EurohealthVolume 16 Number 3, 2010RESEARCH • DEBATE • POLICY • NEWS

User fees in the Czech Republic • Evidence for policymaking: the ECHI initiativeEngland: Independent Sector Treatment Centres • Uzbekistan: barriers to physician workforce development

Improving performance in the English NHS

The performance paradigm: potential, pitfalls and prospects

Health system performance management: quality for

better or worse?

Measuring andmanaging performance

LSE Health, London School of Economics and Political Science, Houghton Street, London WC2A 2AE, UKfax: +44 (0)20 7955 6090http://www.lse.ac.uk/collections/LSEHealth

Editorial Team

EDITORS: David McDaid: +44 (0)20 7955 6381email: d.mcdaid@lse.ac.ukSherry Merkur: +44 (0)20 7955 6194email: s.m.merkur@lse.ac.uk

FOUNDING EDITOR: Elias Mossialos: +44 (0)20 7955 7564email: e.a.mossialos@lse.ac.uk

DEPUTY EDITOR: Philipa Mladovsky: +44 (0)20 7955 7298

ASSISTANT EDITORS: Azusa Sato +44 (0)20 7955 6476email: a.Sato@lse.ac.ukLucia Kossarova +44 (0)20 7107 5306email: l.Kossarova@lse.ac.uk

EDITORIAL BOARD:Reinhard Busse, Josep Figueras, Walter Holland, Julian Le Grand, Martin McKee, Elias Mossialos

SENIOR EDITORIAL ADVISER:Paul Belcher: +44 (0)7970 098 940email: pbelcher@euhealth.org

DESIGN EDITOR: Sarah Moncrieff: +44 (0)20 7834 3444email: sarah@westminstereuropean.co.uk

SUBSCRIPTIONS MANAGER Champa Heidbrink: +44 (0)20 7955 6840email: eurohealth@lse.ac.uk

Advisory BoardTit Albreht; Anders Anell; Rita Baeten; Johan Calltorp; AntonioCorreia de Campos; Mia Defever; Isabelle Durand-Zaleski;Nick Fahy; Giovanni Fattore; Armin Fidler; Unto Häkkinen;Maria Höfmarcher; David Hunter; Egon Jonsson; AllanKrasnik; John Lavis; Kevin McCarthy; Nata Menabde; Bernard Merkel; Willy Palm; Govin Permanand; Josef Probst;Richard Saltman; Jonas Schreyögg; Igor Sheiman; Aris Sissouras; Hans Stein; Ken Thorpe; Miriam Wiley

Article Submission Guidelinessee: www2.lse.ac.uk/LSEHealthAndSocialCare/LSEHealth/documents/Guidelinestowritinganarticleforeurohealth.aspx

Published by LSE Health and the European Observatory onHealth Systems and Policies, with the financial support ofMerck & Co and the European Observatory on Health Systemsand Policies.

Eurohealth is a quarterly publication that provides a forum forresearchers, experts and policymakers to express their views onhealth policy issues and so contribute to a constructive debateon health policy in Europe.

The views expressed in Eurohealth are those of the authorsalone and not necessarily those of LSE Health, Merck & Co. or the European Observatory on Health Systems and Policies.

The European Observatory on Health Systems and Policies is apartnership between the World Health Organization RegionalOffice for Europe, the Governments of Belgium, Finland, Ireland, the Netherlands, Norway, Slovenia, Spain, Sweden andthe Veneto Region of Italy, the European Commission, theEuropean Investment Bank, the World Bank, UNCAM (FrenchNational Union of Health Insurance Funds), the LondonSchool of Economics and Political Science, and the LondonSchool of Hygiene & Tropical Medicine.

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ISSN 1356-1030

Managing performance: what do weknow?If there was ever a time for putting an emphasis on improving performance management then surely this is it. At a time when economic resources are tight but Europeans continue to demand an ever more personalisedapproach to health care, it is of critical importance thatsystems operate as cost-effectively as possible. They alsoneed to maintain high quality standards and be flexibleenough to respond to changing population need. Evenmore fundamentally, health systems need to be held accountable for decisions that are made.

Better performance monitoring mechanisms can potentially help with these issues, but what has happenedin practice? What do we know about how well they work?This issue of Eurohealth focuses on this issue. It featuresarticles that originate from a seminar hosted by LSEHealth and the NHS Confederation and funded by theHigher Education Innovation Fund in April 2010.

The situation is complex. Gwyn Bevan in looking at different motivations to respond to performance assessment measures finds that systems that potentiallyhave an impact on the reputation of service providers, forexample by ranking them publicly, are more likely to generate incentives for poorly performing providers tomake improvements. A reliance on altruism or marketmechanisms is less likely to be effective. Chris Ham looking at experience in England argues that the introduction of targets and national standards has indeed contributed to performance improvement in the English NHS.

Both Mark Exworthy and Niek Klazinga focus on what is measured. Exworthy points out that with all the competing pressures on providers, it is important for regulators, managers and other users of data to agree onwhat will be measured and how data will be used. He further stresses the importance of knowing what does notget measured and how this affects performance. Klazingaalso argues that when utilised improperly data from performance management can result in sub-optimal service delivery.

Clearly no system of performance assessment will ever be perfect, but we need to learn more from systems thathave been implemented. What may be lacking to date issufficient consistency in health policy over time to fullyevaluate the impact of different approaches.

David McDaid EditorSherry Merkur Editor Philipa Mladovsky Deputy EditorLucia Kossarova Assistant EditorAzusa Sato Assistant Editor

MENT

EurohealthCOM

Contents EurohealthVolume 16 Number 3

Arpo Aromaa is Professor, Finnish NationalInstitute for Health and Welfare (THL), Finland.

Gwyn Bevan is Professor of Management Science, Department of Management and LSEHealth, London School of Economics and Political Science, UK.

Mark Exworthy is Reader in Public Manage-ment and Policy, School of Management,Royal Holloway University of London, Egham,UK.

Gary L. Filerman is a member of the Faculty,Georgetown University, Washington DC, USA.

Matthew Gaskins is Research Fellow, Department of Health Care Management atthe Berlin University of Technology, Germany.

Gudrun Kr Gudfinnsdottir is Policy Officer, European Commission, DG SANCO, HealthInformation Unit.

Chris Ham is Chief Executive of the King’sFund, London, UK.

Rachel Irwin is Research Assistant, LSE Health,London School of Economics and Political Science, UK.

Zukhra Karimova is Faculty member, TashkentPaediatric Medical Institute, Uzbekistan.

Niek Klazinga is Professor of Social Medicine,Academic Medical Centre, University of Amsterdam, the Netherlands and Coordinatorof the Organisation for Economic Co-operation and Development’s (OECD)Health Care Quality Indicator project.

Pieter Kramers is Senior Advisor, Dutch National Institute for Public Health and the Environment (RIVM), the Netherlands.

Alena Ottichova is PhD candidate, SalzburgCentre of European Union Studies (SCEUS),Salzburg University, Austria.

Nidhi Vaid is Specialist Registrar in AcuteMedicine, Chelsea and Westminster Hospital,London, UK.

Ewout van Ginneken is Senior Researcher, Department of Health Care Management atthe Berlin University of Technology, Germany.

Marieke Verschuuren is Senior Researcher,Dutch National Institute for Public Health andthe Environment (RIVM), the Netherlands.

Health policy1 User fees in the Czech Republic:

The continuing story of a divisive toolEwout van Ginneken, Alena Ottichova and Matthew Gaskins

4 Providing a solid evidence base for policy makers: ECHI initiativeMarieke Verschuuren, Pieter Kramers, Gudrun Kr Gudfinnsdottirand Arpo Aromaa

8 Private sector providers in England:The implications of Independent Sector Treatment CentresNidhi Vaid

11 Five barriers to physician workforce development in UzbekistanZukhra Karimova and Gary L. Filerman

Performance15 Managing performance: An introduction

Rachel Irwin

16 The performance paradigm in the English NHS: Potential, pitfalls, and prospectsMark Exworthy

20 If neither altruism nor markets have improved NHS performance,what might?Gwyn Bevan

23 Improving performance in the English National Health ServiceChris Ham

26 Health system performance management: Quality for better or for worseNiek Klazinga

Evidence-informed Decision Making 29 “Mythbuster” If a drug makes it to market, it’s safe for everyone

Monitor

31 Publications

32 Web Watch

33 News from around Europe

Eurohealth Vol 16 No 31

HEALTH POLICY

User fees have become a very sensitivepolitical issue in the Czech Republic,sparking debate in Parliament, the mediaand the general public. Their introductionand the ongoing discussions on their con-tinuation have played a key role duringthe last three regional and national elections and were widely seen as a majorcontributor to the collapse of Prime Minister Mirek Topolánek’s centre-rightcoalition in spring 2009.

This seems quite remarkable given thatprivate households’ out-of-pocket pay-ment on health as a percentage of totalhealth expenditure in the Czech Republichas been relatively modest from an international perspective. In 2008, thispercentage stood at 13.7% (compared to13.2% in 2007, the year before user feeswere introduced), which is slightly lowerthan the EU15 average of 14.5% and sub-stantially lower than the percentages forHungary (25.2%), Poland (24.2%) and

Slovakia (26.2%) for that year.1 In thepresent review, we describe the introduc-tion of user fees, the political controversysurrounding them, and their impact onhealth care utilisation in the Czech Republic.

BackgroundSince 1993, the Czech Republic has had asystem of social health insurance (SHI)based on compulsory membership in oneof a range of health insurance funds. Eli-gible residents may freely choose amongthese and among health care providers.SHI contributions are mandatory and cal-culated as a percentage of wages.Compared to Western Europe, the healthsystem is characterised by relatively lowtotal health care expenditure as a share ofgross domestic product (GDP), low out-of-pocket payments and plentiful humanresources, albeit with some substantialregional disparities.

The population enjoys virtually universalcoverage and a broad range of benefits.Some important health indicators arebetter than the EU15 and EU27 averages(such as mortality due to respiratorydisease and infant mortality rates). On theother hand, the standardised death rates fordiseases of the circulatory system andmalignant neoplasms are well above theEU27 average. A range of health care util-isation rates, such as outpatient contactsand average length of stay in acute carehospitals, are also above this average.Overall, there is substantial potential in theCzech Republic for efficiency gains andimproved health outcomes.2 This wasrecognised by the centre-right coalition ledby Prime Minister Mirek Topolánek’sCivic Democratic Party (ODS) from 2007to 2009, forming the rationale for the intro-duction of the user fees in 2008.

Prior to 2008, inpatient and outpatienthealth services were free of charge at thepoint of use, with the exception of someco-payments for prescription pharmaceu-ticals and medical aids. From theperspective of the centre-right coalition,this had in many cases led to high utili-sation rates and the inappropriate use ofscarce health resources. Indeed, thenumber of outpatient contacts per personin the Czech Republic (15.0 per year) was

User fees in the Czech Republic:

The continuing story of a divisive tool

Ewout van Ginneken, Alena Ottichova and Matthew Gaskins

Summary: The introduction of user fees and the ongoing discussions on their continuation have caused a great deal of debate in the Czech Parliament, mediaand general public. Although evidence from the first year after their introductionsuggests a decrease in resource utilisation, second-year data already show a slightincrease for some important indicators. Measuring the effectiveness of user fees isnotoriously difficult, but in the Czech Republic this challenge has been furthercompounded by efforts in some regions to tap into regional budgets to reimbursepatients for user fees, undermining the mechanisms on which the system was based.

Key words: health reform, cost sharing, user fees, Czech Republic

Ewout van Ginneken is a Senior Researcher in the Department of Health Care Management at the Berlin University of Technology, Germany.

Alena Ottichova is a PhD candidate in the Salzburg Centre of European Union Studies(SCEUS), Salzburg University, Austria. Alena.Ottichova2@sbg.ac.at

Matthew Gaskins is a Research Fellow in the Department of Health Care Management at the Berlin University of Technology, Germany.

the highest in the WHO European Regionin 2006.1 Moreover, an estimated CZK4–10 billion (€144–360 million) worth ofprescribed pharmaceuticals were beingwasted or went unused each year.2 Thechief aim of user fees was to reduce over-consumption and inefficiencies in thehealth sector by encouraging people to usehealth services responsibly. The PublicBudgets Stabilisation Act, passed inAugust 2007, introduced small user fees fora variety of health services and changed thesystem for setting prices and reim-bursement rates for pharmaceuticals.

Introducing the user feesA range of user fees were introduced on 1 January 2008, amounting to flat rates ofCZK30 (€1.20) per doctor visit, CZK60(€2.40) per hospital day, CZK90 (€3.60)per use of ambulatory services outside ofstandard office hours, and CZK30 (€1.20)for prescription pharmaceuticals.

Some vulnerable groups were exemptedfrom the fees, including people livingbelow the poverty line, neonates, chroni-cally ill children, pregnant women, patientswith infectious diseases, organ and tissuedonors, and individuals receiving pre-ventive services. Moreover, an annualceiling of CZK5,000 (€200) per insuredindividual was established for selected userfees (excluding user fees for hospital staysand the use of ambulatory services outsideof standard office hours), as well as for co-payments on prescription pharmaceuticalswith a price exceeding the reference pricein a particular pharmaceutical group.

As early as March 2008, user fees began toplay a major role in the campaigns for theregional and Senate elections planned forOctober that year. On 28 March 2008, theChamber of Deputies for the first timerejected the Social Democrats’ (CSSD)proposal to repeal user fees. The CSSDthen pledged to eliminate user fees inregional hospitals and pharmacies if theyregained power. Furthermore, on 28 May2008 the Czech constitutional courtrejected the CSSD’s claim that the user feeswere unconstitutional.3

A large portion of the population opposedthe user charges, and the CSSD could beassured of their backing. Indeed, manypeople in the Czech Republic were notbothered by the amount they had to pay(that is, €1.20–3.60), but by the principleof having to pay user fees, which wentagainst the idea of free health care delivery– one of the main tenets of the Czechhealth care system.4 Furthermore, the

sensitive political nature of the subject andnegative media coverage may have led togeneral uncertainty about the new systemamong insured individuals. This wasreflected in a public opinion poll in whicha third of respondents stated at the timethat they did not know the purpose of theuser fees nor feel that they were necessary.5

The unrest begins It thus came as no surprise that the resultsof the regional and Senate elections inOctober 2008 were a disaster for the gov-erning centre-right coalition. Thirteen ofthe fourteen regions were lost to the oppo-sition. The aftermath of the autumnelections was chaotic. In December 2008,members of the CSSD voted in theChamber of Deputies in favour of abol-ishing user fees for health servicesaltogether. This was rejected by the Senatein January 2009, which instead preferred toreduce the burden on the young and theelderly.

The political landscape remained volatile.In March 2009, in the middle of the CzechPresidency of the European Union, thecentre-right coalition led by MirekTopolánek lost a vote of confidence. Anindependent, Jan Fischer, was selected tobecome the Prime Minister of a caretakergovernment in April. His government,nominated by both major parties (the ODSand the CSSD), was inaugurated on 8 May2009, and new elections were scheduled forMay 2010. Again, the CSSD pledged torepeal user fees if they regained power inthe Chamber of Deputies in the 2010 elections.

