funded.

The criteria that we compared the input/output ratios the systems were in terms of funding,
workforce, and pattern of supply, input/output, rationing, gate keeping, provider behaviour,
equity of finance and the rankings in the World Health Organisation.

We found out that these criteria are useful in comparing but there were flaws in these
methods as the two countries are in different stages of economic and cultural development.
E.g. South African struggles with the Aids epidemic whilst being a developing country.

We discovered many advantages and disadvantages of each system, which we will discuss in
the main body of the essay.

Even though the South African health system ranked 175 out of 191, they had many
advantages in terms of technological innovation and achievement, which many developed
and developing countries lack.

To answer the question “Which country will you rather be ill in and why”. We use two theories
to evaluate the two health care systems, which were John Rawl‟s „Veil of Ignorance‟ and
Mossialos et al.

We decided that the best method of evaluation is John Rawl‟s „Veil of Ignorance‟ because it
took into consideration the uncertainty of the individual‟s earning potential. Therefore we
would rather be ill in the UK due to equity reasons.




                                               1
Introduction
                                                                       1
The NHS was created in 1948 to „provide healthcare for all citizens‟ . It is funded through
taxation and provided by the government. Previously the health care system was operated as
a non-profit making organisation and run by local authorities.

The South African health care system is made up of private and public system. The public
system caters for 80% of the total population, whilst the private system catered for the
remaining 20%. There are 3 main private health providers Afrox, Netcare and MediClinic. The
public health care system is freely available for pregnant women and children under six.
People who do not fulfil these criteria will be means tested on a fee-for-service basis. Since
the end of the apartheid regime, there has been a shift from a racially biased system to a
more accessible primary healthcare.


Comparing the two systems: -

In terms of the way the two systems are funded. The UK is funded through taxation collected
by the government. Whilst the South African health care system consists of both government
expenditure and private contributions from the employers and the employees. The
government contributes for the private and the public sector on a 50/50 basis, even though
there is not a 50/50 distribution in each sector.

The input/output comparison in the UK shows a low input and a high output. This shows that
the UK is very efficient in utilising its resources to satisfy the NHS users. The figure from the
World Health Organisation shows that the UK spent 7.3% of total GDP on health in the year
2000, whereas in South Africa the government spent 8.8% of total GDP on health. But the
South African health care system does not display the same low input/high output as in the
UK. The problem of using this method of comparison is the definition of output. This is
because the World Health Organisation index does not take into consideration cultural,
economical and structural differences.

When we compare the two systems we can see a difference in the pattern of supply. In the
UK there are small differences in the distribution of doctors in rural and urban areas. There
are large numbers of available clinics that a patient can go to but it is sometimes very difficult
to register. In South Africa this difference is very high. Where in rural areas the ratio of the
doctors to patients is 1:30,000 and in urban areas the ratio is 1:650. This shows a substantial
difference in the allocation of resources in rural and urban areas.

The UK health care system workforce consists of a number of highly skilled professionals,
e.g. doctors and consultants. But there is a massive shortage of nurses in the NHS, as there
has been a movement in nursing personnel from the public sector hospitals to private sector
hospitals. The shortages have been alleviated by the migration of nursing staff from
developing countries such as China and South Africa. This in turn explains the shortages of
nurses in the South African health care system, notably their public health care sector. Their
private health care sector does not encounter this problem, as it consists of the best specialist
and nurses in the world.

The gate keeping method is different between the two countries. In the UK, there is a primary
to secondary progress. This is where a patient goes to see a general practitioner (GP) before
they are referred to a consultant. In South Africa the choice of primary or secondary pathways
is optional. The rationing method also differs in both countries. In the UK, non-price-rationing
method are used. For example: - waiting lists are ranked by importance, long queues in
Emergency and Accident department etc. This method of rationing is similar to South African
public health system. In the South African private health care sector the price-rationing
method is used. This is where people forgo small medical procedure in order to save their


1
    www.nhs.uk


                                                2
medical insurance contributions for bigger operations. This seems to be a form of self-
rationing due to costs and it also indicates a reduction in moral hazard.

In the public system (NHS) the evaluation of the provider behaviour shows that doctors have
budget restrictions. This is because the doctors who are given a budget to work with
sometimes under perform, as they know that if they work within the budget it will be reduced
                                                                  2
in the following year. Therefore they participate in „end of year‟ spending sprees in order to
prove that there are no excess resources. In South Africa there is also a budget restriction in
their public health care sector and competitive behaviour in the private sector where they
compete competitively to gain more patients. This can sometimes lead to supplier induced
demand in-order to increase profits.

Another way of comparing the two systems is equity of their financing source. It is progressive
when richer individuals pay a higher proportion of their income on the health care system than
the lower income individuals. Regressive is when low-income individuals spend a higher
proportion of their income on the health care system, thus taking a higher proportion of
income from those who are poor. We have found that the NHS is progressive and the South
African health care system is regressive.

The advantages in the NHS are the cost effectiveness of the system and how the system
covers the whole population. Being cost effective is derived from the ability to produce high
outputs from low investment. The system is very equitable, as people with similar conditions
wait for the same length of time. Showing that every patient in the NHS is equal.

The disadvantages are plentiful. There is an insufficient distribution of funding in some parts
of the system evidently seen in the lack of investment in cancer technology and severe
shortage e.g. long queues for dentist (recently highlighted in the news). There are also
shortages of doctors and nurses as mention above. There is also a „Lack of incentives‟ to
promote performance improvement within traditional reimbursement mechanisms. This
because the employees of the NHS are paid on a salary basis, therefore not needed to over-
perform.

There is a high level of moral hazard in the NHS. This is because everyone is treated equally
no matter how the injuries were sustained. E.g. drink-driving casualties are treated the same
as a heart attack victim. Even though the NHS users are treated equally there is a high level
of dissatisfaction with the system, due to long waiting lists etc. There is a high level of
bureaucracy, and „red tape‟ means that doctors‟ time is wasted on completing government
paperwork.

