COMMISSIONING
Health care reform: a tale of continuing failure
For decades public and private commissioners of health care have been striving and largely failing to improve the efficiency with which scarce health care resources are used and to control expenditure growth, says Professor Alan Maynard
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n insurance based systems such as the United States, insurers have used co- payments and a variety of purchasing policies (eg “managed care”) to control expenditure growth and improve their leverage on inefficient providers of care. Evidence of their failure to control provider power can be seen in premia rates growing by two and three times the rate of inflation.
In the tax based and social insurance systems of Europe, similar problems continue. The English regularly “re- disorganise” the structure of the NHS. Health authorities in the nineties were followed by primary care groups, then over 300 primary care trusts, then by merger and the creation of 152 primary care groups, which in turn are now to be transformed into GP consortia.
These expensive and disruptive changes in purchasing or the commissioning of health care have largely failed as chronicled for instance early this year by the House of Commons Select Committee on Health (1)
Like reformers worldwide, the English have the religious belief that if you change the
22 nhe
of the health care delivered to patients had robust evidence base which demonstrated effectiveness (2)
. Nowadays, Alan Maynard
organisational structure of the NHS, this will always and everywhere lead to improved efficiency in the delivery of health care processes, which in turn will improve patient outcomes.
Sadly this faith cannot be evidenced. Shifting the deckchairs on the NHS Titanic does not improve the vigilance of the crew or the welfare of the passengers!!!
What are the causes of reform failure?
The principal problems facing reformers are that they may know from the evidence base what the problems are but they have neither the sense nor the courage to act to protect taxpayers and patients. The cause of this is the power of provider groups such as the pharmaceutical industry, the medical professions and managers, which is used to defend narrow institutional and professional interests.
The inefficiencies of health care systems, public and private, have been researched for many decades. The physician Archie Cochrane argued nearly forty years ago that only ten per cent
perhaps thirty five per cent of the interventions in a physicians’ armoury are evidence based. However even though evidenced, these effective treatments are often not delivered to patients e.g. inadequate stroke care. Failure to deliver effective care imposes avoidable mortality and morbidity on patients.
Uncertainty about effectiveness and cost effectiveness of care and poor governance results in large and wasteful variations in clinical care. Patients with similar health care needs and similar personal characteristics get very different levels and quality of care. In the USA, it is argued that the adoption of conservative safe practices would save 30 per cent of Medicare expenditure for the elderly (3)
. Darzi “rediscovered”
variations in his report in 2007 (4)
, although the Department of Health was emphasising such issues in 1976 (5)
.
In the UK and US, the twenty first century saw the rediscovery of patient safety issues. For instance, the rise of infections such as MRSA and C.Difficile led to large investments in hygiene.
The Hungarian physician Semmelweis demonstrated the need for hand hygiene in a Vienna maternity unit in the late 1840s. He was ostracised by his clinical colleagues and was buried in a pauper’s grave, demonstrating nicely that medical pioneers are often not loved by their professional colleagues!
Tardily, the measurement of outcomes is making some progress. Comparative mortality data offers insights into relative failure eg Mid Staffs. Mortality data is being used to identify outliers needing further investigation i.e. these data are for screening to identify potential problems rather than a diagnostic that tells you that you have a problem.
Catching up with the objectives of the architects of the 1845 Lunacy Act, the English Department of Health has begun to invest in patient reported outcome measures (PROMs)
Nov/Dec 10
The current vogue for rightly emphasising the measurement and management of patient outcomes also has an interesting history. The Lunacy Act of 1845 required health care institutions to measure and report regularly whether their patients were “dead, recovered, relived or unrelieved”. Florence Nightingale subsequently adopted a version of these criteria her work on the reform of hospitals (6)
.
A pioneer in measuring “success” in medical care was the American surgeon Ernest Codman. In the early part of the twentieth century he advocated the publication of surgical mortality data in Massachusetts. His “reward” was to be denied operating rates in the Massachusetts General hospital. When he published his surgical mortality rates, he lost customers as his peers implied but did not demonstrate they were better and, like Semmelweis, he was buried in pauper’s grave.
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