Under enormous political pressure, thenew caretaker government adjusted theuser fee system in April 2009. Althoughthe annual ceiling had been reached byonly approximately 0.2% of insured indi-viduals in 2008,2 the ceiling was lowered.As of 1 April 2009, a new annual ceiling ofCZK2,500 (€100) was set for personsunder 18 years or over 65 years of age;moreover, those under 18 years were alsoexempted from user fees for doctor visits.In June 2009, the Czech Senate rejectednew efforts by the Chamber of Deputies toabolish user fees.

The regions revoltIn the meantime, the regions, which byFebruary 2009 were all governed by theCSSD with the exception of Prague, haddecided on the 1st of that month to pay thefees from their own budgets on behalf ofpatients. To achieve this end, the regions

implemented their own reimbursementsystems, leading to a different system inalmost every region. In several regions,patients were automatically reimbursed foruser fees, while in other regions patientshad to file a written request for reim-bursement.

Since January 2009, great uncertainty hasprevailed. For example, some public hos-pital pharmacies have tapped into regionalbudgets to reimburse patients for the userfees, whereas privately owned pharmacieshave not. In some cases, actions likes thesehave been prohibited by the courts on thegrounds of unfair competition after com-plaints made by the private pharmacies.6

Furthermore, the Czech Ministry ofHealth began an administrative proceedingagainst four regions in January 2010, andnine sickness funds protested openlyagainst regional hospitals and their phar-macies that had not been collecting userfees.7

As a countermeasure, the CSSD launcheda ‘struggle against fees’ campaign and filedtwo complaints with the ConstitutionalCourt in February 2010.8 The EuropeanCommission voiced the informal view thatthe current system, in which regionalauthorities pay the fees, is discriminatoryand, if formally investigated, might bedeemed as conflicting with European state-aid rules.9 Another problem is the costs:reimbursing patients for the fees places agreat burden on regional budgets. Afterone year, approximately two thirds ofpatients in regions governed by the CSSDtook advantage of user-fee reimbursement,leading to a total cost of CZK478 million(€19 million).10

Have the user fees worked?Data from the Czech Institute of HealthInformation and Statistics show that thenumber of visits to ambulatory specialistsfell by 17% in 2008.11 The decrease in theuse of ambulatory care services outside ofstandard office hours was even more pro-nounced at 41%; importantly, this was notaccompanied by an increase in the use ofemergency services.

Looking at hospitalisations in 2008, thenumber of hospital days decreased by4.4% in acute care hospitals and by 3.2%in non-acute care hospitals11 even thoughthe number of hospitalised patientsincreased by 3% and 5%, respectively,during the same period.2 This suggests areduction in the average length of stay,which is confirmed by Health for All(HFA) data, which show a reduction of 0.6

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days (to an average of 7.4 days) between2006 and 2008 for all hospitals observed.1

It should be noted, however, that adecrease in the average length of stay wasalready visible in 2007, the year prior to theintroduction of user fees.

Finally, the number of prescribed pharma-ceuticals and the number of unit packs ofprescribed pharmaceuticals fell by 26.7%and 7.4%, respectively. At the same time,SHI expenditure on prescribed pharma-ceuticals rose by 8.3%, indicating a shift inSHI reimbursement from less expensive,everyday pharmaceuticals to more costlypharmaceutical treatments and bigger unitpacks.11

For 2009, utilisation data for healthservices show a moderate reversal of thetrend seen in 2008. For example, thenumber of prescribed pharmaceuticalsincreased by 6%.12 Although the numberof unit packs of prescribed pharmaceuticalsfell by 1.8%, expenditure on prescribedpharmaceuticals rose by 9.6%.13 Theaverage number of hospital bed daysincreased slightly, by 1.3 days to 255.5days, while the average length of stayremained at 7.4 days.14 Also, the numberof visits to ambulatory specialists and theuse of ambulatory care services outside ofstandard office hours in 2009 increased by9.2% and 10.1%, respectively.13

The 2009 statistics may reflect the effect ofthe reimbursement of user fees by theregions, which likely undermines the effec-tiveness of the system. It should also benoted, however, that measuring both theshort- and long-term effects of user fees isnotoriously difficult. Even decreasing util-isation rates may give an incompletepicture of the cost-saving potential of userfees, with costs arising elsewhere in thesystem. For example, patients may forgonecessary treatment or fail to adhere totreatment, which could lead to the need forcostlier treatments at a later time. Interna-tional evidence on the effectiveness of userfees, especially over the long term, isinconclusive.15,16 More data will be neededin the coming years to make useful inter-pretations about the effectiveness of themeasures taken in the Czech Republic.

Latest developments: the unrest continuesAgainst all expectations, the CSSD wonthe May 2010 elections of the Chamber of Deputies with only 22% of the vote, followed closely by the ODS with 20%,the newly founded TOP 09 party with anunexpected share of 16.7%, the Commu-nists (KSCM) with 11.3% and the newly

established Public Affairs party (VV) with10.9% of the vote. The success of TOP 09and VV was unparalleled in the politicalhistory of the Czech Republic. The elec-tions were a political earthquake in whichthe established parties suffered heavylosses. As a result, another centre-rightcoalition was formed, this time with theODS, TOP 09 and VV.

Opinions about user fees remain divided.It seems unlikely that the new centre-rightcoalition will abolish or significantlyreform the user fee system. On the con-trary, the new coalition inherited a healthsystem affected by the financial crisis andwith a large deficit (CZK 10 billion in 2009,€400 million) and is currently looking atways to increase out-of-pocket paymentsand the responsibility of patients to sharein costs.17 The opposition CSSD andCommunist Party continue to call for therepeal of the user fees. Since June 2010,health facilities in some regions have abol-ished the reimbursement of user fees toretain more resources and to lessen theiradministrative burden.18

ConclusionUser fees remain a divisive issue in Czechpolitics. Although out-of-pocket spendingis still low from an international per-spective, the concept of having to pay forsomething that had been historically pro-vided for free has led to a great deal ofpublic debate and played a large role inseveral elections since 2008. The intro-duction of user fees is widely thought tohave contributed to a change in politicalleadership, which if true shows the abilityof this relatively small measure to pack abig punch. Other countries contemplatingthe introduction or expansion of user fees might want to consider the Czechexperience.

Good evidence is essential when deliber-ating whether to introduce user fees.Although evidence from the first year afterthe fees were introduced suggests adecrease in resource utilisation, the secondyear data already show a slight increase forsome important indicators. When inter-preting these data, however, it is importantto keep in mind that the mechanisms onwhich the system was based were under-mined by the regions that chose toreimburse patients for the user fees fromthe regional budgets. Several more years ofdata are needed before any definitive conclusions can be drawn on the impact ofuser fees in the Czech Republic.

REFERENCES

1. WHO Regional Office for Europe. European Health for All Database. Copenhagen: WHO Regional Office forEurope, 2010. Available at:http://www.euro.who.int/hfadb

2. Bryndová L, Pavloková K, Roubal T,Rokosová M, Gaskins M, van Ginneken E.Czech Republic: Health system review.Health Systems in Transition2009;11(1):1–122.

3. �Cabanová A, Šenký� M. Soud: U lékarese bude platit dál [Court judgment: Keepon paying at the doctors]. Lidové noviny29 May 2008. Available at: http://www.lidovky.cz/ soud-u-lekare-se-bude-platit-dal-dmy/ln_noviny.asp?c=A080529_000003_ln_noviny_sko

4. Antonova P, Jacobs DI, Bojar M et al.Czech health two decades on from the Velvet Revolution. The Lancet2010;375:179–81.

5. STEM/MARK agency public opinion research, 5–9 August. In: Ctvrtina lidí neví,k cemu slouží zdravotnické poplatky [Athird of people do not know the purpose ofuser fees]. Ceske noviny 12 August 2010.Available at: http://www.ceskenoviny.cz/zpravy/ctvrtina-lidi-nevi-k-cemu-slouzi-zdravotnicke-poplatky/514955?rss

6. P°urová Z. Vrchní soud podporil zákazRathových klicek s poplatky [High Courtsupports ban on Rath’s fee loopholes].Mladá Fronta Dnes 17 September 2009.Available at: http://zpravy.idnes.cz/vrchni-soud-podporil-zakaz-rathovych-klicek-s-poplatky-pj2-/domaci.asp?c=A090917_ 143415_domaci_taj

7. Pojišt’ovny zacnou rozdávat pokuty zaneplacení poplatk°u [Sickness funds will impose fines for non-payment of fees].Mladá Fronta Dnes 9 February 2009. Avail-able at: http://zpravy.idnes.cz/pojistovny-zacnou-rozdavat-pokuty-za-neplaceni-poplatku-p32-/domaci.asp?c=A090209_174636_domaci_ban

8. Kopecký J. Pred volbami sílí boj opoplatky, k soudu mírí hned dve� ústavnístížnosti [Fight against fees grows beforeelections, two constitutional complaint before court]. Mladá Fronta Dnes 5 Febru-ary 2010. Available at: http://zpravy.idnes.cz/pred-volbami-sili-boj-o-poplatky-k-soudu-miri-hned-dve-ustavni-stiznosti-14c-/domaci. asp?c=A100205_140636_domaci_kop

9. EC denounces payment of health fees byCzech regions. Prague Daily Monitor2 June 2010. Available at: http://praguemonitor.com/2010/06/02/ec-denounces-payment-health-fees-czech-regions

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10. Syslová J, Tvarohová J. Proplácenípoplatk°u� už stálo kraje p°ul miliardy. Jakonekolik kalamit [Reimbursement of feeshave already cost regions half a billionCzech Crowns]. Mladá Fronta Dnes 21January 2010. Available at: http://zpravy.idnes.cz/proplaceni-poplatku-uz-stalo-kraje-pul-miliardy-jako-nekolik-kalamit-12e-/domaci.asp?c=A100121_101015_domaci_ban

11. ÚZIS. Institute of Health Informationand Statistics of the Czech Republic. Consumption of Health Services in theYears 2005–2008. Prague: ÚZIS, 2009;63. Available at: http://www.uzis.cz

12. ÚZIS. Institute of Health Informationand Statistics of the Czech Republic. Phar-maceutical Services in 2009. Prague: ÚZIS,2010;21. Available at: http://www.uzis.cz

13. ÚZIS. Institute of Health Informationand Statistics of the Czech Republic. Consumption of Health Services in theYears 2006–2009. Prague: ÚZIS, 2010;46.Available at: http://www.uzis.cz

14. ÚZIS. Institute of Health Informationand Statistics of the Czech Republic. Hospitals in the Czech Republic in 2009.Prague: ÚZIS 2010;5:4. Available at: http://www.uzis.cz

15. Lagarde M, Palmer N. The impact ofuser fees on health service utilization inlow- and middle-income countries: howstrong is the evidence? Bulletin of theWorld Health Organization2008;86:839–48.

16. Thomson S, Foubister T, Mossialos E.Can user charges make health care more efficient? British Medical Journal2010;341:c5225.

17. Petrášová L, Syslová L. Ve zdravot-nictví chybí už deset miliard, strany ale oreforme nemluví [Ten billion missing inhealth care system, but parties don’t talkabout reform]. Mladá Fronta Dnes 11 May2010. Available at: http://zpravy.idnes.cz/ve-zdravotnictvi-chybi-uz-deset-miliard-strany-ale-o-reforme-nemluvi-1ju-/domaci.asp?c=A100510_205611_domaci_vel

18. Králová S, Ríhová B. Pardubický krajruší jako první proplácení poplatk°u vnemocnicích [Pardubice region is the firstto abolish the reimbursement of fees inhospitals].Mladá Fronta Dnes 1 June 2010.Available at: http://zpravy.idnes.cz/pardubicky-kraj-rusi-jako-prvni-proplaceni-poplatku-v-nemocnicich-10h-/domaci.asp?c= A100601 _155131_domaci_bar

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Providing a solid evidencebase for policy makers:ECHI initiative

Marieke Verschuuren, Pieter Kramers and Gudrun Kr Gudfinnsdottir and Arpo Aromaa

Summary: With the aim of providing a solid evidence base for policy making, theEuropean Commission initiated a European public health monitoring policy adecade ago. The European Community Health Indicators (ECHI) projects haveplayed a central role in the development of this policy. ECHI currently is in itsfourth phase (Joint Action for ECHIM). Twenty-four EU Member States are engaged in an effort to implement the ECHI shortlist (88 indicators). One of the major challenges will be to find sustainable solutions for public health monitoring, both at Member State and at European level.

Key words: evidence-based policy making, public health monitoring, indicators,European Union.

Marieke Verschuuren is Senior Researcher and Pieter Kramers Senior Advisor, Dutch National Institute for Public Health and the Environment (RIVM). Gudrun KrGudfinnsdottir is Policy Officer, European Commission, DG SANCO, Health Information Unit and Arpo Aromaa, Professor, Finnish National Institute for Health and Welfare (THL). Email: marieke.verschuuren@rivm.nl

The need for international public healthcomparisonsThe gap between the Netherlands and theEuropean Union (EU) average is wideningfor rates of female cancer mortality. TheNetherlands has higher than average ratesof smoking while relatively few mothersbreastfeed their babies. The 30-day in-hos-pital fatality rate for stroke in theNetherlands is high compared to otherEuropean countries. On the other hand,injury-related mortality is very low in theNetherlands, and it is among the bestscoring countries when looking at healthdeterminants such as levels of physicalactivity and overweight.

These are some of the main conclusions ofthe report Dare to Compare! Bench-marking Dutch health with the EuropeanCommunity Health Indicators (ECHI),written by the Dutch Public HealthInstitute (RIVM) in 2008.1 The indicator

information presented in the report raisesquestions; why do so many Dutch peoplesmoke? Are the anti-smoke policies incountries with a lower smoking rate dif-ferent than the policies applied in theNetherlands? Are there other factors, suchas cultural differences, which may explainthe different smoking rates in the EUcountries? The same kind of questions maybe asked of the indicators for which theNetherlands is doing relatively well.

These examples illustrate the usefulnessand necessity of international public healthmonitoring by means of indicators forpolicy making. Through internationalbenchmarks, authorities may be madeaware of good practice examples in othercountries. Moreover, this international ori-entation may draw attention to some of thecauses of avoidable health inequalitiesbetween European citizens, achievablehealth gains and the efficient use of

resources. That such an approach is suc-cessful is shown by figures from Finlandthat reflect a remarkable decline in the ratesof many cancers, as well as a largereduction in traffic accidents and cardio-vascular deaths, which were among thehighest in Europe in the 1970s.