The advantages of the South African system are that the user has a choice of
primary/secondary health care. This also includes the availability of trained traditional healers
to provide treatment. The private health care system is very efficient. The UN ranks the
private healthcare system 39 out 162 countries for technological innovation and achievement.
The government invests 8.5% of GDP on health care, even though the government invests a
large amount it is not sufficient in producing high standard of care in the public health care
system. But this type of investment enables them to provide a national health carrier
                                                                            3
Transnet, which brings affordable heath care to many rural communities . There is a low
moral hazard, as patients have to pay for some of their treatment and in the future, a higher
premium if they participate in risky activities.

The disadvantage of the South African system is that the system cannot cope with the rise of
AIDS. The poverty related illnesses suffered by public health care users e.g. TB drains
resources. The rise of AIDS related illnesses, fills up 40% of the beds in most hospitals. The
high cost of medicine means that patients cannot afford them buy, which can cause minor
disorders to escalate to major illnesses. There is a degree of adverse selection as high-risk
patients purchase cheaper health insurance which increases the premium for other patients.


2
    Health Economics: An International Perspective; Barbara Mcpake et al
3
    Healthcare in South Africa; Hilary Bassett


                                                   3
There is also a bad distribution of health care in rural and urban areas. There are also high
levels of bureaucracy due to the corruption in the government.


Where would you rather be ill and why?

Using John Rawl‟s „Veil of Ignorance‟ we would say that it would be better to be ill in the UK
as the NHS provides fair health care to all. If you are a low-income earner the NHS system
would cater for your needs more cost effectively than the South African one. But if you
happen to be a high-income earner it would be better for you to be ill in South Africa. This is
because their private health care system is better in terms of resources and expertise.

 If you were to use the Mossialos‟ method, which considers equity, efficiency and satisfaction,
we would conclude that the NHS is very efficient in terms of using resources. More so than in
South Africa as they spend more on their health care system with less return. But in the UK a
lot of people are unsatisfied with the long waiting lists. Middle and high income earning South
African‟s are more satisfied with their private health system than low-income earning South
African‟s with the public health system.

It also depends on what illness you are suffering from, illnesses such as cancer are better
treated in South Africa than in the UK.




                                                4
             Bibliography: -

                Culyer A J, Maynard A K, Posnett J W, Competition in Health Care, Reforming the NHS,
                 Macmillian Press, Basingstoke, England
                McPake B, Kumaranayake L, Normand C, Health Economics, an international perspective,
                 Routledge, New York
                Elias Mossialos, Funding Health Care: Options for Europe, Open University Press
                www.bbc.co.uk
                www.hst.org.za/sahr
                www.nhs.uk
                www.who.int




             Appendix: -



WHO Selected Health Indicators for Countries
                                                                UK                                SOUTH AFRICA
Population Estimates
Total Population (000's)                                                                 59541                   43,791
Dependency ratio ( per 100)                                                                 53                       60
Percentage of pop aged 60+                                                                20.7                      5.8
Total Fertility rates                                                                      1.6                      2.9

Health Indicators
Life Expectancy at birth (years)
Total Population                                                                           77.5                      49
Males                                                                                      75.1                    47.7
Females                                                                                    79.9                    50.3
Child Mortality (probability of dying under 5 years, per 1000)
Males                                                                                         7                    103
Females                                                                                       6                     90
Adult Mortality (probability of dying between 15-59, per 1000
Males                                                                                       109                    596
Females                                                                                      69                    526
Healthy life expectancy at birth (years)
Total Population                                                                           69.6                    41.3
Males                                                                                      68.4                      40
Females                                                                                    70.9                    42.7

National Health Accounts Indicators
Total health expenditure
Per capita GDP in International Dollars                                                 24,462                    7,555
Total expenditure on health as % of GDP                                                 7.30%                    8.80%
Per capita total expenditure on health in dollars                                        1,774                      663
Public health expenditure
General Government expenditure on health as % of total
expenditure on health                                                                        81                    42.2
Per capita government expenditure on health in
international dollars                                                                     1,437                    280

                                                            5
Health System Attainment and performance in all Member States
                                                                                                UK South Africa
Health:-
Level (Dale)                                                                                      14               160
Distribution                                                                                       2               128

Responsiveness:-
Level                                                                                       26-27               73-74
Distribution                                                                               3. - .38                147

Fairness in overall contribution                                                           8. - .11          142 - 143

Overall goal attainment                                                                            9               151

Health Expenditure per capita in International Dollars                                            26                57

Performance:-
On Level of Health                                                                                24               182
Overall Health System Performance                                                                 18               175




           Methods of Comparisons: -


           John Rawl’s ‘Veil of Ignorance’: It is a method of evaluating a health system. This is done
           by determining which health system would benefit the individual most without knowing in
           which deciles of the income distribution the individual lies in.

           Mossialos et al: states that making decisions regarding which health care systems are
           favourable by analysing equity, efficiency and satisfaction.



           News Articles:-

           From The South Africa Times

           Doctoring up SA's healthcare system
           Medical Insurance
           By Adels Shevel 01/02/2004

           The Department of Health's two-phase social health insurance plan would provide for 65% of
           the population's healthcare needs.
           Only 16.2% of the population has private medical aid, said Patrick Matshidze of the Council
           for Medical Schemes at a meeting held by the Institute for International Research this week.
           The remaining 83.8% relies on government services.
           The department is working on the plan, but it could be two to three years before its social
           health insurance materialises, and it's certainly no done deal.
           It has demonstrated its intention to reduce the cost of healthcare by way of key amendments
           to the Medical Schemes Act 1997, implemented in 2000.
           One article of the amendment, which came into effect this year, places 25 categories of
           chronic illness under prescribed minimum benefits for which medical aid schemes must
           provide.
           Another development, the risk equalisation fund, discussed this week in a technical forum
           with international experts, heralds further healthcare changes.
           The fund is intended to counteract volatility in the medical scheme industry and seeks to allow
           businesses to manage risk better, says Council for Medical Schemes spokesman Pat Sidley.




                                                          6
The fund relates only to prescribed minimum benefits - the minimum standard every scheme
is expected to cover.
What all this means, practically, is that schemes with a younger, healthier membership base
will cross-subsidise those with older, more sickly members because government's intention is
for healthy people to help the aged with their disproportionate costs.
Industry, aware that the fund can create stability, largely supports the initiative.
Debates are likely to rage around another issue, the proposed changes to corporate and
personal tax subsidies - valued at around R7.8-billion.
Employers are already capping contributions to healthcare, with implications for all wage
earners above a certain threshold.
Meanwhile, employees are already reeling due to medical inflation that is consistently higher
than consumer inflation.
The tax subsidy in its current form benefits the wealthy because the more expensive the
product, the greater the subsidy.
Proponents of social health insurance want to fund the initiative through a dedicated payroll
tax.
However, Treasury has expressed concern that if health wants its own tax, other social
service departments may want the same. Why should health be granted its own source of
funding and education, for instance, not? All of this adds to taxpayer bills.
Part of the health department's plan is to have all government employees covered by a single
fund. There are now almost 80 schemes servicing the sector. It intends bringing up to 1.5
million new members into the private healthcare system by way of about 400 000 state
workers not currently covered and their dependants.
In a separate bid to curb healthcare costs, the medical aid regulator has told certain medical
scheme administrators to "cap" their earnings as a means of dealing with problems such as
low solvency levels.
And it is illegal for schemes to risk-rate members based on age or health status or to prevent
more "unattractive" (older, sicklier) people from joining the scheme.
Some schemes were attracting younger people by focusing their chronic-care products, which
are needed by the elderly, on the high end of the market, in effect making care for healthy
people cheaper.
Then there is the question of whether the young and healthy want to subsidise the older and
more sickly. They may choose to cover their own costs.
Gary Taylor, managing director of group services at Medscheme, says: "One of the ways is to
make coverage mandatory. The other is to disincentivise people from joining schemes late in
life."
So far the net effect of the legislation has not been to widen access. The number of medical
aid members has remained static at about 7-million for close to a decade.
Social health insurance initiatives are intended to increase the number of people covered by
private healthcare.
The Council for Medical Schemes' Matshidze says the first phase will make cover for middle-
and high-income earners (3-million to 4 million people) mandatory.
The second phase involves pitching voluntary cover to low-income earners, expected to be
another 5-million people.
Only the lowest-income groups and those without income will remain within the public system.
Social health insurance is by no means set in stone .
Treasury is not convinced by the proposed tax subsidy changes nor several other initiatives of
the health department for that matter.
And Cosatu is more interested in national health insurance (which will cover a greater number
of people) than a social health insurance.
In yet another development, draft regulations released this month aim to cut the cost of
medicines, and cap costs within the supply-chain - pharmacists, wholesalers and distributors.
Drugs comprise about 30% of the medical bill.
The one area that has remained relatively free from regulatory involvement is private
hospitals. But medical specialists and hospital groups are responsible for a large portion of
the cost increases within the private sector.
Private hospitals in this country have proved to be among the best in the world - both
medically and financially. Their shareholders are happy with plump returns and management
of the three listed hospital groups is highly regarded.
There are no indications of the health department getting involved in this sector as yet.



                                              7
But based on what is going on in the context of healthcare and the cost drivers, it is possible it
won't remain this way for long.



Sunday Times Editorial Comment
Healthy, wealthy and wise
25/01/2004

Healthcare - or access to healthcare - is a highly emotive issue all over the world. So it should
be. Affordable healthcare is essential for the wellbeing of any nation. It is, indeed, a matter of
life and death.
Our rights-based Constitution recognises healthcare as a fundamental human right. It follows,
therefore, that any government would make a priority of providing or facilitating easy access
to necessary medical services, ranging from adequate primary health to the most
sophisticated, high-level medical care.
Unfortunately, given South Africa's level of development, our public healthcare system is far
from ideal. Although healthcare takes a huge chunk of the national Budget, there are the
perennial problems of staffing and shortages of equipment, infrastructure and drugs. There is
also the issue of inequalities in services that the social engineering of apartheid has
bequeathed to our young nation.
The price of medicine is central to the provision of decent medical services. It was to be
expected, therefore, that the government would want to bring down the cost of drugs. Hence
its advocacy of the widespread use of generics, which cost a fraction of the branded originals.
This is much to the chagrin of the powerful pharmaceutical multinationals.
Predictably, the proposed new drug -pricing regime, which seeks to rei n in medical inflation
and make drugs 40% to 70% cheaper, has unsettled the private healthcare sector.
It complains that the new prices, which, according to one medical aid group, could save the
public around R4-billion a year, would harm the viability of the industry. And the
pharmaceutical companies say it would harm their ability to develop much-needed new
products.
That seems hard to believe. South Africa is but a tiny fraction of the global pharmaceutical
market - 0.6% - and lower profits in this country would hardly make a dent in the
multinationals' research budgets.
But it would be foolhardy to drive their local operations out of business. A way has to be found
to ensure that there are no losers in this noble quest to make healthcare affordable.
The last thing we need is to destroy a key industry and employer. Fortunately, what we are
talking about here are draft medicine price regulations, rather than a decree.
There is still a long way to go before any regulations take effect. There is scope for rational
discussion and compromise.
However, the outcome must ensure that medicines become accessible to every person who
needs them, irrespective of his or her social standing.
Pharmaceutical companies must also be willing to do their bit for the welfare of the societies
from which they earn their profits. This is especially true in a developing country such as ours.
It is against this background that some of the pharmaceutical companies should be
congratulated for allowing manufacturers of generics to copy their anti-Aids drugs.
Threatening to leave the country - as some have already done - rather than helping to find
creative ways of making drugs more affordable is hardly the way to go.
The forgotten victim
Waking a nation up from a deep slumber takes a lot of noise. This week there was much
noise, and the nation awoke to just how powerful and damaging false words of accusation
can be.
On Sunday, Salom้้Isaacs accused one of South Africa's leading jurists, Judge Siraj Desai, of
raping her in his hotel room in Mumbai in the early hours of the morning.
By Friday she had issued a complete public retraction of her accusation. In an affidavit, she
said she "unequivocally and fully" withdrew the allegation.
In a separate statement, she said she "unconditionally" withdrew the allegation.
Her about-turn has, ironically, not led to an outpouring of sympathy for Desai, who has spent
days in jail facing trumped-up charges which would have annihilated his career and branded
him a social outcast for life.