The ECHI initiativeAiming to meet policy makers’ need forcomparable international public healthinformation, more than a decade ago theEuropean Commission initiated aEuropean public health monitoring policy,starting with the EU Health MonitoringProgramme, which ran from 1997 until2002. Within this Programme, manyprojects were involved in indicator devel-opment. The ECHI-I project acquired akey role, collecting proposals for indicatordefinitions from all of these projects. Theseproposals were arranged systematically inthe so-called ECHI long list, comprising atthat time more than 200 indicators.2

It was clearly not feasible to implement allindicators on the ECHI long list at once.Therefore, DG SANCO and the ECHIexperts decided to create a shortlist for pri-ority implementation. Further refinementof the indicator selection was coordinatedby the ECHI-II project, and carried out inclose cooperation with DG SANCO andits working parties and committees underthe Health Information Strand. The nextphase, under the Public Health Programme2003–2008, was coordinated by theECHIM project (M stands for Moni-toring). ECHIM identified national healthinformation experts, and started mappingthe availability of data in the EU MemberStates for calculating the shortlist indi-cators. Indicator metadata (definitions,calculation methods, preferred datasources etc) was documented in a struc-tured way in ECHI DocumentationSheets.3

In 2007 the EU Health Strategy WhitePaper Together for Health was adopted,stating as one of its actions the implemen-tation of a European ECHI system.4 In2008 the European Commission thereforecalled for a Joint Action for ECHIM. Thisnew financing mechanism implies a directinvitation from the Commission to theMember States to present a proposal.Public health institutes from five countriestook the lead in preparing the proposal,and twenty-four Member States in totalgave a declaration of intent to participatein the Joint Action for ECHIM. It startedon 1 January 2009 and has a three year

duration.5 (See Box for an overview of theJoint Action for ECHIM partners and par-ticipating countries).

The ECHI shortlistThe following set of criteria was appliedfor selecting indicators in the ECHI longand subsequent shortlists:

– The list should cover the entire publichealth field, following the commonlyapplied structure of the well knownLalonde model; health status, determi-nants of health, health interventions/health services, and socioeconomic anddemographic factors.6

– The indicators should serve user needs,meaning that they should supportpotential policy action, both at EU andMember State level.

– Existing indicator systems, such as theWHO-Health for All (WHO-HFA)and Organisation for Economic Co-operation and Development (OECD)indicators, should be made use of asmuch as possible, but there is also roomfor innovation.

– Adopt viewpoint of the general publichealth official (‘cockpit’) as a frame ofreference.

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Box: Joint Action for ECHIM: participating countries, Core Group members and project partners

Member States

1 Belgium (Core group member)

2 Bulgaria

3 Czech Republic (Core group member)

4 Cyprus

5 Denmark

6 Estonia (Core group member)

7 Finland (Core group member and project partner)

8 France

9 Germany (Core group member and project partner)

10 Greece (Core group member)

11 Hungary

12 Ireland (Core group member)

13 Italy (Core group member and project partner)

14 Latvia

15 Lithuania (Core group member and project partner)

16 Luxembourg

17 Malta

18 Netherlands (Core group member and project partner)

19 Poland

20 Portugal

21 Slovenia (Core group member)

22 Spain (Core group member)

23 Sweden (Core group member)

24 United Kingdom (Core group member)

Other countries

25 Iceland

26 Norway

27 Moldova

Other Core Group Members

DG SANCO

DG EUROSTAT

WHO-Europe

– Focus on large public health problems,including health inequalities.

– Focus on the greatest potential foreffective policy action.

Applying these criteria resulted in aselection of about 80 indicators. This so-called ECHI shortlist was approved in2005 by the European Commission andthe Network of Competent Authorities ofthe Health Information Strand under thethen Public Health Programme. Under theECHIM project an update of the shortlistwas carried out. The most importantchange was the addition of seven new indi-cators which represented emerging policyinformation needs, such as heat waverelated mortality and selected communi-cable diseases. The current version of theshortlist contains 88 indicators.7

The shortlist is divided into an implemen-tation section and a development section.The first section holds the indicators forwhich detailed definitions and calculationmethods have been developed, and forwhich data are either available in existinginternational databases or in a reasonablenumber of EU Members States at nationallevel. The development section holds theindicators covering those areas of publichealth for which there is a need for data,but for which no common indicatormethodologies and data collections exist inmost EU Member States. The ECHIMexperts and the European Commission arededicated to facilitating further work onthe development section being placed onthe political agenda.

Added value and specific features ECHIcompared with existing indicator systemsWhat is the added value of the ECHI ini-tiative? After all, there are severalinternational indicator databases con-taining public health data, such asWHO-HFA, OECD and Eurostat. Fur-thermore, there are several EuropeanAgencies collecting data for their specificareas of practice, for example, theEuropean Monitoring Centre for Drugsand Drugs Addiction (EMCDDA), theEuropean Centre for Disease Preventionand Control (ECDC) and the EuropeanEnvironmental Agency (EEA).

The ECHI shortlist is a practical publichealth policy tool for general use. A theo-retical framework was applied for theselection of indicators, leading to theECHI shortlist representing in a veryfocused yet comprehensive way the publichealth topics which are most relevant for

policy makers. This distinguishes theECHI shortlist from many other existingdata collection initiatives, which may eitherapply a broader or more limited orien-tation.

The ECHI shortlist represents a carefullyconsidered selection of available publichealth data, which was supplemented by anumber of indicators covering importantpublic health issues currently not (ade-quately) described by existing datacollections. This explicit attention onhealth information gaps also distinguishesECHI from other health data initiatives.

The ECHI shortlist was developedthrough intense cooperation with a largenumber of European health informationprojects and Member State experts, whichhas resulted in the incorporation of inno-vative results. This holds especially true inthose areas for which currently no compa-rable data are readily and regularlyavailable. Examples are the attack rates ofacute myocardial infarction and stroke,perinatal health and health promotion.

ECHI also focuses on obtaining data fromthe Member States for the shortlist indi-cators for relevant subgroups, mostimportantly subgroups defined by socio-economic status. It is widelyacknowledged that there is an urgent needfor public health data stratified by socio-economic status. Yet, adequate data to alarge extent are still lacking. Several initiatives have started in recent years toovercome this lack of information, one ofthe most important being the social pro-tection and social inclusion indicatorswhich are being developed through theOpen Method of Coordination (OMC).8

ECHI will build on the work alreadycarried out in this field, in particular theOMC work.

A final characteristic of the ECHI initiativeis the strong focus on communicationaimed at the dissemination of health infor-mation to policy makers - as a first targetaudience - and other user groups. Oneaspect of this communication within thecurrent Joint Action will be the dissemi-nation of meta-data, explaining in astructured and clarifying way to whatextent the data are valid and comparable.For indicator information to be used as anevidence base for decision making, thiskind of information is essential.

Synergy with Eurostat and other Commission activitiesAs the Statistical Office of the European

Communities, Eurostat is the main dataprovider for ECHI.7 From the onset of theECHI initiative, Eurostat has beeninvolved in the developmental work. Themain result of this ECHI-Eurostat coop-eration is the embedding of the ECHIshortlist in the new Regulation on Com-munity statistics on public health andhealth and safety at work, which states thatits aim is to obtain “…data for structuralindicators, sustainable development indi-cators and European Community HealthIndicators (ECHI), as well as for the othersets of indicators which it is necessary todevelop for the purpose of monitoringCommunity actions in the fields of publichealth and health and safety at work”.9

The above-mentioned Regulation providesa general framework for the developmentof several detailed implementing acts. Oneof the first implementing acts to be realisedwill be on the European Health InterviewSurvey (EHIS), which contains manytopics from the ECHI shortlist. Currently,comparable Health Interview Survey(HIS) data at European level are scarce dueto variations in methodology. SomeEuropean surveys, such as the LabourForce Survey (LFS) and the Survey onIncome and Living Conditions (SILC) docontain several questions on health or onhealth related topics. A harmonisedEuropean Health Interview Surveytherefore will be an important step forwardfor ECHI and thus for European publichealth monitoring.

Another important development initiatedby the Commission is the EuropeanHealth Examination Survey (EHES),starting with the FEHES project in 2003,which examined the feasibility of carryingout an EHES in the EU Member States.10

In 2009 the Commission called for a JointAction for the implementation of a pilotEuropean Health Examination Survey, and14 countries responded to this call. Infuture, when EHES will be fully imple-mented, this survey will be an importantdata source for ECHI.

Towards implementation of the ECHIshortlistDuring the ECHI-I and ECHI-II projects,the focus was on the development andselection of indicators. The ECHIMproject prepared for the process of imple-mentation of the ECHI shortlist, byassessing the availability of data for theECHI shortlist indicators in the MemberStates and by establishing a network ofnational health information experts.3 With

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the Joint Action for ECHIM the worknow moves into a new phase; the phase ofactual implementation at Member Statelevel.

Implementation of the ECHI shortlistindicators entails putting the indicatorsinto practical use in the Member States by:

– introducing the indicators to national(and possibly regional/local) adminis-trators and decision makers

– modifying existing data sources,applying new calculation methods andcreating new data sources in order toimprove national data availability andquality

– setting up a sustainable data flow fromMember States to a central ECHIdatabase

– setting up a presentation system, inte-grating the ECHI shortlist with existingnational health reporting systems (ifexisting)

– analysing and interpreting the resultsfor health policy and planning

General guidelines for implementationhave been developed by the ECHIMexperts to support the national contacts informulating feasible short- and long-termnational implementation plans. A centralelement in the national implementationplans is the formation of national imple-mentation teams, which should consist ofrepresentatives of the major stakeholdersin health information. At the time ofwriting of this paper (September 2010),most of the countries represented in theECHIM Core Group, as well as somenon-Core Group countries, have startedforming their national implementationteams and drafting their national imple-mentation plans. The remaining countriesparticipating in the Joint Action forECHIM will do so in the coming months.

Within the Joint Action a system to facil-itate data flow from the Member States toa central ECHI database will be tested.This central database will be hosted by theEuropean Commission and is linked to aEuropean level web-based data presen-tation system.11 The ECHIM Core Groupmembers, who are experts in the field ofpublic health statistics and monitoring, areworking together with the Commission to ensure that the data presentations willmeet basic quality standards for presentinginternational public health comparisons to a policy maker audience. These basicrequirements are reflected in a data presen-

tation pilot, which was developed by theECHIM experts.7 The results of this pilotserve as an example for other(inter)national ECHI data presentation ini-tiatives.

Challenges aheadSuccessful implementation of the ECHIindicators requires close cooperationbetween the European Commission, theECHIM experts and Member States. It isalso clear that future development of theECHI system is dependent on policysupport and sustainable financing.

Regarding the cooperation between thedifferent stakeholders, the DirectorateGeneral Health and Consumers (DGSANCO) of the European Commissionorganised an ‘extended ECHIM coregroup’ meeting in February 2010, in whichrepresentatives from all Member Stateshave had the opportunity to participate.This has been an essential step forward forthe implementation process. Furthermore,DG SANCO’s Expert Group on HealthInformation (former Health InformationCommittee, HIC) can play a key role asthe principle advisory committee for theEuropean Commission on health infor-mation.

DG SANCO mainly funds activitiesthrough projects or tenders. A Joint Actionis slightly different as a financing mech-anism as it involves a more explicitcommitment from Member State author-ities. However, it too is a temporaryconstruction. Health information systemsare not static; they need to be constantlydeveloped in order to reflect current policyneeds and advancing scientific insights. Itis therefore important that considerationalready be given to possible venues for thecontinuation of work on the ECHI indi-cators to ensure sustainability ofdevelopmental work as well as in imple-mentation.

National health information systems formthe basis of the European ECHI moni-toring system. The involvement ofMember States therefore is a prerequisiteto success. As illustrated at the beginningof this paper, national health informationsystems producing relevant and compa-rable indicators are of direct use toMember States. The financial burden of theECHI monitoring system should thereforenot be carried by the European Com-mission alone. National authorities need torecognise the importance of basic healthdata collection for a well functioninghealth system. Working towards a long-

term commitment to valid and comparablehealth monitoring is a challenge forMember States, particularly in these daysof financial restrictions.

REFERENCES

1. Harbers MM, Wilk EA van der, KramersPGN et al. Dare to Compare! Bench-marking Dutch health with the EuropeanCommunity Health Indicators (ECHI).Bilthoven: RIVM, 2008. Available at:http://www.rivm.nl/bibliotheek/rapporten/270051011.html

2. ECHI-I final report: design for a set ofEuropean Community Health Indicators.2001. Available at: http://ec.europa.eu/health/ph_projects/1998/monitoring/fp_monitoring_1998_frep_08_en.pdf

3. Kilpeläinen K, Aromaa A and theECHIM Core Group (Eds). EuropeanHealth Indicators: Development and InitialImplementation. Final Report of theECHIM Project. Helsinki: KTL, 2008.Available at www.healthindicators.eu

4. Commission of the European Commu-nities. Together for Health: A StrategicApproach for the EU 2008–13. Brussels:Commission of the European Commu-nities, 2007. vailable at:http://ec.europa.eu/health-eu/doc/whitepaper_en.pdf

5. ECHIM project website:www.echim.org

6. Kramers PGN. ECHI-II final report:Public Health Indicators for Europe:Context, Selection, Definition. Bilthoven:RIVM, 2005. Available at:http://www.rivm.nl/bibliotheek/rapporten/271558006.html

7. ECHIM products website:www.healthindicators.eu

8. Social protection and inclusion indi-cators. See: http://ec.europa.eu/employment_social/spsi/joint_reports_en.htm

9. Regulation (EC) No 1338/2008 of theEuropean Parliament and of the Council of 16 December 2008 on Community statistics on public health and health andsafety at work. Available at: http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:L:2008:354:0070:0081:EN:PDF

10. Feasibility of a European Health Examination Survey (FEHES) project. See: http://www.ktl.fi/fehes/

11. European Health Indicators data pres-entation tool at website DG SANCO:http://ec.europa.eu/health/indicators/indicators/index_en.htm

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The National Health Service (NHS) is thepublicly-funded health care system in theUnited Kingdom. In 2002, there werealready sixteen NHS-run treatmentcentres. They vary in the scope of care pro-vided but centre mainly on the provisionof elective surgery, together with diag-nostic and outpatient services. As part ofreforms in the first years of the previousLabour government, bids for such serviceswere invited from the private sector. Thesenew Independent Sector TreatmentCentres (ISTCs), while privately owned,have contracts to treat NHS patients.

The ISTCs were designed with severalobjectives in mind. Their main focus wasto reduce waiting lists, thus movingtowards the ‘patient centred’ model pro-posed in the 2000 NHS Plan. Additionalproposed benefits included encouragementof reform within the NHS by providingcompetition, facilitating innovation andreducing spot purchasing prices*, thusimproving value for money.

There have been two phases or ‘waves’ ofISTCs procured by the Department ofHealth (DH) throughout England and

Scotland, with the first ISTC opening in2003. This was followed by further pro-curement with the first of the second waveopened in 2007. The locations for the newISTCs were identified by local servicecommissioners. The criteria for an ISTCwas either a lack of capacity or longwaiting times. In the first wave 25 fixed siteand two mobile site ISTCs were opened.The second wave was originally intendedto develop 24 schemes but this was subse-quently reduced to just ten with the DHstating that the extra capacity was nolonger required.1,2 This article aims todiscuss the implication of contracting outclinical services to the private sector, usingthe introduction of ISTCs in the Englishhealth care system as an example.

What are the implications for health care professionals?During the first wave, ISTCs were unableto employ staff who had worked in theNHS in the preceding six months. Thisresulted in ISTCs being staffed largely byoverseas doctors. This led to questionsregarding not only the quality of theirtraining, but also their suitability to beworking with potentially unfamiliar NHStechniques and processes. The policy washeavily criticised by the British Medical

Association (BMA) and the Royal Collegeof Physicians, with suggestions that theprocedures ensuring adequate competencewere not rigorous enough.1,3 It has alsobeen suggested that this policy hinderedintegration between ISTCs and NHStrusts; in fact staff mobility was key tocooperation between the two providers.The rules were subsequently relaxedduring the second wave and NHS staff cannow, albeit with some restrictions, work inISTCs.