                                                8
It would seem that many believe this is the price he should pay for consorting with a woman
other than his wife in the early hours of the morning.
This is unfair. There is no evidence that Desai did cheat on his wife. Even if he did, it may
point to a character weakness but it is not a criminal offence, nor is it a moral outrage of the
order of rape.
Desai must be allowed to return to his career in the law. He deserves our sympathy.



Money can't buy us health
Jeremy Lawrence 31/03/2002
South Africans are among the unhealthiest people in the world - even though we spend as
much on healthcare as those who are fittest.
A recent world health survey by a London-based research company, World Markets Research
Centre, found that while South Africa had "reasonably high levels of expenditure", it has a
poor health status . South Africa was placed 96 out of 175 countries .
Belgium topped the list, followed by Iceland, the Netherlands, France, Switzerland, Austria
and Sweden. Cuba, Puerto Rico, Lebanon and Bosnia-Herzegovina all ranked above South
Africa.
South Africans are, however, the second healthiest people in Africa.
According to the survey, South Africa as a whole spends as much per person as the world's
healthiest nations on healthcare each year.
But most South Africans receive healthcare from a "stretched public sector, in rundown
facilities that lack both beds and doctors".
Only 20% of South Africans receive world-class healthcare.
The survey attributed its findings to the high number of people who cannot afford, and
therefore do not have access to, first-rate healthcare.
Other findings include:
South Africa operates a two-tier system in which a minority of patients pay heavily for high-
quality private healthcare while the majority receive poorer service;
Less than half the total healthcare budget is spent in the public sector, which provides for
80% of the population;
Healthcare has not been made a high priority in Africa and has declined in many countries in
the past 20 years; and
African countries have the lowest healthcare expenditure and the heaviest burden of
communicable diseases. Their inhabitants are the most likely to die young in any region of the
world.



The Guardian

Comment

A sickness in the system

Pumping more money into the NHS won't work - what we need is comprehensive health
insurance and private providers

Sheila Lawlor
Friday February 13, 2004
The Guardian

When you are older and poorer, take comfort in one thing. Your earnings went in ever heavier taxes.
There may be less for life's necessities - clothes, food, transport, a roof over your head, helping your
family or saving for retirement. But if you are sick you can hope for Gordon Brown's promise of a
"world-class health service". His line, and that of most on the left, is that the failures of the NHS have
been the result of "underfunding".



                                                     9
The evidence proves different, as Politeia's latest study shows. The system itself is so flawed that even
the most generous funding would make little difference. Look no further than the old East Germany
where, by the time of German unification, the state-directed health system had reached a stage of decay
similar to that of the NHS. The remedy was not to prolong the Stalinist structure and throw more
money at it, but to introduce the West German market model.
As Georg Baum, one of the country's most senior health officials, explains: "People's needs are best
met ... where competition exists and ... private suppliers work for patients." Competition, he says, "is at
the very heart of the philosophy ... of healthcare" in Germany. Suppliers are mainly private, with all
primary care in private hands and hospital care shared between public (55% of beds) and private and
voluntary (45%). East Germany's old state-planned system was swept away, and within two years it
was reorganised along West German lines. Private doctors and dentists offered primary care, and
hospital medicine was taken over by charitable or private providers or by local government.
Funding in Germany, as in France, is linked to the individual and based on compulsory insurance
contributions and additional co-payments. In both countries, costs are spread across the population,
with poorer people fully covered from public funds.
In Germany, sickness funds are seen as "better guardians of people's rights ... than state bureaucracies".
In France, according to a senior official at the French audit office, Jean L de Brive, the funding system
involves individuals directly. They "can choose between different private and public providers, and ...
the system can allow for increased expenditure without increased levels of tax if people are ready to
accept a reduction in the rates of reimbursement and an increase in the cost of top-up insurance".
Primary - GP and specialist - care is mainly private, and hospital care is divided between public (75%
beds) and private (35%).
These systems are far nearer to the original NHS inspired by Beveridge and announced by the cross-
party wartime coalition in the 1944 white paper. That was to be based on mixed providers - GPs and
hospitals - and mixed funding, in the main tax and insurance. But, after the war, Aneurin Bevan
abandoned the mixed scheme and went instead for a centrally planned and run system, nationalised and
to be funded almost exclusively from tax. The upshot has continued to be a chaotic, unwieldy structure
incapable of providing the healthcare that individuals need. It is one where the state dominance over
the medical profession supersedes the vital doctor-patient relationship.
This government, like its predecessors, will discover the truth of Beveridge's warning that tax alone can
never be enough to fund the health service. It will also find - as others before it have done - that the
complicated and expensive attempts to restructure will founder, as every major plan has done each
decade since 1946. The only winners are the bureaucrats and officials, the parasites of our health
service. Indeed, already, the huge increase in funding has had little impact on the proportions of
specialists, GPs or nurses.
While the "headcounts" may have increased, the proportion as a total of the workforce remains the
same, or has even fallen. Consultants amount to only 2.4% of almost 1 million workers, and qualified
nurses are outnumbered by managers and support staff. It may be that all systems fall prey to excessive
bureaucracy. But the UK's priorities appear to be of a different order to those of France, for instance,
where there are 3.3 doctors for every 1,000 people as opposed to 1.8 here.
Radical reform is needed - perhaps along the lines suggested by Deepak Lal, who points out that the
planned expenditure by the NHS per capita in 2005-6 is no greater than the premium charged by the
Kaiser Permanente insurance scheme (which has a spread of liabilities similar to that of the NHS) for
much better healthcare. Why doesn't the government just decide to buy everyone comprehensive health
insurance? The failings of Britain's healthcare system can no longer be blamed on under-funding,
because our funding levels are rapidly catching up with those of France and even Germany.
This year (2003-4), annual spending on health per capita is around £1,270 to £1,300, not far from
Germany's £1,390 - or the last available figure for France of £1,344 in 2000. And the gap between the
proportion of GDP spent on health in Britain and in continental countries is also growing smaller.
While it is true that spending as a percentage of GDP in 1998 was 6.8% in the UK and 9.3% in France
and 10.3% in Germany, that gap is closing. By 2001, the UK spent 7.6 % to France's 9.5% and
Germany's 10.7%, and this proportion is rising at a higher rate than for France and Germany, according
to the most recent figures.
Now, thanks to Gordon Brown's ineffective extravagance, it is much clearer that the deficiencies in our
healthcare are the result of the system - the very system that the chancellor is trying to preserve.
· Sheila Lawlor is director of Politeia; Systems for Success: Models for Healthcare Reform, by Georg
Baum, Jean-Louis Beaud de Brive, Deepak Lal and Sheila Lawlor, is published by Politeia




                                                    10
Adverse events

Malcolm Dean on moves to lower the huge number of avoidable deaths in NHS hospitals

Wednesday February 18, 2004
The Guardian

More people are killed by avoidable and preventable accidents in hospitals - known in the medical
world as "adverse events" - than the combined number of accidents in homes, on roads, rail and
construction sites. What can be done?
A group of senior health officials drawn from all parts of the NHS and brought together by Nigel
Edwards, policy director of the NHS Confederation, has just held a seminar to examine how NHS
treatment could be made safer, but also more efficient. The two are linked, as the Bristol inquiry into
the unnecessary deaths of infants undergoing cardiac surgery starkly documented.

Sir Brian Jarman, the medical member of the Bristol inquiry, guided the seminar through the grim
mortality statistics. Some 40% of all deaths each year - 240,000 out of 610,000 - occur in hospital. His
analysis of hospital deaths suggests 12% - more than 28,000 - are caused by avoidable adverse events.

A fourfold variation in death rates between hospitals means at the top end the best hospitals have 400
fewer deaths annually than the average, and those at the bottom end 200 more. Variation does not stop
with death rates. It is found in all NHS activity.

Alan Maynard, health economist and co-leader of the seminar, presented his latest statistics on medical
activity. The returns on the work of general surgeons - one of five categories of hospital doctors
examined - show a 30-fold variation between the top band and the bottom. As he noted, there could be
explanations for some of the variation - royal college or British Medical Association work - but the
NHS rarely examines and never explains these variations.

The challenge facing policy makers, in Maynard's view, was to find ways of changing medical
behaviour. There was a general consensus from senior medics present that conversion followed a cycle:
first denial; then reluctant acceptance, tied to the assertion that nothing could be done; and then final
conversion.

Maynard's view that financial incentives are the key has supporting evidence. One of the most dramatic
changes in the past two decades has been the prescribing patterns of GPs. In 1980 only 18% of
prescriptions were for cost-effective generic drugs; now, following moves that allow GPs to take a
share in the savings, 78% of all prescriptions are generic.

The new GP contract includes further financial incentives to encourage more preventive medicine and
end "the rule of halves": half of all patients with high blood pressure have not been diagnosed by their
GP; half of those diagnosed are not treated; half of those treated, are not adequately treated. This more
pro-active approach, linked to an extra £2bn over three years in incentives added to the £6bn GP salary
bill, should radically reduce strokes, heart failure and renal problems - heart problems still remain the
single biggest killer. GPs with long patient lists but providing little service will not benefit. Those who
take prevention seriously, could increase their incomes by between 10% and 50%.

A new fee-for-service (FFS), which historically has always been resisted by consultants, will shortly be
announced involving 30 acute hospital trusts, which will use FFS to pay for extra work from their
orthopaedic surgeons. A recent study of 12 states, from the Organisation for Economic Cooperation
and Development, found that FFS produced more operations, higher productivity, shorter waiting
times. Earlier studies that pre-dated the NHS Plan showed that increasing medical staff numbers does
not always increase outcomes. A 50% increase in orthopaedic surgeons coincided with the average
number of operations dropping to six.

New moves by Sir Liam Donaldson, the chief medical officer, to encourage staff to be open about their
mistakes - with the aim of ensuring they are not repeated - should help reduce hospital deaths. Studies
in Sweden have shown that the hospitals with the highest reported adverse events - signalling they are
being vigilant in their reporting - have the lowest death rates, because they are also vigilant in




                                                    11
correcting them. At present, the NHS system is based on a voluntary basis. Some people at the seminar
questioned whether this was enough.

Three other proposals emerged. First, that a new independent data centre should be based in the new
Commission for Healthcare, Audit and Inspection (Chai), which starts in April. Far too little use is
made by chief executives - or their board members - of hospital episode statistics (HES), which
monitor the work of all hospital doctors and identify low performers. (HES, which tracks and records
all that happens to 12 million patients who pass through hospital each year, contain 800m items of
information). Placing it in Chai, where its findings could be incorporated systematically into inspection
reports, would require trusts to look at their poor performers.

Second, the other dozen royal colleges should follow the lead of the Royal College of Physicians,
which has urged its members to validate and use HES data to manage clinical performance.

Third the NHS, which already conducts extensive inpatient surveys, should follow the lead of Bupa,
the private provider, which sends out questionnaires to patients to report on their state of health three
months after hospital treatment. This is a much more appropriate time for measuring effectiveness.

NHS quality and performance
Deadly heart condition squeezes NHS

Press Association
Tuesday February 17, 2004

The cost of treating an "insidious and deadly" heart condition is placing a substantial burden on the
NHS which will only increase in the coming years, according to new research published in the medical
journal Heart.

Atrial fibrillation (AF) is the most common form of heart rhythm abnormality, affecting one in 100
people in the UK and one in 10 of those over the age of 65.