Although all doctors employed by anISTC are required to be registered with theGeneral Medical Council, there is noequivalent to the NHS Advisory Appoint-ments Committees to act as a qualitycontrol mechanism. Consequently, ISTCstake on responsibility not only forrecruitment, but also professional devel-opment and appraisal, an area where theHealthcare Commission in 2007 identifiedsome shortfalls.4

With regards to training, concerns havebeen voiced by senior surgeons that thetransfer of ‘straightforward’ elective pro-cedures, suitable for training juniordoctors, from NHS hospitals to ISTCs hasimpacted negatively on training.5 The

Private sector providers in England:The implications of Independent Sector Treatment

Centres

Nidhi Vaid

Summary: Over the last few years, private sector providers have begun to have anincreasing role in the NHS. This article outlines the advantages and disadvantages ofprivate sector involvement following the introduction of one such initiative, the inde-pendent sector treatment centre. It further discusses how we should learn from themistakes made and apply what we have learnt to the proposed government reformsthat have been outlined in the recent White Paper “Equity and Excellence: Liberat-ing the NHS”. There are certainly potential benefits to be gained from private sector involvement; however, we must take care not to develop a segregated, two-tier NHSthat disregards the principles on which it was originally founded.

Key words: NHS, private, commissioning, reforms, ISTCs

Nidhi Vaid is Specialist Registrar in AcuteMedicine, Chelsea and Westminster Hospital, London, UK. Email: nvaid07@gmail.com

* Treatment in the private sector which is purchased by the NHS on an ad hoc basis in orderto cut waiting lists.

apparent efficiency of ISTCs may also inpart be accounted for by a lack of respon-sibility for training which, although timeconsuming, is extremely important. Asolution is to place junior doctors in ISTCswhere they can be trained in a ‘highvolume, low risk’ arena; subsequentlyISTCs in the second wave were obliged toinclude a training component if requestedby postgraduate deans.

Innovative workforce management, suchas in the case of Blakelands NHS treatmentcentre, includes regular staff consultationsand multi-tasking, and has led to a four dayworking week by maximally utilising the-atres and clinic rooms, leaving Fridays foradministration.6 Based on case studies ofindividual ISTCs, it certainly seems thatnovel workforce management is increasingefficiency and there are lessons to belearned for the NHS where clinical andadministrative agendas are not always wellintegrated.

What are the implications for health careusers?One of the main stated objectives of theintroduction of ISTCs was to provide amore patient centred system. The sepa-ration of emergency from electiveprocedures ensures that patient appoint-ments and procedures do not have to becancelled if an emergency case is admitted.Since ISTCs concentrate on specific proce-dures, streamlined patient care pathwayswith efficient pre-operative processes haveled to high ratings in patient satisfactionsurveys. However, one may also argue thatpatient satisfaction outcomes have nodemonstrable correlation with health out-comes and although clearly important,they should be given less importance thanother indicators.

Under new initiatives, patients are able tochoose where they have their procedureperformed, however, they are not givenany information regarding the quality ofcare provided, thus their choices are notinformed, questioning whether it is reallypatient choice or government waiting listtargets that have driven ISTCs. ISTCs havebeen criticised by clinicians for providinginferior care with a low level of monitoringand governance, for example, the BritishOrthopaedic Association has stated thatmore revisions of operations are requiredwhen patients are treated at ISTCs.7 Thisstatement however has not been supportedby the National Centre for Health Out-comes Development (NCHOD),8 and infact the chief executive of the Healthcare

Commission warned that it is difficult toform such conclusions since the data is notdirectly comparable.1

ISTCs were intended to reduce waitingtimes by both adding capacity and intro-ducing competition, consequentlystimulating productivity within NHS facil-ities. Although in certain specialties ISTCsaccount for a substantial proportion ofactivity, nationally, ISTCs account for only2% of NHS elective activity, indicating thatthey have not been a significant contrib-utory factor to the reduction in waitingtimes.9 Additionally, an analysis by theKing’s Fund found no difference in the rateat which waiting times were reduced whencomparing areas with and without ISTCs.10

How are they financed?Funding for ISTCs is negotiated by theDH in the form of five year contracts andpayment is made based on the NHSnational tariff, together with a furtherpremium to cover capital costs. During thefirst wave, ISTCs received a ‘take or pay’guarantee meaning that they received thefull contracted value from PCTs irre-spective of whether or not they reachedactivity targets, a payment strategy whichhas been heavily criticised. The DHinformed the House of Commons thatWave 1 ISTC providers received, onaverage, payments that were 11.2% greaterthan the NHS equivalent cost which incor-porates other NHS costs such as pensions¹. The payment structure was modified inthe second wave and although the full con-tract value is no longer guaranteed, ISTCsstill receive guaranteed fixed value pay-ments from the DH.

There have been further criticisms withregards to both under and over-commis-sioning of services. Poor initial needsanalysis and projected demands haveresulted in flawed commissioning andunder-utilisation of ISTCs. The Raven-scourt Park treatment centre in Londonwas forced to close just four years afteropening. It was operating at just 50%capacity and failing to be cost-effective.Improvements in integrating referrals,both vertically and horizontally, from theNHS are certainly required in order toprevent other centres facing a similardemise. Over-commissioning has also beena problem, with more procedures beingcommissioned than individuals on currentNHS waiting lists, with resultant negativefinancial consequences.

Criticisms even extend to include selectionpolicies, with some ISTCs being allowed

to choose less complex cases, leaving theNHS with complex cases together withlonger, more expensive inpatient stays.There have been calls by the BMA for thepayment structure of selective ISTCs to bealtered to reflect this.

Is the data comparable?ISTCs are required to provide dataregarding quality outcome and monitoringto the DH in the form of performanceindicators; however, the DH retains thepublication rights of these data. Someauthors have concluded that the data pro-vided by the ISTCs are of poor quality, andas discussed below, not directly compa-rable with NHS data. This clearly needsimprovement, and following recommenda-tions by the Healthcare Commission in2007,4 changes have been made toreporting methods in ISTCs; despiteimprovements in the last two years, thequality of data is still not equivalent to thatcollected by NHS providers making com-parisons difficult.11

Regulation of the ISTCs, as for the NHS,is carried out by the Care Quality Com-mission. However, whilst NHS providersare required to meet ‘core standards’together with ‘developmental standards’,ISTCs are only required to meet the‘National Minimum Standards’. A newregistration system has been introduced inan attempt to standardise regulation butthere are now new ‘improvement stan-dards’ which will still only be applicable tothe public sector. Whilst these discrep-ancies in required standards and datapublication remain, quantitative compar-isons are impossible. The variation incase-mix between ISTCs and NHS facil-ities is also marked, making evenqualitative comparisons challenging.12

Further implications for the health system Encouraging innovation is certainly thecase in some ISTCs, for example, Bostonand Gainsborough Treatment Centreimplemented a new technique for generalanaesthesia which decreased post-operativeside effects and enhanced recovery timewith subsequent improvements in patientcare as well as improved productivitymeasures for the ISTC.6 Many prominentsurgeons have argued that these, and anal-ogous techniques, have previously beenevaluated in the NHS, and they are neitheroriginal nor innovative and have no discernible impact on service delivery ¹.

There are suggestions that some NHSproviders have responded to a new ISTC

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in their area by improving service deliveryand increasing productivity; a joint reportfrom the Audit Commission andHealthcare Commission found that insome cases, competition introduced byISTCs provided “a useful tool to engageclinicians and work with them to deliverchange”.9 The House of Commons HealthCommittee concluded that the effects ofcompetition may have been one of thegreatest benefits of ISTCs, but criticisedthe government’s lack of systematic evalu-ation of this effect and recommended thatthe National Audit Office should conductan evaluation.1

A review of the first Scottish RegionalTreatment Centre by Allyson Pollock andGraham Kirkwood in 2009, resulted in adamning report which criticised lack ofdata, payment methods and wastage offunds. Extrapolating from the Scottishdata, they estimated that in England, up to£927 million may have been paid for treat-ments that were never actually carried outand recommended that there should nofurther signing or renewal of contractsuntil a comprehensive evaluationaddressing their concerns has been under-taken and published.13

New proposals for reformThe economic crisis and its financial impli-cations for all public sector services,including the NHS, has prompted therecent publication of a government WhitePaper outlining radical NHS reforms.14

The paper includes plans for phasing outPCTs and SHAs and replacing them withGeneral Practitioner (GP) consortia. Withall GPs being part of a local consortium,these new consortia will be responsible forcommissioning services for the majority ofNHS services, including elective and emer-gency hospital care. Commissioning willbe based on knowledge of local needs, thustheoretically avoiding the previousproblems with over-commissioning ofservices and subsequent financial waste.Importantly, the role of purchasingservices for primary care will be theresponsibility of the NHS commissioningboards. A crucial flaw in this systemappears to be the lack of input to the con-sortia from secondary and tertiary careproviders or public health specialists aswell as the lack of competency and expe-rience of GPs to manage commissioning ofspecialist areas such as mental health.

Economic regulation will come fromMonitor, and consortia will be accountableto the NHS commissioning board. The roleof Monitor will include licensing providers

and regulating prices as well as promotionof competition in health care, a featurewhich has been viewed negatively by some,including the BMA. Concerns stem fromthe fact that encouraging competitionrather than the quality of health care mayadversely impact on patient care. Anessential remit of Monitor must thereforebe to ensure that no advantage, financial orotherwise, is given to private providers, ashas clearly been the case in ISTCs. Also, theuse of ‘any willing provider’ of health careservices rather than encouraging NHSproviders builds on the ISTC precedent ofinvolving the private sector in NHS care,an approach that has so far not demon-strated a significant or consistentimprovement in health care. The involve-ment of several small providers will requirehighly skilled integration to avoid pro-viding fragmented health care to patients.

The new plans once again focus onincreasing patient choice with regards tochoice of provider, diagnostics andmaternity services, as well as choice of anamed consultant-led team with quality ofcare being reported by both clinical out-comes and patient reported outcomemeasures (PROMs). Although patientchoice is important, the reforms fail tooutline tools for data collection or theirvalidity. As with ISTCs, it can be arguedthat PROMs do not correlate with healthoutcomes and PROMs should not be usedin isolation to judge good quality care.Moreover, in order to avoid the problemswith data reporting that have been experi-enced with ISTCs, there need to be clearand comparable guidelines and regulationsfor both commissioners and providers.

In addition, all NHS trusts are set to begranted Foundation Trust status thusencouraging what the government hastermed ‘employee-led social enterprise’.Currently, Foundation Trusts have a capon income derived from private rather thanNHS services. The White Paper aims toabolish this cap and whilst theoreticallybeneficially to staff and patients, in reality,removal of restrictions encourages privatesector involvement which faces the samehurdles as other private sector initiativesalready mentioned in this article.

ConclusionThe introduction of independent providersinto the NHS, traditionally thought to bethe foundation of public sector services inthe UK, has certainly had effects on bothhealth care users and providers as well asthe health system as a whole. However,

despite a heightened awareness of costs,efficiency and accountability, the changeshave been insufficient, and at times illthought out.15 The expected outcomessuch as ‘value for money’ have been notbeen achieved, and in fact there are manycases of financial waste. Despite recog-nition and remedial action of problemsfrom the first wave, many would argue thatthe changes do not go far enough, and thatthe intended benefits are yet to materialise.Even a reduction in waiting times cannotbe attributed to the introduction of ISTCs.Theoretically, ISTCs could have achievedmuch more, but a lack of appropriate needsanalysis, flawed procurement and poorintegration with existing NHS services hasproduced disappointing results. Perhapsincreased utilisation of existing NHStreatment centres which are already wellintegrated, or using NHS facilities out ofhours, would be a more cost-effective andefficient way of meeting demands.

Furthermore, the recently outlinedreforms are likely to come at a significantcost and at a time that the NHS has beenrequired to make efficiency savings inexcess of £20 billion, one wonders if this isthe most appropriate time to be once again,introducing radical re-structuring pro-grammes.

There are beneficial effects of cooperationwith the independent sector, but for ISTCsto succeed and truly encourage NHSreforms there needs to be equal regulationand transparency for all providers. Byintroducing inequalities in humanresources, infrastructure, data provisionand financing, we are in danger of creatinga two tier system in which the NHS loses.Patients need to make an informed choiceand commissioning needs to be based onoutputs rather than projected inputs. This,together with appropriate recruitment andtraining, should help to integrate ISTCsand other private sector providers into theNHS more effectively, thus pushingforward and reaping the benefits of reform,rather than creating an uneconomicalsystem that has promised far more than ithas delivered.

REFERENCES

1. House of Commons Health Committee.Independent Sector Treatment Centres.Fourth Report of Session 2005–06. VolumeI. HC 934–I. London: The StationeryOffice, 2006.

2. ISTC manual. London: Department ofHealth, 2006. Available at: www.dh.gov.uk/

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en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4128133

3. Independent sector treatments centres(ISTCs). London: British Medical Associ-ation. Available at: http://lookafterournhs.org.uk/wp-content/uploads/independent-sector-treatment-centres-01062.pdf

4. Healthcare Commission. IndependentSector Treatment Centres: A Review of theQuality of Care. London: Commission forHealthcare Audit and Inspection, 2007.

5. Clamp JA et al. Do independent sectortreatment centres impact on specialist reg-istrar training in primary hip and kneearthroplasty? Ann R Coll Surg Engl2008;90:492–96.

6. CBI. ISTCs and the NHS: StickingPlaster or Real Reform. London: CBI,2008. Available at: www.cbi.org.uk/ndbs/press.nsf/0363c1f07c6ca12a8025671c00381cc7/e085125c16f8cb1b802573ec003991a3/$FILE/CBI%20ISTCs%20report.pdf

7. Written evidence provided to the healthselect committee. Session 2004–5. Availableat: www.publications.parliament.uk/pa/cm200506/cmselect/cmhealth/934/934we16.htm

8. ISTC Performance ManagementAnalysis Service. Preliminary OverviewReport for Schemes GSUP1C, OC123, LP4and LP5. Report to the Department ofHealth. London: National Centre forHealth Outcomes Development, 2005.

9. Health National Report. Is the treatmentworking? Progress with the NHS ReformProgramme. London: Audit Commission,2008.

10. Naylor C, Gregory S. Briefing: Inde-pendent Sector Treatment Centres. London:Kings Fund, 2009.

11. NHS Information Centre. DataQuality Report for Independent SectorNHS Funded Treatment 2008/9. London:NHS Information Centre, 2009.

12. Browne J et al. Case-mix and patients’reports of outcome in Independent sectortreatment centres: comparison with NHSproviders. BMC Health Serv Res2008;8:78.