Researchers from the Western infirmary in Glasgow said conservative estimates suggested the direct
cost of treating the condition almost doubled in the five years between 1995 and 2000, to £459m.

When associated nursing home costs - estimated at £111m a year - were taken into account, the total
was well over £500m, according to the study.

AF occurs when the electrical signals which keep the heart pumping are disturbed. This causes the
upper chambers of the heart to quiver rather than pump, allowing blood to pool and clot in the
chambers rather than being forced out, so increasing the risk of stroke.

The researchers, led by Professor John McMurray, estimated how the financial costs of AF rose
between 1995 and 2000 by looking at data such as drug prescriptions, GP consultations, hospital
admissions and long-term residential care.

In 1995, the cost of treating the 534,000 people with AF was estimated at £244m, or 0.6% of the entire
NHS budget. Around half of this cost was for hospital treatment, while drugs accounted for around
20%.

By 2000, direct healthcare costs had risen to £459m, or 1% of the total NHS budget. Long-term nursing
home costs related to the condition also rose in this period, from £46m to £111m.

The researchers said that given the ageing population and increases in hospitalisation linked to AF, the
condition was "likely to impose a substantial and growing economic burden on health care systems".
NHS quality and performance
Waiting list rises by 14,200

John Carvel
Saturday February 14, 2004


                                                    12
The Guardian

The number of patients on the NHS waiting list in England rose by 14,200 last December, according to
figures from the Department of Health that spoiled a recent run of steady monthly reductions in the
queue.

Sir Nigel Crisp, the NHS chief executive, said it was a seasonal blip in the run up to Christmas, when
hospitals reduce their operating schedules to leave spare capacity for winter emergencies.

The number waiting more than nine months rose by 400 to just over 35,000 at the end of December,
but hospitals will give priority to clearing these cases in the next three months. A year ago the figure
was 86,700.

"We are on track to meet the March targets of no one waiting more than nine months for inpatient
admission, or 17 weeks for a first outpatient appointment," Sir Nigel said.

NHS quality and performance
Heart patients 'blocking beds'

Press Association
Friday February 13, 2004

Heart attack patients are blocking beds by being kept in hospital far longer than necessary, researchers
said today.

Past studies have outlined how early discharge of low-risk patients after a heart attack is feasible after
four days, with no additional risk.

Yet a study of more than 50,000 people around the world, published in today's Lancet, found that many
low-risk heart attack patients were not being discharged within this recommended time, especially in
the European countries studied.

The researchers, from Alberta University in Canada, revealed that early discharge rates were
consistently low in Belgium, France, Germany, Spain and Poland, at less than 2% during 1990 and
1998.

Early discharge rates were higher in the US, Canada, Australia and New Zealand, but were still no
more than 40% of eligible patients.

Although the UK was not included in the study, a commentary written by researchers from London's
chest hospital revealed that the average hospital stay in the UK was nine days.

Dr Adam Timmis, of London's chest hospital, said that because of a lack of facilities and trained staff
in the NHS, many UK patients were staying in hospital even longer than the Lancet study had found
elsewhere.

He said: "There are also important inefficiencies built into the UK system of coronary care, with
unavailability of senior staff at weekends to make or implement discharge decisions, thus often
prolonging by up to three days the hospital stay of patients."

The Department of Health is currently working with Californian health company Kaiser Permanente to
reduce hospital stays for common treatments, including patients who suffered heart attacks.

The study coincides with calls by the medical profession to make cholesterol-busting drugs statins
available on private prescriptions.

Currently the drugs are only offered to patients whose risk of heart disease is more than 3%, at an
annual cost of £337 per person.

Researchers writing today in the British Medical Journal, suggested that statins would benefit people
with an annual risk of 0.6% or more, and could potentially save thousands of lives.


                                                    13
Heart disease is a leading causes of illness and death in Britain, with around 100,000 deaths from
300,000 heart attacks every year.

The Department of Health is looking at the possibility of making statins - drugs which cut the risk of
heart attacks - available over-the-counter, although this has been criticised because treatment would be
unmonitored.

But a private prescription from a GP could mean that those willing to pay would benefit while also
getting advice from their doctor.

NHS quality and performance
NHS targets

The art of aiming high

Leader
Wednesday February 11, 2004
The Guardian

Nurses, doctors and health managers all welcomed yesterday's pledge from the health secretary to
reduce the number of NHS performance targets and place a stronger emphasis on quality of care. So
too did the physiotherapists and the biggest union representing support staff (care assistants, porters
and cleaners). But then they all would, wouldn't they? All of them are producers. The people whose
reaction matters most are the patients. Even here, the King's Fund, the independent health thinktank,
thought the move would be good for them too.
So is this decision a climb-down (the Liberal Democrat charge), a u-turn (Evening Standard) or a
retreat (yesterday's Guardian headline)? To be fair to ministers, they have been talking about loosening
central controls of public services for more than a year. The theme was re-emphasised by the prime
minister in a major domestic speech to the Guardian's public service conference just two weeks ago.
And, just one day earlier than yesterday's NHS announcement, the chief inspector of schools sensibly
announced more regular but less intrusive inspections, with smaller teams, a narrower focus, and much
smaller reports (down from 80 pages to six).

Targets can generate multiple problems: unfair pressure on frontline staff, demoralisation when targets
are over-ambitious, demotivation when they are centrally devised. Then there are the frequent
unintended consequences. Take the ambulance service's target that requires 75% of all urgent
emergency calls to be met within eight minutes - but requiring no change to their rating if the other
25% wait a week.

Criticism of targets is fashionable. But it risks forgetting what went before. Prior to Labour's public
service agreements, some patients had to wait 18 months for treatments for which the wait will have
fallen to six months by next year. Fewer than half of Thatcher's children reached the expected level of
numeracy and literacy in 1995; now 73% and 75% respectively do. True, too many targets were
introduced. Up to a third of them were either not met or could not be measured. But the numbers of
targets have been drastically cut - from 400 to 62 in health - which is roughly one target for every
billion pounds spent by the NHS. Is that really such an onerous system of accountability?

Now a new regime is promised. Yesterday's consultative document proposes 24 core standards against
which the NHS should be judged from April next year, covering areas such as patient safety, cost
effectiveness, accessible and responsive care and public health. At first reading, the document is
worryingly full of waffle, with vague calls for the obvious, such as "minimising" the risk of cross
infection, handling medicines safely and ensuring clinical practice follows best practice. Does this
mean we are to move from over-mechanistic targets to merely anodyne standards? Not quite. The new
inspectorate that begins this April is charged with using the many targets already established by expert
groups, like the national service framework teams, to raise standards. Nor is there a danger that waiting
times will be allowed to slip back. Current targets will act as a baseline, above which the service must
rise.




                                                    14
Will the current simplistic star ratings for hospitals survive? The health secretary says yes; the
chairman of the new inspectors, Sir Ian Kennedy, says no. He has been saying this for some time - and
rightly so. Complex institutions like acute hospitals cannot be reduced to four crude grades (0 to 3
stars). There may be 40 specialities with the vast majority superb. Yet it only has to fail on one of nine
key performance indicators and three stars are denied. Moreover, the current yardsticks barely cover
the quality of care. John Reid should let Sir Ian have his way. A fairer system is needed.


Health | NHS quality and performance

Well connected

"PCTs desperately need some relief"

Health agencies are drowning in a tidal wave of inspection, says Geoffrey Hollis. They need
to be liberated if they are to get on with the job they are supposed to do

Wednesday February 11, 2004

I have been "CHI'd" and I can't say that I enjoyed it. The Commission for Health Improvement is to
NHS trusts what Ofsted is to schools, and it has just inspected the primary care trust (PCT) of which I
am a non-executive director.
My interview lasted for half an hour, and was conducted by a non-exec from another PCT, a GP and an
observer. It was amicable, but they meant business. Several times I was asked if I knew what patients
thought of the service. I vainly waved a copy of the CHI's own survey of patients, which I had copied
off their website and which I thought was bound to score brownie points. It did not impress.

At the end came the ritual question: "Is there anything else you want to tell us?" The phrase "before we
pass sentence" never followed, but I knew it was what they were thinking.

I think I failed to prepare myself thoroughly. This was partly because I have been quizzed several times
recently. Not long ago it was by the Audit Commission, and as chair of the trust's audit committee, I
had a lengthy grilling. A little while before that, the social services inspectorate had inquired into
progress on the older persons' national service framework, for which I am the lead non-exec.

These inspections are very demanding of staff time. Last autumn, our chief executive sent an email to
our strategic health authority headed: Inspection Overload. He had received notiÞcation from the Audit
Commission of a 10-day visit, just when he was starting the CHI inspection and when he was about to
be inspected by the IWL (improving working lives) accreditation body.

Peat (patient environment action teams) were also inspecting our two community hospitals for
cleanliness, while the former community health council was monitoring treatments. On top of this, our
chief executive had to produce a plan detailing how we were going to improve our one-star status, a
business plan, a health improvement plan, an estates strategy, a nursing strategy and other responses to
central demands.

Seeing this email, I asked how many organisations inspected or made demands on PCTs. I was shown a
list of 32 bodies. This was something of a shock, although it did provide me with an easy way to break
the ice at NHS gatherings: "How many agencies does it take to inspect a PCT?"

This list is a good indication of the "challenge" (NHS euphemism for "hopeless task") that PCTs face.
It shows the diverse areas they cover and the wide-ranging standards they are expected to meet. In fact,
this multitude can be broken down into four broad areas: Þnance, clinical effectiveness, resources and
professional accreditation. It ought to be possible to rationalise them.

The government knows about this list, and I believe ministers are convening a working party to ponder
what might be done to simplify things. A large step towards simpliÞcation was meant to be taken by
the creation of the Commission for Healthcare Audit and Inspection, due to be set up from April.




                                                    15
This new body is intended to carry out some of the current health activities of the Audit Commission
and all those of the CHI. Although the dust has not settled on this reorganisation, I am told it is unlikely
to signiÞcantly reduce the number of inspections because it is proving difÞcult to merge tasks.

I have much experience of inspecting and being inspected. I was once in charge of alcoholic drinks at
the Ministry of Agriculture, which involved overseeing a wine inspectorate. Later, I was responsible
for egg inspectors in the ministry.

I am now a school governor, and therefore see Ofsted at Þrst hand, and I am on the management
committee of a care home, which is regularly inspected. Most inspections do not turn up much, but
have to be carried out to Þnd the small percentage of failing bodies. What is needed is a system of
inspections that minimises the burden on the majority of effective PCTs, hospitals and schools, etc.

It should be possible to reduce the number of agencies that carry out inspections. The CHI is very
thorough - a team of 14 people crawled over my PCT - and its Þndings should be used by other
agencies with allied responsibilities. Many agencies need not carry out inspections.

Let us hope that the government's working party can persuade the agencies on the list of 32 to cut the
number of their inspections by relying on the work of others. From past experience, this will require
some determined action, but PCTs desperately need some relief.

· Geoffrey Hollis is a non-executive director of the Welwyn Hatfield primary care trust

For more on the Commission for Health Improvement: www.chi.nhs.uk

The NHS plan
NHS 'pays more for private sector ops'

Tash Shifrin
Thursday February 5, 2004

The health service is paying up to 50% more for operations in the private sector than the same
procedures would cost if they were carried out in NHS hospitals, Department of Health figures are
expected to show today.

The figures are set to be revealed when ministers publish the new NHS tariff - a price list for treatments
that effectively reintroduces the market into the NHS - seven years after Labour pledged to "undo the
damage" the market had caused under the Conservatives.

The new "payment by results" system will be phased in from this year, with money following the
patient: NHS hospitals will be paid a fixed price - set in the tariff - for each patient they treat. The
scheme is intended to extend to treatments bought from the private sector by 2008.

But today's figures will confirm that the NHS has been paying the private sector far higher rates, the
Financial Times reports today. It estimates that premiums paid to private hospitals could have cost the
taxpayer as much as £100m.