13. Pollock A, Kirkwood G. Independentsector treatment centres: learning from aScottish case study. BMJ 2009; 338:b1421.

14. Department of Health. Equity andExcellence: Liberating the NHS. London:Department of Health, 2010.

15. Player S, Leys C. Confuse and Conceal:The NHS and Independent SectorTreatment Centres. London: Merlin Press,2008.

The Uzbek health system has undergonesignificant change since the countrybecame independent in 1991. Followingindependence, health system reforms wereintroduced with the aim of adapting to thechallenges of the new social, political andeconomic environment. The reformsplaced an emphasis on increased efficiency,self-financing mechanisms and privatesector development.

The Uzbek health system includes public,private and other non-public entities. Thevoluntary National Health Insurance Programme provides support for bothpublic and private services. Private prac-tices and clinics have rapidly been set up inan effort to mobilise additional resources,increase efficiency and improve quality.Since 1994 1,075 health care entities,including hospitals, ambulatory clinics andsolo practices, have been privatised. In2004, there were 1,165 hospitals with a bedcapacity of 142,900; of these the privatesector accounted for 141 hospitals (12.1%) with a bed capacity of 3,000 (2.1%).1

However, a higher proportion of ambulatory clinics are under privatecontrol – 1,220 of 5,536 clinics (22%).2

Medical education and graduatesIn Uzbekistan, as in many other countries,aligning the development of the physicianworkforce to match the needs of theemerging health care system is a complexchallenge. A substantial portion of medicalgraduates are not employed in the pro-fession. Even though legislation requiresfive years of practice in the public sectorbefore a physician can enter privatepractice, of the 2,571 graduates of medicalschools in 2005, only 895 (36%) enteredmedical practice in the public sector1

(Figure 1). While a small number of grad-uates went to work for the pharmaceuticalindustry, the majority of graduates enteredother professions, emigrated or ended upbeing unemployed. This loss of expen-sively educated medical professionals is amajor issue for human resource devel-opment in the country.

The cost to the individual of a medical edu-cation is high. The tuition fee for each ofthe seven years in training is ~US$800–850.An individual entering the general work-force directly from a high school orcommunity college can expect to earnabout $1,200 per year. The opportunitycost of a medical education is therefore

Five barriers to physicianworkforce development inUzbekistan

Zukhra Karimova and Gary L. Filerman

Summary: The 1998-2005 health system reform in Uzbekistan aimed to increase efficiency, self-financing mechanisms and develop the private sector.However, the reform process has also had implications for the physicianworkforce, including the low number of medical school graduates employedas physicians. This article identifies five key barriers that contributed to thepoor alignment between the number of medical graduates in the countryand the number of working physicians. It presents recommendations for improving the health resource planning process in the country.

Keywords: health care reform, physician supply and demand, education,health workforce planning, Uzbekistan

Zukhra Karimova is a member of the Faculty, Tashkent Paediatric Medical Institute, Uzbekistan. Email: zukhramahmit@googlemail.com. Gary L. Filerman is amember of the Faculty, Georgetown University, Washington DC, USA.

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~$14,175 ($5,775 in tuition fees plusforegone income of $8,400 over sevenyears). This is a conservative calculationand does not include other expenditurethat must be incurred by students.

According to the United National Devel-opment Programme (UNDP), 69% and75% of all university students study on afee paying basis at Bachelor’s and Master’slevel respectively.3 Here, we assume thatthe proportion of medical students whomust pay tuition fees is similar. Estimatesof public expenditure on education varysubstantially. According to one UNICEFsurvey Uzbekistan reportedly spent about12% of Gross Domestic Product (GDP)on education, which is the highest per-centage in the sub-region and region.4

According to the 2001 Resolution of theCabinet of Ministers of the Republic ofUzbekistan, any income derived from stu-dents’ fees should not decrease the amountof financing from the state budget, whichstill can be used entirely for the needs ofthe educational institution.3 To the extentthat graduating physicians do not practicein the country, a substantial portion ofgovernment investment is being wasted.

Thus, the question is: why do studentswho have invested on average over $14,000not work in the health sector? In thisarticle, we identify five factors that con-tribute to the poor match between thenumber of medical school graduates andlevels of employment in the profession.

1. Lack of financial incentivesThe annual incomes of state employees ingeneral, and in the public health sector inparticular, are substantially less than theincomes of professionals in the privatesector, such as for construction, retail andthe service industries. On average, the basicmonthly salaries of physicians in the publicsector range from US$80 to US$150. Insome cases these salaries are lower than themiddle class standard of living. These salarylevels are based on professional categoryand calculated by multiplying the size ofthe official minimal wage by some coeffi-cient (from 2 to 7). Starting from 1 August2009, the minimum wage was set at 33,645soums per month5 (around US$24)*.

Medical degrees are awarded on a grad-uated basis, with the level of degreeincreasing over time based on experienceand acquisition of additional qualifications.

All new graduates are awarded a third leveldegree. Physicians can then be promotedto a second level degree after completingfive years’ working in the public sector andsuccessfully passing the National Centrefor Licensing and Accreditation Test. Sub-sequently working for another five yearsand completing 288 hours of continuingeducation is required before a physiciancan apply for a first degree. The highestlevel of degree (the higher) requires anadditional five years’ experience andpassing an exam in front of an expert panel.The data presented in Table 1 reflect thesituation in 2005, before the requirementto apply for advancement every five yearsbecame mandatory in 2009.6

The financial rewards gained for improvedprofessional status are small, thus theyprovide little incentive for physicians toincrease their knowledge and skills. Thisclear lack of motivation to gain newknowledge further contributes to the gen-erally low numbers of practisingphysicians. It is estimated that approxi-mately 27% of physicians had notcompleted any advanced training afterfifteen years of practice.7

As Figure 2 shows the low levels offinancial remuneration lead to a poor socialstatus for physicians, as well as limitedservices and other quality issues forpatients. There is a dependence on

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* In January 2009, the official exchange ratewas US$1 = 1,396 soums, but on the black market the rate climbs to 1,700 soums.

Table 1: Proportion of medical graduates by level of degree obtained in 2005

Highest Degree First Degree Second Degree Third Degree

Proportion of graduates 17.8% 30.4% 3% 48.8%

Numbers 6,168 10,535 1,040 34,654

Source: 1

Figure 1: Demand and supply of new medical graduates in Uzbekistan

Medical Schools

Ministry of Health

Human Resource Department

Medical Institutes, hospitals, medical units,ambulance, policlinics,emergency stations, dispensaries

Other medical (e.g. pharmaceutical industry)

Non medical activities

more than 40% of new graduates

demand for new graduates

less than 60% of new graduates

Figure 2: The consequences of low physicians salaries’ in the public sector

Low quality of medicalservice

Low qualification ofphysicians

Informal payments frompatients to physicians

Social role in communitydecreasing

Low salary

informal payments that flow from patientsdirectly to physicians and hospitals. Thereare no data on the magnitude of these pay-ments but they are clearly substantial.These funds are not used for improvingworking conditions, expanding tech-nology, purchasing equipment ordeveloping facilities. Rather, they set a tonein the relationship between patients andproviders that demeans the status of healthprofessionals in the community.

2. High rate of emigration of medicalprofessionalsMost migrants are seeking better livingstandards, better access to education fortheir children and higher quality healthcare. According to the UNDP, Uzbekistanhas an emigration rate of 8.5%. Othersources estimate the number of emigrantsto vary between 250,000 and 1.5 million in2008. Russia accounts for 70% of migrantsand Kazakhstan perhaps a further10–15%.8

One way of measuring the magnitude ofemigration is by the increase in the annualinflow of official remittance. According tothe Central Bank of Uzbekistan, over the2002–2006 period the annual inflow ofofficial remittances to the country increasedfive-fold, reaching almost US$1.4 billion or8.2% of GDP in 2006. Unfortunately, thedata do not reveal the professions of thosesending money to Uzbekistan.

Citizens of Uzbekistan speak Russian andthe Uzbek medical diploma is recognisedin Russia and Kazakhstan. In an attempt toreduce shortages of medical staff in its ownrural regions, Russia encourages the immi-gration process by providing significantstart up financial capital to newcomers.The salaries of medical staff in Russia and

Kazakhstan, which are several timesgreater than those in Uzbekistan, areanother attraction.

3. High level of unemploymentNew physicians enter a difficultemployment market. Job creation in thegeneral labour market has been slow: just2.1% between 2000–2004 compared withan average annual growth in the working-age population of 3.2%.9While the officialunemployment rate was just 0.9% in 2009,unofficial sources report that unem-ployment and underemployment are veryhigh at 8% and 25% respectively,10 butreliable figures are difficult to obtain, as norecent credible surveying has been done.

4. Inadequate working conditionsAccording to a recent sociological survey,health workers in Uzbekistan are notcontent with their working conditionsbecause of the lack of equipment and sup-plies, lack of proper recognition for theirwork, and limited opportunities toimprove their knowledge.1 According tostatistical reports, in any one year only14% of mid-level health workers have achance to improve their skills. This isclearly not enough to give all specialists anopportunity to update their knowledge atleast once in five years.7 Moreover, manyhealth care facilities are in need of reno-vation, better cold and hot water suppliesand telephone lines. The problem is mostsevere in rural areas. Thus, the majority ofhealth care institutions are in need of tech-nical upgrades.7

5. Weak health care workforce planningand managementThe Department of Human Resources andScience, Medical Education Institutions

and the Ministry of Health are responsiblefor forecasting the requirements for healthpersonnel and for planning humanresources development. Two mechanismsare used to regulate the supply of healthprofessionals: enrolment in universities andprofessional colleges, and the licensingframework for the private sector.7 Thenumber of undergraduate and post-graduate medical student positions isestablished by the Cabinet of Ministers,based on the recommendations of the Ministry of Health. A perceived surplus of physicians in the early years of inde-pendence resulted in cutbacks in enrolmentin medical schools. The number of grad-uates of medical schools decreased from apeak of 5,156 in 1996 to 3,020 in 2004.

The total population of Uzbekistan in 2004was 25.6 million people with populationgrowth of 1.9%. In 2010, the population is28 million with population growth at aslightly lower level of 1.7%.11 The ratio ofphysicians to the population has decreasedsteadily over the period from 1991 to 2010(Figure 3). It decreased from 3.7 physiciansper 1,000 population in 2001 to 2.9 and2.66 (2010) per 1,000 population in 2005and 2010 respectively.12 This comparesunfavourably with ratios elsewhere,including in the Central Asian Republicsand Kazakhstan (CARK) and the Com-monwealth of Independent States (CIS)14

(Table 2). If policies are left unchanged,based on these data, economic factors pre-viously discussed and the current level ofmedical student enrolment, it is estimatedthat Uzbekistan faces a continuing under-supply of 23,520 physicians compared tothe Eurasian average.

Despite the observed shortage of physi-cians, there is actually a surplus of medicalgraduates. In 2009, while there was ashortage of 1,635 physicians there weremore than 2,500 graduates from medicalschool.13 As noted, many new profes-sionals choose not to work in the healthsector for financial and career developmentreasons. A further deterrent is that mostmedical schools are located in Tashkentand other cities. After graduation, themajority of young doctors do not want towork in rural areas but cannot find a jobwithin their specialty in the cities, thus,they seek employment in other professions(see Table 3).1 Additionally, based on Table3, it is evident that the supply of doctorsand beds is concentrated in the cities.Other factors that contribute to theproblem of effective planning include traditional customs, such as women leaving

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200

300

400

CARK

CIS

European Region

Uzbekistan

2007200520001995199019851980

Figure 3: Number of physicians per 1,000 population 1990–2007

Source: 13

their jobs after marriage, widespreadgender stereotyping issues and theinfluence of Muslim traditions.

ConclusionThe important factors that contribute tothe imbalance between the supply anddemand for physicians in Uzbekistaninclude: the lack of financial incentives; thehigh emigration rate of medical profes-sionals; the high rate of generalunemployment; inadequate working con-ditions; and inadequate workforceplanning and management. Of these, thelast is the most important.

Uzbekistan currently has 2.66 physiciansper 1,000 population. Although thenumber of medical graduates is more thanthe Uzbek population requires, manymedical graduates are taking up work inother professions or moving abroad.Therefore, it appears that the health sectoris clearly under financed, with a totalhealth care expenditure of only 2.4% ofGDP in 2005.

A substantial reform of the health work-force planning process is required, withmore realistic links to general economicconditions and the structure of medicalpractice. It appears that improving remu-neration is key to improving retentionrates, as well as working conditions. Per-formance-based remuneration schemesshould be considered as well as steps toexpand private practice.

REFERENCES

1. Akcura F, Ahmedova D, Menlikulov P etal. Health For All: A Key Goal for Uzbek-istan in the New Millennium. Tashkent:United Nations Development Programme,2006.

2. State Statistical Committee of Uzbek-istan. Trends in Developing of PrivateHealth Care Institutions.

3. Higher Education in Uzbekistan.National Programme for PersonnelTraining. Available at: http://eacea.ec.

europa.eu/tempus/participating_countries/higher/uzbekistan.pdf

4. UNICEF. Country Profile, Education inUzbekistan. UNICEF, 2008.

5. Resolution of Cabinet of Ministers, No319. Regulation on Procedures for Trainingand Retraining Health Workers. Tashkent,18 December 2009.

6. President of Uzbekistan, Islam Karimov.Decree. 8 July 2009.

7. Ahmedov M, Azimov R, Alimova V,Rechel B. Uzbekistan: Health systemreview. Health Systems in Transition2007;9(3):1–210.

8. Hashimova U. Financial crisis hitsUzbekistan. CACI Analyst 28 January2009. Available at:http://www.cacianalyst.org/?q=node/5025

9. Country Strategy and Programme 2006–2010: Uzbekistan. Philippines: AsianDevelopment Bank. Available at:http://www.adb.org/Documents/CSPs/UZB/2006/csp100.asp

10. US State Department. UzbekistanCountry Background Notes, 2010.Available at: http://www.state.gov/r/pa/ei/bgn/2924.htm

11. National Statistic Committee ofUzbekistan. Available at:http://www.uz.dayly.com

12. Health for All database. Copenhagen:World Health Organization, 2010.

13. Health Workforce Policies in the WHOEuropean Region. Copenhagen: WorldHealth Organization, 2009. Available at:http://tinyurl.com/3xeqw7p

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Table 3: Number of population per doctor, nurse and bed in various areas

Per doctor Per nurse Per bed

Nationwide 334 98 182

Djizzak Region 474 111 209

Surkhandarya 451 106 224

Tashkent City 131 77 118

Source: 1

Table 2: Number of physicians per 1,000 population

Uzbekistan 2.66

CARK 2.82

European region 3.39

CIS 3.76

Source: 14

CONFERENCE ANNOUNCEMENT

Main conference topics will include:

• What can be understood by better healthgain and salutogenesis?

• How can health gain orientation withinhospitals/health services be improved?

• How can better health gain be improvedby strengthening continuity of care inhealthcare systems?

• How can cooperation between healthservices and other settings contribute tobetter health gain? And what can be thecontribution to ecological sustainabilityand environmental friendliness?

The 19th International Conference onHealth Promoting Hospitals andHealth Services (HPH) will take placein Turku, Finland 1–3 June 2011.

The call for papers is now open until31 January 2011.

It will be possible to submit paperson other issues of relevance to healthpromoting health services.

For further information and to submita paper see the confernce websitewww.hphconferences.org/turku2011

Improving health gain orientation in all services: Better cooperation for continuity in care

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PERFORMANCE

Why manage performance?The John Radcliffe Hospital in Oxfordsuspended child heart operations after fourchildren died over the course of a fewmonths in March 2010.1 The hospital wasalso investigated by the Healthcare Com-mission in November 2005 after it wasdiscovered that the number of patientswho died between April 2002 and March2005 after their first coronary arterybypass graft was more than double thenational average.2 Better ongoing per-formance measurement provides evidencethat can be used as a starting point toimprove safety and quality of care and thushelp reduce the number of such adverseevents. In recent decades, the public’sexpectations have increased and measuringperformance is a way to satisfy this: whatNolte and McKee have deemed a “questfor accountability”.3 Cross-country com-parisons of performance can also giveimpetus to governmental reforms.

Measuring performance is not a newconcept. It can be dated back to FlorenceNightingale’s work during the CrimeanWar and her subsequent epidemiologicaland statistical studies on surgical mortalityin London that lay the groundwork forsurgical audit. However, using this infor-mation to manage performance hasbecome a new paradigm over the past twodecades in an attempt to manage publicservices, control professional autonomy,contain costs and accommodate risingpublic expectations. Moreover, even beforewe found ourselves living in an ‘age of aus-terity’, measuring and managingperformance was seen as a way to improvecost-effectiveness.

This issue of Eurohealth sets out to explorethese issues further. It features four articles

that originate from a seminar hosted byLSE Health and the NHS Confederationand funded by the Higher Education Inno-vation Fund in April 2010. Topics coveredincluded how and why we measure per-formance; how quality indicators andquality systems in health care can bedeveloped; and the impact of performancemeasures on the English NHS.

Managing performance As Gwyn Bevan sets out in his article,there are three main pathways for usingperformance data to manage performance.Firstly, in the change pathway, whereproviders may use information to makechanges without external pressure. Specif-ically, if they see that they are performingbadly against their peers, then they will actto improve. This is Julian LeGrand’snotion of knights: politicians and civil ser-vants do the best job they can to respondto the needs of the population they serve.4

Secondly, the selection pathway occurswhen providers may make changes inresponse to market pressures in whichpatients choose good providers over poorones, typically based on publicallyavailable ‘report cards’. However, there issimply little evidence that patients switchproviders, even when given information onperformance.

Finally, Bevan notes that providers mayrespond to systems that report on per-formance in a way that may affect theirown reputation (the reputation pathway).Perhaps the most famous example was the“targets and terror” regime in the EnglishNational Health Service (NHS).5 Thisreferred to the aggressive policy of targets,together with sanctions for poorly per-forming managers and the publicpublication of waiting times data at thehospital level. This gave managers anincentive to see their targets improve andthus secure their jobs.

Mark Exworthy begins his contribution tothe issue by noting that managing per-formance necessitates that we decide whatto measure and how to do so. His startingpoint is that performance is a contestedconcept. When a situation occurs wherethe measured indicators are the only onesthat are measured, why would a managerconcentrate on improving quality in anarea which is not reported? Therefore, wemust be acutely aware of what does not getmeasured and how this affects performanceas well. With all the competing pressureson providers, it is important for regulators,managers and other users of indicator datato agree on what will be measured and howthese data will be used.

Chris Ham points to the contribution thattargets and standards have made to per-formance improvement in the EnglishNHS and cautions against a simplerejection of policies from previous govern-ments without careful consideration oftheir strengths and weaknesses. In themeantime, Niek Klazinga discusses meas-uring and managing health systems’performance, arguing that when utilisedimproperly, performance management canresult in sub-optimisation. That is, if onestarts to increase management in one areaof health care because it is measurable, thisdoes not always lead to overallimprovement in the health system. He alsodiscusses some of the hazards of cross-country comparisons and the importanceof using the right indicators for the rightpurposes.

ConclusionsAlthough these articles cover the gamut ofissues surrounding performance man-agement, three main themes emerge.Firstly, consistency over time is important:consistency in vision, regulation and in theuse of market incentives. While GwynBevan has argued that the market incen-tives did not work in England, Peter Smith

Managing performance:

An introduction

Rachel Irwin

Rachel Irwin is Research Assistant, LSEHealth, London School of Economics andPolitical Science. Email: r.irwin@lse.ac.uk

Potentials and pitfalls of performanceOver the past two decades, in many coun-tries, the performance paradigm hasbecome firmly established by governmentsseeking to manage public services, tocontrol professionals, to contain costs andto accommodate rising publicexpectations.1,2,3 It is not surprising,therefore, that notions of performancehave been central to the way in which

health policy has developed. The NationalHealth Service (NHS) in England is noexception; indeed, it has arguably been atthe forefront of developments. To examinethe potential, pitfalls and prospects of theperformance paradigm, this article focuseson the English NHS.

Varying notions of ‘performance’ havebeen prevalent and different approaches

The performance paradigm in theEnglish NHS:

Potential, pitfalls, and prospects

Mark Exworthy

Summary: Managing the performance of health services has become a dominant paradigm in policy and research in many countries over the past two decades. Attention has been directed to thedevelopment and implementation of performance ‘products’ such as management systems andmetrics (for example, indicators). Whilst this approach offers some benefits, the limitations of relying solely on this approach are increasingly apparent. It is not always clear how such `products’generate improved performance and whether unintended consequences are apparent elsewhere inthe health system. Understandings about performance could benefit from stronger and more explicit conceptual foundations. This article highlights one example of how research could bebroadened to elicit a more rounded perspective on performance; namely, a focus on ‘informal’ aspects of performance. The article concludes that continued pressure from government, the publicand health service users will demand on-going improvements. However, it is likely that, in an eraof constrained budgets, new ways of thinking must be sought to meet rising expectations.

Keywords: Performance, health policy, NHS, subjectivity, England.

Mark Exworthy is Reader in Public Management and Policy, School of Management, Royal Holloway University of London, Egham, UK.Email: M.Exworthy@rhul.ac.uk

of Imperial College London, who chairedthe seminar, has argued that the market hadnever been properly tested because therehas been no long-term consistency due tofrequent political changes. Ham concurswith this pointing out that the Englishhealth system has been the subject ofendless new initiatives, in which reform islaid upon reform, and stability is lacking.

Secondly, tensions lie between self-improvement, self-regulation and externalpressures. Where the best balance liesbetween these forms of regulation givesrise to further questions on the role ofmanagers, peer reviews and external regu-lators. Thirdly, there is concern that the use

of targets tends to concentrate activity onthe areas measured, whilst neglecting otherareas, so that what gets measured getsmanaged, but questions remain over thatwhich is not measured.

REFERENCES

1. BBC News. Oxford John Radcliffe Hospital suspends child heart ops. 4 March2010. Available at: http://news.bbc.co.uk/2/hi/uk_news/england/oxfordshire/8548568.stm

2. BBC News. Heart op report criticisesTrust. 28 March 2007. Available at:http://news.bbc.co.uk/2/hi/uk_news/england/oxfordshire/6499457.stm

3. Nolte E, McKee M. Measuring thehealth of nations: analysis of mortalityamenable to health care. British MedicalJournal 2003; 327:1129–34.

4. Le Grand, J. Motivation, Agency andPublic Policy: of Knights and Knaves,Pawns and Queens. Oxford: Oxford University Press, 2003.

5. Hood C, Bevan G. What’s Measured isWhat Matters: Targets and Gaming in theEnglish Public Health Care System. ThePublic Services Programme: Quality, Per-formance and Delivery. Discussion PaperSeries. No. 0501, December 2005. Availableat: http://www.publicservices.ac.uk/wp-content/uploads/dp0501.pdf

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have previously been attempted.4 Forexample, Smith5 has defined performancemanagement as a: “set of managerialinstruments designed to secure optimalperformance of the health care system overtime, in line with policy objectives”

Performance has thus become a centralpre-occupation of health policy-makersand managers over the past twenty years orso. The performance paradigm has beenpivotal to the wave of approaches to man-aging public services (especially healthservices) that have been called ‘new publicmanagement’ (NPM).6,7

Managers were given specific responsi-bility for managing the performance ofservices and staff. Performance was thusnot only to be measured but also to beactively ‘managed’. Many governments,especially those in the ‘Anglo’ andnorthern European countries, often had arevolutionary zeal towards NPM in beingable to transform services through a greaterfocus on managing performance andservice improvement. Osbourne andGaebler8 were at the forefront of pro-moting NPM in the form of‘entrepreneurial government.’ A newapproach to performance was central totheir thesis: “Entrepreneurial governmentspromote competition between serviceproviders… they measure the performanceof their agencies, focusing not on inputsbut outcomes. They are driven by theirgoals – their missions – not by their rulesand regulations”.

A key aspect of the performance paradigmhas been the development and introductionof quantitative metrics, comprising per-formance indicators, targets, benchmarksand comparisons.9,10 Services and the activ-ities of staff had to be standardised in orderto facilitate such measures and aid compar-isons. Information from such comparisonswas also central to the operation ofmarket-style mechanisms, introduced bythe separation of purchasers and providers– another key feature of NPM.11 It followsthat qualitative measures have been lessevident.

The performance paradigm has receivedmuch negative criticism for its short-comings.4,12 Any performance systemsuffers from incompleteness; it is inevitablethat some aspect of service delivery will beomitted from performance measures. Theimplication is that measured aspects getpriority and unmeasured ones are neg-lected; hence, the adage ‘what getsmeasured gets done’.13 This can lead to

behaviour whereby agents ‘game’ the per-formance system as an end in itself.Attribution of decisions to subsequent per-formance is complicated by the opensystems within which health servicesoperate, as well as the robustness of themeasures themselves.14 Patient behaviour,plus the many interactions with differentagencies, make assessment of (health) out-comes problematic. Attribution is furtherhampered by ‘performance churn’whereby there is little consistency in per-formance measures between successiveapplications.15 This makes it difficult togauge whether ‘performance’ (as measuredby those indicators) has improved or notover time. This churn highlights a finalfactor – the short-term focus of many per-formance systems. Annual measures maynot necessarily capture ‘improvements’and yet managers are held accountable overthis short time period.

Health services are characterised bygeneric features which make direct com-parisons of performance difficult,including:

– ambiguous goals;

– few reliable measures of effectiveness;

– multiple definitions of ‘success’ whichare likely to compete and conflict;

– complexity of cases (such as individualswith multiple social problems or co-morbidities);

– perverse incentives (including the so-called ‘efficiency trap’ whereby ‘good’organisations were not rewarded);

– limited ‘user choice’, implying a greaterreliance on professional proxies (such asGPs or care managers); and

– professional dominance.

In England, the approach to performancemanagement in the NHS has consisted ofguidance, monitoring and response.5 Overthe past decade or so, this English per-formance paradigm has tended to becentralised.1,2

The shifting parameters of performanceThe traditional approach to managing per-formance has been a minimalist one withfew (if any) explicit mechanisms to dealwith ‘poor’ performance and promote‘good’ performance. This approach is out-lined in Table 1.

More recently, the approach to managinghealth service performance has evolvedwith three developments being prominent:

1. New ‘steering’ organisations includingregulators, such as the Care QualityCommission (CQC) or the Office ofStandards in Education (OFSTED);

2. Extensive use of information tech-nology (in performance management);

3. Greater challenge to professional normsand practices.17

These features are consistent with theemergence of post-bureaucratic organisa-tions.15 The traditional approach has thusundergone transformative change but the‘new’ approach remains emergent in dif-ferent spheres of health policy. Not allperformance measures are, for example,directed towards individuals; organisationsremain the predominant unit of analysis.Nonetheless, the direction of travel awayfrom the traditional approach is clear(Table 2).

The implications of this approach arebecoming increasingly apparent. First, thenumber of stakeholders involved in per-formance is increasing and goes wellbeyond traditional health policy networks.For example, the growth of summativeperformance has been associated with newregulatory regimes such as the CQC whichassess the quality of service and financialmanagement. Equally, patients, the publicand the media have become more centrallyinvolved, not least through their use of thedisseminated performance information.Second, the growing attention on namedindividuals is challenging professionals’practice. Previously held claims of profes-sional autonomy have been challenged, forexample, by the disclosure of clinical per-formance on the internet (see next section).Third, performance measures are increas-ingly addressing (multiple) clinicaloutcomes rather than just inputs (such asstaffing).

Performance in practice: a case-studyCase-studies can illustrate the short-comings of existing performance systemsand also the shifting parameters of per-formance in health systems. Here, the caseof ‘informal’ performance is used to illus-trate the need to broaden perspectives onperformance.

The English performance paradigm hasprimarily been quantitative in nature,through measures such as rankings, leaguetables and performance indicators. Thesemeasures become the ‘official’ metrics,published by government agencies. Theyare retrospective in that they report pre-vious performance from previous time

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periods. Moreover, these data do not coverall of the areas which would enablerounded judgements to be made about anorganisation’s performance.18 Thisapproach can be described as ‘formal’ per-formance,16 akin to the notion of ‘hard’information.16 Formal measures imply adegree of precision and are apparentlyobjective statements. They also have afunction as a ‘safety net’ for managers andothers in that it directs attention tominimal standards of performance.16 Itthus tends to focus on ‘poor’ performancerather than improving good performance.

A different approach is the notion of‘informal’ performance. This refers to the‘soft’ information that is founded on sub-jective judgements and perceptions. Itrefers to the ways in which performance isconceived, constructed and managedthrough a series of subjective judgements.

It can be found in notions of reputation,goodwill, tacit knowledge and credibility.Health managers might, for example, referto another as a ‘safe pair of hands’ or on theneed to ‘keep an eye on them.’ Othersmight question ‘what is really happening?’despite the surfeit of formal performancedata. Informal performance may be biasedand incomplete but, if it affects agents’behaviour towards managing performance,it nonetheless has real effects. Informalperformance comprises qualitative infor-mation that can be prospective. Goddardet al16 suggest that informal performanceplays substitution and complementaryfunctions in relation to formal per-formance. The application of notions ofinformal performance is illustrated below.

Autonomy of NHS Foundation Trusts:

Since 2004, the policy of FoundationTrusts (FTs) in England has granted greater

autonomy to high ‘performing’ Trusts as away of enabling further performanceimprovements. In general, FTs have not‘performed’ as expected,19 raising the pos-sibility that autonomy is not such apanacea after all. Technically, FTs do havethe ability to exercise autonomy throughtheir ability, for example, to retain savingsand to avoid traditional NHS performancemanagement mechanisms. However, it isapparent that many FTs have lacked thewillingness to exercise such autonomy.16

The reasons for this unwillingness include:

– the greater risk to which FTs areexposed;

– continued uncertainty about the com-ponents of health system reform (suchas the extent of competition);

– the generally weak levels of engagementand legitimacy that FTs have securedfrom local stakeholders;

– the fear of negative impact ofautonomous decisions upon the localhealth economy; and

– the degree of extant autonomy alreadyenjoyed by these high ‘performing’organisations.

There is a need to explore the informal per-formance aspects of FT managers’motivations and attitudes towards theaward and use of autonomy.