The DoH figures will bear out October's findings by the Commons health select committee, which
heard NHS finance director Richard Douglas admit that figures produced by the Office for Health
Economics thinktank showing private hospitals were receiving around 40% more cash for operations
were "reasonable".

The OHE figures showed that in 2001 the average price charged by the private sector for cataract
operations was £922, compared with £632 for operations carried out in the NHS - making the private
procedure 46% more expensive than the NHS operation. Hip replacements were 33% more expensive,
while knee replacements were cost 44% more. Coronary bypass grafts were 40% more expensive in the
private sector.




                                                     16
The OHE data covered operations that NHS trusts bought from the private sector under the "concordat"
agreed between the government and the UK private healthcare industry, as part of the drive to cut
waiting lists.

But operations farmed out to the new independent sector treatment centres - dubbed "surgery factories"
- set up by overseas healthcare companies will also cost more than the same procedures in NHS
hospitals, as the government will pay a "market forces factor" to cover the firms' start-up costs. This is
expected to add tens of millions of pounds to the cost of the centres that are due to carry out 250,000
operations a year by 2005.


NHS quality and performance

Inequality in dementia treatment

James Meikle
Wednesday January 7, 2004
The Guardian

People with dementia are receiving unequal drug treatment despite official guidance which was meant
to end postcode prescribing, it was claimed last night.

A survey of NHS spending on the three main drugs found big differences around Britain.

Statisticians working for Pfizer, which markets Aricept, one of the drugs, found the biggest gap was
between the Eastern Health and Social Services Board in Northern Ireland, where spending was the
equivalent of £10 for every person over 65 compared with £1 in Lothian, Scotland.

In England the low spenders were health authorities in the Thames Valley, Birmingham and the Black
Country, Shropshire and Staffordshire, Leicestershire, Northamptonshire and Rutland, and County
Durham and Tees Valley. In Wales, Bro Taf covering Cardiff, and Iechyd Morgannwg, covering
Swansea, were named. High spenders were all the Northern Ireland health boards, the Scottish health
boards of Lanarkshire, Argyll and Clyde, Ayrshire and Arran, and Fife, and the English health
authority for Cumbria and Lancashire.

Roger Bullock, of the Kingshill Memory Research Centre, Swindon, said the government's guidelines
had failed to produce equality of treatment

NHS quality and performance
Rich patients get better NHS care

John Carvel, social affairs editor
Friday November 7, 2003
The Guardian

Middle-class people benefit more from the NHS than the poor, according to a report today from senior
government advisers that overturns the long-standing boast of ministers that the health service's
greatest virtue was fairness to all-comers.

They found that "affluent achievers" from the professional classes were 40% more likely to get a heart
bypass than the "have-nots" from lower socio-economic groups, despite much higher mortality from
heart disease in the deprived group.

Poorer people were 20% less likely to get a hip replacement, although they were 30% more likely to
need one.

And even in the GP's surgery, class made a difference to the standard of care that patients could expect.
Those from the two most affluent social groups got about 10 minutes of the doctor's time, while those
from the other five groups averaged just over eight minutes.



                                                    17
The report was written by Julian le Grand, Tony Blair's health policy adviser in the Downing Street
policy directorate, Anna Dixon, an adviser to John Reid, the health secretary, and three colleagues in
the Department of Health.

The report said: "Relative to the better off, when ill, the poor either tend not to go to the doctor at all, or
be present at a later stage in their illness.

"They often go to accident and emergency departments instead of GP surgeries, and when well, they do
not access prevention services, or at least not as much as the better off."

Prof le Grand and his colleagues cast doubt on previous research showing that the poor use the NHS as
much as the rich. But by studying a range of conditions they found more affluent groups benefited
disproportionately in relation to their needs.

They found that patients from the lower social groups had 10% fewer preventive consultations than
those from the top two groups.

The government had previously acknowledged a need to do more to improve the efficiency of the NHS
and address inequalities that contributed to a wide variation in mortality rates between the inner cities
and prosperous shires. But ministers continued to insist that the NHS was the fairest healthcare system
in the world.

Mr Reid will develop a new argument today in a speech to the New Health Network in London. He
will not try to rebut Prof le Grand's charge of unfairness, but will argue that the government's NHS
reforms are the best way to improve.

He is expected to say the middle classes get more out of the health service because they are more
articulate, more confident and more persistent.

They are more likely to have health professionals in their families and social networks who can help
them to play the system. By contrast, patients from poorer communities are more likely to have a
fatalistic view of their illness and resort to self-treatment.


NHS quality and performance | The NHS plan
Put patients first, Reid tells doctors

Michael White, political editor
Saturday November 8, 2003
The Guardian

The health secretary, John Reid, yesterday urged NHS consultants to stop sending "doctor to doctor"
letters about their patients' diagnoses and treatments and to write explanatory letters to the patient first.

Addressing the advantages enjoyed by better-educated NHS patients, he conceded that poor people
suffer from the lower demands and expectations they have of the system.

They "tend to self-manage ill-health" and have "a fatalistic view of their illness not shared by people
from higher socio-economic groups".

"At the moment most medical correspondence about a patient is sent from consultant doctor to doctor.
The doctor sometimes then informs the patient," he said.

"In an NHS which genuinely places the patient at the centre this is obviously wrong," he said in a
speech to the New Health Network in London. "Why shouldn't letters be sent to the patient to ensure
that they are the first port of call for all information about their health?"

Mr Reid is battling to carry forward costly NHS reforms which seek to put patients at the centre of
treatment and to devolve budgets and decision making to GPs and hospitals.




                                                      18
He was responding to a report on the "inverse care law" - whereby those with the worst health get the
least treatment - drawn up by health economists at the London School of Economics. They found that
affluent and educated people got a lot more coronary care and elective surgery than poorer people.

Hip replacements among the poor are 20% lower than average when there is 30% higher need.
Screening for illness prevention also reflects class factors.
Mr Reid has been persuaded that patients who get personal letters explaining the medical options
become more involved in their treatment and recover more quickly and better.




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