Mid-Staffordshire NHS Foundation Trust:

As an FT, ‘Mid-Staffs’ was a supposedlyhigh performing organisation. However,such performance was illusory. Its per-formance failings came to light when datarevealed that:

“At least 400 patients died unnecessarilyafter undergoing treatment between 2005and 2008 at the hospital, where regulatorslater found a catalogue of failings includingpoor accident and emergency care, badhygiene, and patients being helped by rela-tives because staff were too busy”.20

Moreover, its ‘formal’ performance hadbeen less than ideal to become an FT, asPaton21 notes:

“In the four years from 2002 until 2005 (thelast year of the star ratings system whichranked trusts from 0- to 3-stars)*, Staffordhad got, respectively, 2, 3, 0 and 1 star. Yetit was encouraged or ‘invited’ to seek FTstatus.”

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* Star ratings were the previous formal performance metric in the English NHS

Table 1. The ‘traditional’ approach to performance16

Feature Hallmarks of the traditional approach

1. Unit of analysis Organisational level (such as the hospital, school or prison)

2. Specificity Anonymous

3. Motivation Intrinsic

4. Participation by practitioner Voluntary

5. Focus Inputs (e.g. staffing) and outputs (e.g. service delivery)

6. Purpose Developmental and formative

7. Reference group Professional peers (e.g. peer review by fellow clinicians)

Table 2. The ‘emergent’ approach to performance16

Feature Hallmarks of the ‘emergent; approach

1. Unit of analysis Individual (such as the surgeon)

2. Specificity Named

3. Motivation Extrinsic

4. Participation by practitioner Compulsory

5. Focus Outputs and outcomes

6. Purpose Judgemental and summative

7. Reference group External

The performance paradigm was ‘gamed’ byMid-Staffs’ managers to meet targets,rather than necessarily delivering goodpatient care).22 However, from the Francisinquiry, it appeared that patients and staff‘knew’ about ‘poor’ performance:

“I remember at the time when our staffinglevels were cut and we were just literallyrunning around. Our ward was known asBeirut from several other wards. I heard itnicknamed that. ITU used to call usBeirut… I remember saying: this will haverepercussions, this can’t go on like this.Because relatives were regularly coming upto us and saying: my Mum has beenbuzzing for this long, there has been abuzzer going there for that long”.

The behaviour of managers and percep-tions of staff and the public tend to suggestthat the informal performance of Mid-Staffs was apparent but overlooked by thedominant formal performance mode.

This case-study does not necessarily implythat informal performance should be pri-oritised above formal performance. Rather,both forms need to be considered, not leastbecause the boundary between them is notfixed or permanent. It is thus vital toexamine the interaction and reactionbetween the two in order to assess theways in which performance is conceived,constructed and reproduced in local andnational health systems.

Prospects for performanceThis article has sought to take a criticallook at the way in which notions of per-formance have been applied in the EnglishNHS. It has shown that performance is acontested concept which does not neces-sarily determine specific courses of action.Performance is thus political, as Stewartand Walsh23 argue that there is a “need torecognise the imperfections and limitationsof [performance] measures, and to usethem as a means of supporting politicallyinformed judgements”.

Research and policy needs to pay muchcloser attention to the contested nature ofperformance, for example through anexamination of the interplay betweenformal and informal aspects of per-formance. This might be achieved byaddressing the coherence, capacity andclinical engagement of performance para-digms.5

REFERENCES

1. Bevan G, Hood C. What's measured iswhat matters: targets and gaming in theEnglish public health care system. PublicAdministration 2006;84(3):517–38.

2. Greener I. Performance in the NHS:insistence of measurement and confusion ofcontent. Public Performance and Management Review 2003;26:237–50.

3. Propper C, Sutton M, Whitnall C, Windmeijer F. Did ‘Targets and Terror’Reduce English Waiting Times for ElectiveHospital Care? Bristol: Bristol University,CMPO Working Paper No. 07/179, 2007.

4. Talbot C. Performance management. In:Ferlie E, Lynn LE, Pollitt C (eds). OxfordHandbook of Public Management. Oxford;Oxford University Press, 2005.

5. Smith P C. Performance management inBritish health care: will it deliver? HealthAffairs 2002; May/June:103–15.

6. Ferlie E, Lynn LE, Pollitt C (eds).Oxford Handbook of Public Management.Oxford; Oxford University Press, 2005.

7. Pollitt C, Bouckaert G. Public Management Reform: A ComparativeAnalysis. Oxford; Oxford University Press,2004.

8. Osborne D, Gaebler T. ReinventingGovernment: How the EntrepreneurialSpirit is Transforming the Public Sector.New York: Addison-Wesley, 1992.

9. Carter N, Klein R, Day P. How Organisations Measure Success: The Use ofPerformance Indicators in Government.London: Routledge, 1992.

10. Hartley J, Donaldson C, Skelcher Cand Wallace M. Managing to ImprovePublic Services. Cambridge: CambridgeUniversity Press, 2008.

11. Le Grand J, Bartlett W (eds). Quasi-markets and Social Policy. Basingstoke: Macmillan Press, 1993.

12. Sheaff R et al. Organisational Factorsand Performance: A Review of the Literature. London: NHS Service Deliveryand Organisation Research & Development Programme, 2004. Availableat: http://www.sdo.nihr.ac.uk/files/project/55-final-report.pdf

13. Wilson D, Croxson B, Atkinson A.What gets measured gets done. head-

teachers’ responses to the english secondary school performance management system. Policy Studies 2006;27(2):153–71.

14. Jacobs R, Goddard M, Smith PC. How robust are hospital ranks based oncomposite performance measures? MedicalCare 2005;43(12):1177–84.

15. Pollitt C. Bureacuracies remember,post-bureaucratic organisations forget?Public Administration 2009;87(2):198–218.

16. Exworthy M et al. Decentralisation andperformance: autonomy and incentives inlocal health economies. Report for theNational Co-ordinating Centre for NHSService Delivery and Organisation R&D(NCCSDO), 2010. Available at:http://www.sdo.nihr.ac.uk/projdetails.php?ref=08-1618-125

17. Hoggett P. New modes of control inthe public sector. Public Administration1996;74:9–32.

18. Goddard, M, Mannion R, Smith PC.Assessing the performance of NHS Hospital Trusts: the role of 'hard' and 'soft'information. Health Policy 1999(48):119–34.

19. House of Commons Health SelectCommittee. Foundation Trusts andMonitor. HC833, 2008.

20. Campbell D. Andrew Lansleyannounces inquiry into Mid-Staffs hospitalscandal.’ Guardian 9 June 2010. Availableat: http://www.guardian.co.uk/society/2010/jun/09/andrew-lansley-inquiry-mid-staffs-hospital

21. Paton C. What we still need to knowabout Stafford. Public Service 14 April2010. Available at: http://www.publicservice.co.uk/feature_story.asp?id=13870

22. Francis R. Independent Inquiry intoCare Provided by Mid Staffordshire NHSFoundation Trust January 2005 – March2009. London: Stationery Office, 2010.Available at: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_113447.pdf

23. Stewart J, Walsh K. Performance measurement: when performance can neverbe finally defined. Public Money and Management 1994;April–June:45–49.

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ACKNOWLEDGEMENTS: The research upon which some of this article is based was funded by the NIHR Service, Delivery and Organisation programmehttp://www.sdo.nihr.ac.uk. I am grateful to them for their funding and to the rest of the research team.

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Three behavioural models may be used tounderstand the incentives on managers ofproviders of health care to use informationon their performance to improve. First,altruism, that assumes that reporting tomanagers of providers of health care infor-mation that identifies scope forimprovement will, of itself, generate incen-tives for improvement. Second, markets,that assume that public reporting of infor-mation will cause purchasers of health careand patients to switch from providers withpoor to those with better performance; andthus that threats to market share will gen-erate incentives for managers ofpoorly-performing providers to improve.Third, reputation, that assumes that ifinformation is designed to rank providerperformance in a way that the public canunderstand, then this generates incentivesfor managers of poorly performingproviders to improve to remedy thedamage to their reputation.

The rationale for the three models

Policies in England

Julian Le Grand1 has nicely laid out therationale for policies based on the model ofaltruism: the guiding assumption of the

post-war British welfare state that all thekey players were ‘knights’: ‘politicians,civil servants, state bureaucrats, and man-agers were supposed accurately to divinesocial and individual needs in the areasconcerned, to be motivated to meet thoseneeds and hence operate services that didthe best possible job from the resourcesavailable’. This Panglossian assumption isthe only justification for the traditionalBritish response of rewarding failingproviders with extra resources. As LeGrand argues, this assumption was rejectedby Margaret Thatcher’s conservative gov-ernment. This change was marked by theintroduction, from 1989, of policies thatreorganised the hierarchical NHS into an‘internal market’ by creating ‘purchasers’and ‘providers’ with the objective that‘purchasers’ would contract with com-peting providers on grounds of price andquality.2 The aim was to replicate thedesirable characteristics of effectivemarkets, in which competition systemi-cally reduces costs and improves quality,and avoid the disadvantages of ability topay being a barrier to access to health care.

The Labour Government elected in 1997,however, rejected the ‘internal market’ andre-introduced a policy based on the modelof altruism (in a search for a ‘third way’)that again rewarded failing providers withextra resources. When this proved to beineffective in tackling the problems of longwaiting times in the English NHS, the gov-ernment, in parallel with dramatically

increasing funding for the NHS from 2000,also implemented a radically new systemof performance management that penalisedthose that failed to deliver the gov-ernment’s priorities and rewarded thosethat succeeded.3 This system of annual ‘starratings’ of NHS organisations, which ranfrom 2000 to 2005, satisfied the four char-acteristics identified to have an impactthrough the reputation model,4–7 i.e. thesystem of reporting performance must be:

– based on a ranking system;

– published and widely disseminated;

– easily understood by the public (so thatthey can see which providers are per-forming well and poorly); and

– followed up by future reports (thatshow whether performance hasimproved or not).

Hospitals that failed to achieve the gov-ernment’s waiting time ‘key targets’ (whichincluded referral for a first outpatientappointment and elective admission) wereat risk of being ‘zero rated’ and publicly‘named and shamed’ as ‘failing’. Ambu-lance services that failed to meet the ‘keytarget’ of 75% of ambulance responsetimes to what may be life-threateningemergency calls (Category A) in less thaneight minutes faced the same fate. From2002, however, the government returned topolicies that sought to develop a moreeffective ‘internal market’ with a particularemphasis on patient choice for elective

If neither altruism nor marketshave improved NHS performance,what might?

Gwyn Bevan

Summary: This article considers three behavioural models of the incentives on man-agers of providers of health care to use information on their performance to improve,and evidence of the effectiveness of each model from the United States and the UnitedKingdom. The three models are: altruism, markets and reputation. This article outlinesthe rationale for the three models in the English National Health Service (NHS), theevidence from the US and the UK on each model, and concludes with a paradox.

Key words: National Health Service, devolution, performance measurement, targets

Gwyn Bevan is Professor of ManagementScience at the Department of Manage-ment and LSE Health, London School ofEconomics and Political Science, UK.Email: R.G.Bevan@lse.ac.uk

care. Barber and Le Grand have argued therationale for this new policy: that thesystem of ‘naming and shaming’ through‘star rating’ was effective, but only inimproving the systemic performance fromappalling to mediocre, and that to deliver ahigh-performing English NHS it was necessary to re-introduce a market.8,9

Policies in the devolved countries

Devolution in 1999 offered scope for thegovernments in Scotland and Wales (devo-lution was largely suspended in NorthernIreland) to develop different policies fortheir NHSs. Although each country alsointroduced targets for hospital waitingtimes7 and ambulance response times toCategory A calls6 there was no policy to‘name and shame’ organisations that failedto achieve these targets. Indeed those whoworked in the NHSs of Scotland and Walesperceived that such failure was rewardedby their governments. Later, when the gov-ernment in England implemented policiesthat sought to create another ‘internalmarket’, the governments in Scotland andWales abolished the purchaser/providersplit.10

Evidence from the USTwo systematic reviews of the literature onreporting performance in the US foundlittle evidence of markets being effective.The first found that information onprovider performance “has only a limitedeffect on consumer decision making” and“only a small, although possibly increasingeffect on purchaser behaviour”.11 Eightyears later, another review12 failed toidentify this increasing effect: the generalconclusion across various studies was that“publicly reporting performance data didnot affect selection of hospitals”. As JudithHibbard13 has argued, US evidence of theineffectiveness of altruism is implicit insystems of public reporting that are notdesigned to damage the reputations ofpoorly-performing providers (i.e., do notsatisfy the characteristics to do so). Twostudies provide information on the com-parative effectiveness of the three models.

An account of the impacts of the CardiacSurgery Reporting System (CSRS) of NewYork State14 emphasises that the key driverfor change was the reputation modelthrough adverse publicity from CSRSidentifying outlier hospitals performingpoorly. Neither markets nor altruism hadmuch effect: “Market forces played norole. Managed care companies did not usethe data in any way to reward better per-forming hospitals or to drive patients

toward them. Nor did patients avoid high-mortality hospitals or seek out those withlow mortality ... the impetus to use the datato improve has been limited almost entirelyto hospitals that have been named as out-liers with poor performance … hospitalsnot faced with the opprobrium attached tobeing named as poorly performing outliershave largely failed to use the rich per-formance data to find ways to liftthemselves from mediocrity to excellence”.

A controlled experiment in south centralWisconsin4,5 looked at reporting infor-mation on quality of hospital care acrossthree sets of hospitals: public-report, wherea concerted effort was made to disseminatethe report widely to the public; private-report, where the report was supplied tomanagers only; and no-report, where noinformation was reported to managers. Ifaltruism were powerful, then there oughtto be no difference between the public-report and private-report sets of hospitals,but the public-report set made significantlygreater efforts to improve quality than theother two sets. The managers of hospitalsin the public-report set did not see thereport as affecting their market shares andlater analysis showed that that they werecorrect: “There were no significant changesin market share among the hospitals in thepublic report from the pre to the postperiod”.5 The reputation model, however,was crucial: the managers of hospitalsshown to have been performing poorly inthe public-report group took action,because of their concerns over the impactsof the report on their hospitals’ reputations.

Evidence from the UKThe Scottish Clinical Resource and AuditGroup (CRAG)15 pioneered the publicreporting of information on hospital out-comes in Europe, but as the reportseschewed any ranking of performance,their effectiveness essentially depended onaltruism. Evaluations of CRAG16,17 con-cluded that CRAG reports had not beeneffective: the information was rarely usedby staff in hospitals, the boards to whichthe hospitals were accountable, and generalpractitioners in discussions with patients.CRAG’s own Clinical Indicators SupportTeam15 came to similarly depressing con-clusions on the reports’ lack of impact.

Figures 1 and 2 report comparisons overtime for performance for hospital waitingtimes in England, Wales and NorthernIreland (there are no comparable data forScotland) in terms of numbers waitingmore than six months for elective

admission and three months for referral fora first outpatient appointment. Figures 1and 2 show: dramatic improvements inEngland in reducing both waiting timesafter moving from a policy based onaltruism (the ‘third way’ from 1997 to2000) to reputation (‘star ratings’ from2001); the policy based on altruism inWales and Northern Ireland resulted inperformance worsening initially after 2001;and although there was some improvementlater in reducing waiting times for electiveadmission, this appears to have been at theexpense of increasing waiting times forreferral for a first outpatient appointment.Figure 3 reports comparisons over time forperformance of ambulance services inresponse times to Category A calls inEngland, Wales and Scotland (there are nocomparable data for Northern Ireland).This again shows dramatic improvementsin England after the introduction of ‘starratings’ from 2002; with much worse per-formance in Wales and Scotland.

From 2002, the government in Englandsought to re-introduce a market into theEnglish NHS (and replaced ‘star ratings’with the annual Healthcheck from 2006).Evaluations of this package of systemreforms show that it has, however, so far,had disappointing results. The Audit Com-mission and Healthcare Commission18

identified problems with implementing keyelements of this package, little hard evi-dence of systemic improvements andlonger-term concerns over its impact. Areview19 of the evidence on the impacts ofthe market-based policies introduced bythe Thatcher and Blair governments con-cluded that “the reforms have not beenproven to bring about the beneficial out-comes that classical economic theorypredicts of markets” such as providerresponsiveness to patients and purchasers;large-scale reduction in costs; and inno-vation in service provision; and that theNHS has incurred the transaction costs ofseeking to introduce competitive marketswithout experiencing their benefits. Thiswas echoed by the concluding observationof the review of commissioning by theHouse of Commons Health Committee: “anumber of witnesses argued that we havehad the disadvantages of an adversarialsystem without as yet seeing many benefitsfrom the purchaser/provider split”.20

Evidence-based policy making?The evidence from the very differentsystems of health care in the US and theUK is surprisingly consistent: only for thereputation model is there strong evidence

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of its effectiveness. This finding is para-doxical because no UK government now ispursuing such policies. For governments ofthe devolved countries, policies based onaltruism remain attractive. For the new UKgovernment, which is responsible for theNHS in England, the new policiesemphasise markets and the abandonmentof national targets .21

REFERENCES

1. Le Grand J. Motivation, Agency andPublic Policy: of Knights and Knaves,Pawns and Queens. Oxford: Oxford University Press, 2003.

2. Bevan G, Robinson R. The interplay between economic and political logics: pathdependency in health care in England.Journal of Health Politics, Policy and Law2005;30(1):53–78.

3. Bevan G, Hood C. What’s measured iswhat matters: targets and gaming in theEnglish public health care system. PublicAdministration 2006;84(3):517–38.

4. Hibbard JH, Stockard J, Tusler M. Doespublicizing hospital performance stimulatequality improvement efforts? Health Affairs 2003;22(2):84–94.

5. Hibbard JH, Stockard J, Tusler M. Hospital performance reports: impact onquality, market share, and reputation.Health Affairs 2005;24(4):1150–60.

6. Bevan G, Hamblin R. Hitting and missing targets by ambulance services foremergency calls: impacts of different sys-tems of performance measurement withinthe UK. Journal of the Royal Statistical Society (A) 2009;172(1):1–30. Available at:http://www3.interscience.wiley.com/cgi-bin/fulltext/120848267/PDFSTART

7. Bevan G. Approaches and impacts of different systems of assessing hospital performance. Journal of Comparative Policy Analysis 2010;12(1&2):33–56.

8. Barber M. Instruction to Deliver: TonyBlair, the Public Services and the Challengeof Achieving Targets. London: Politico’s,2007.

9. Le Grand J. The Other Invisible Hand:Delivering Public Services Through Choiceand Competition. Woodstock: PrincetonUniversity Press, 2007.

10. Connolly S, Bevan G, Mays N. Fundingand Performance of Healthcare Systems inthe Four Countries of the UK before andafter Devolution. London: the NuffieldTrust, 2010.

11. Marshall MN, Shekelle PG, Leather-man S, Brook RH. The public release ofperformance data: what do we expect to

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0

5

10

15

20

1997 1998 1999 2000 2001 2002 2003 2004 2005

England Wales N Ireland

Number per ‘000

star ratings published

Figure 1: Waiting more than six months for elective hospital admission

England Wales N Ireland

Number per ‘000

star ratings published

0

5

10

15

20

1997 1998 1999 2000 2001 2002 2003 2004 2005

Figure 2: Waiting more than three months for referral to first outpatient appointment

England Wales N Ireland

Percentage calls in less than 8 minutes

star ratings published

45

55

65

75

85

1999 2001 2003 2005 2007

target

Figure 3: Ambulance response times to life-threatening emergencies

Source: 22

Source: 22

Source: 6

gain? A review of the evidence. Journal ofthe American Medical Association2000;283(14):1866–74.

12. Fung CH, Lim Y-W, Mattke S et al.Systematic review: The evidence that publishing patient care performance dataimproves quality of care. Annals of InternalMedicine 2008;148:111–23.

13. Hibbard JH. What can we say aboutthe impact of public reporting? Inconsis-tent execution yields variable results. An-nals of Internal Medicine 2008;148:160–61.

14. Chassin MR. Achieving and sustainingimproved quality: Lessons from New YorkState and cardiac surgery. Health Affairs2002;21(4):40–51.

15. CRAG. Clinical Outcome Indicators. A report from the Clinical Outcomes Working Group. Edinburgh: NHS Quality Improvement Scotland, 2002. Available at:www.show.scot.nhs.uk/crag

16. Mannion R, Goddard M. Impact ofpublished clinical outcomes data: casestudy in NHS hospital organisations.British Medical Journal 2001;323:260–63.

17. Mannion R, Goddard M. Public disclo-sure of comparative clinical performancedata: lessons from the Scottish experience.Journal of Evaluation in Clinical Practice2003;9(2):277–86.

18. Audit Commission and HealthcareCommission. Is the Treatment Working?London: Audit Commission, 2008. Available at: http://www.audit-commission.gov.uk/SiteCollectionDocuments/AuditCommissionReports/NationalStudies/IstheTreatmentWorking.pdf

19. Brereton L, Vasoodaven V. The Impactof the NHS Market. London: Civitas, 2010.Available at: http://www.civitas.org.uk/nhs/download/Civitas_LiteratureReview_NHS_market_Feb10.pdf

20. House of Commons Health Commit-tee. Commissioning (Fourth Report of Session 2009–10, Volume I) HC 268-I.London: The Stationery Office Limited,2010. Available at: http://www.parliament.the-stationery-office.co.uk/pa/cm200910/cmselect/cmhealth/268/26802.htm

21. Secretary of State for Health. Equityand Excellence: Liberating the NHS.Cm7881. London: The Stationery OfficeLimited, 2010. Available at: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_117352.pdf

22. Bevan G. Have targets done more harmthan good in the English NHS? No. BritishMedical Journal 2009;338: a3129. Availableat: http://www.bmj.com/content/338/bmj.a3129.full

What is the evidence from 1997–2010?A recent review by the King’s Fund foundthat considerable progress has been madein improving the performance of theNational Health Service (NHS) in Englandunder the Labour Government first electedin 1997.1 Notable achievements includemajor and sustained reductions in waitingtimes for treatment, reductions in rates ofhealth care associated infections, improve-ments in areas of clinical priority such ascancer and cardiac care and progress inreducing rates of cigarette smoking. Theseachievements have resulted from substan-tially increased spending on the NHSlinked to an ongoing programme ofreform.

The Labour Government’s reform pro-gramme focused initially on the use ofgovernment targets and national standardsto bring about improvements. Examplesincluded targets to cut the length of timepatients have to wait for an appointmentand standards set out in national serviceframeworks to improve clinical services.Subsequently, steps were taken to increasepatient choice and stimulate provider com-petition, alongside measures to strengtheninspection and regulation. The most recent

phase of reform has sought to place greateremphasis on the role of clinicians inimproving the quality and safety of healthcare in recognition of the limits of targetsas a means of achieving sustainableimprovements in care.

Political devolution to the four countriesthat make up the United Kingdom since1999 has resulted in different approachesto health care reform as well as differentresults. An analysis carried out by theNuffield Trust compared the experiencesof England with what has been achieved inNorthern Ireland, Scotland and Wales inthe last decade.2 The analysis concludedthat England had made greater progressthan the other three countries over thisperiod and it argued that the main reasonfor this was the greater emphasis placed inEngland on targets and standards as ameans of reform.

This conclusion is echoed in other studiesthat have drawn attention to the role of‘targets and terror’3 in contributing towaiting time reductions in England. Specif-ically, the strengthening of performancemanagement, and the holding to accountof NHS organisations for the delivery ofthe government’s health policy objectives,has focused the attention of leaders at alocal level on the implementation of highpriority targets. The boards of NHS

Improving performance inthe English National HealthService

Chris Ham

Performance improvement in the English NHS since 1997 has resulted mainlyfrom targets and terror. The Coalition Government elected in May 2010 is committed to reducing the use of process oriented targets, and instead will seek to bring about further improvements in performance through patient choice andprovider competition. The adversarial political system in Britain contains the riskthat newly elected governments will throw the baby out with the bathwater.Health policy makers should resist the temptation to reject policies inherited fromtheir opponents and should seek to provide direction from the top and empowerfront line teams in taking forward reform.

Key words: targets, performance management, choice and competition

Chris Ham is Chief Executive of theKing’s Fund, London.

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organisations, and particularly chief exec-utives and their senior colleagues, knowthat their jobs are at risk if they fail to meet these targets, and this has had theeffect of concentrating management efforton those targets seen as being of greatestimportance.

Also significant has been the growinginfluence of the regulators, such as theHealthcare Commission, the body thatoversees the quality of care, and Monitor,the organisation that regulates NHS Foun-dation Trusts, in reinforcing the focus onnational targets and standards. Not onlythis, but also the regulators have intervenedwhen NHS organisations have experiencedfinancial difficulties or the quality of carethey provide has come into question. I canspeak from experience as a non-executivedirector of an NHS Foundation Trustabout the large amount of time and effortlocal leaders spend ensuring that they meetthe requirements of the regulators andkeeping them at arm’s length.

By comparison, patient choice andprovider competition appear to have had alimited impact on performance to date.This was the view of a joint review carriedout by the Audit Commission and theHealthcare Commission in 20084 and hasbeen confirmed by recent research by theKing’s Fund into the way in which policyon choice has worked to date.5 Similarly,empowering clinicians to improve qualityand safety remains an aspiration ratherthan a day-to-day reality in most parts ofthe NHS, notwithstanding attempts to giveGPs control over budgets under thepractice based commissioning policy andto involve hospital doctors in service linemanagement.

The Labour Government’s approach toperformance improvement was reviewedin three reports commissioned by theDepartment of Health during the NHSNext Stage Review in 2008. The reportshighlighted the negative consequences of acommand and control style of leadership,and the lack of engagement of clinicians inquality improvement. The picture paintedin the reports was of an NHS driven by aculture of compliance where the oppor-tunity for learning was crowded out by thefear of failure.6 The implication was thatmuch more attention should be given toachieving improvement bottom up ratherthan top down.

Implications for the new governmentThe election of a Coalition Governmentmade up of Conservative and Liberal

Democrat politicians in the May 2010general election heralds a new approach toperformance improvement in the EnglishNHS. The government has already made itclear that less reliance will be placed onprocess oriented targets in future and moreattention will be given to improving healthoutcomes, such as cancer survival rates.Patient choice and provider competitionwill also be given priority and renewedefforts will be made to empower cliniciansto bring about improvements in care. Particular emphasis is being placed on therole of general practitioners who will beexpected to take control over budgets withwhich to commission most care for theirpatients in a radical development of thepractice based commissioning policy promoted by the previous government.

The question that arises is whether thesepolicies will be sufficient to build on theprogress made in England since 1997 andto enable areas of under achievement, suchas improving productivity and focusingmuch more on quality and safety, to beaddressed? In addressing this question, theresults of recent research into high per-forming health care organisations aroundthe world hold some pointers.7,8 Thisresearch indicates that in many of theseorganisations performance improvementderives more from building internal capa-bilities for improvement than respondingto external pressures such as targets,national standards and regulators. Toborrow a phrase from Kaiser Permanente,performance improvement results from‘commitment rather than compliance’, anddepends critically on engaging clinicians inthe work that needs to be done.

Evidence from Kaiser Permanente, as wellas other high performing organisationssuch as Jonkoping County Council inSweden, the Veterans’ Health Adminis-tration and Intermountain Health Care inthe US, also indicates that performanceimprovement requires a consistency ofpurpose over time and much greater sta-bility in leadership than is usually the casein the NHS. Raising standards of care isnot amenable to quick fixes, and patienceis needed before the results ofimprovement efforts become apparent.Particularly important is investment intraining and development for staff andbuilding the leadership and change man-agement capabilities to implement andsustain improvements over time. Thisincludes setting goals for improvement,measuring progress towards theirattainment and publishing the results.

The role of choice and competition inimproving performance remains an issue ofdebate. In organisations like JonkopingCounty Council competition worksmainly through transparent reporting ofinformation and comparing what isachieved in relation to other countycouncils in Sweden. Much the same appliesin the Veterans’ Health Administration(VA) where the use of comparative infor-mation on the performance of regionalnetworks is used to stimulateimprovement. In the VA and in Inter-mountain Health Care, there is a clear andconsistent focus on the quality of care,underpinned by a culture of measurementand reporting. This includes investment ininformation systems and deep engagementby clinicians. By contrast, it has beenargued that the ability of patients to chooseanother health plan and the threat posed bycompeting providers are important factorsin enabling Kaiser Permanente to leveragethe benefits of being an integrated systemto achieve high levels of performance.9

One of the conclusions from research intohigh performing health care organisationsis that skills in execution and implemen-tation may have a bigger influence onquality improvement than the particularmethods of improvement (for example,lean, total quality management and qualitycollaboratives) that are adopted. This rein-forces the need to invest in internalcapabilities for improvement to make areality of change being driven bottom upinstead of top down. If clinicians areexpected to play an increasing role in performance improvement, then giving pri-ority to the development of clinical leadersand providing them with the appropriateskills is likely to be necessary. This hasobvious implications for the success ofpolicies like commissioning in future.

The pendulum effect in health policyAs policy on the NHS in England migratesfrom targets and terror to empoweredclinical teams as the main means ofimproving performance, together with agreater emphasis on patient choice andprovider competition, there is the perennialrisk that the pendulum will swing too farand too fast in the opposite direction.Studies of high performing companies havedrawn attention to the need to work acrossa series of dualities in seeking to improveperformance.10 These dualities include:

– providing direction from the top andempowering front line teams to makechange happen

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PERFORMANCE

– promoting competition where it offersthe greatest potential and supportingcollaboration where organisations needto work together to improve per-formance

– working through the hierarchy as wellas building relationships through net-works

– emphasising the importance of clinicalengagement and leadership whilevaluing the role of managers

– managing the present and planning forthe future

The adversarial political system in Britaincontains the ever present danger that newlyelected governments will, in colloquialterms, ‘throw the baby out with the bath-water’ and reject policies they inheritbecause they were developed by theiropponents. At some future date thesepolicies are refreshed when the preferredapproaches of the politicians in power donot have the desired effects. This is pre-cisely what happened on the election of theLabour Government in 1997 with theending of the internal market experimentpromulgated under the Thatcher andMajor governments followed by its rein-vention in a much more radical form byTony Blair in 2002.

In the current context, there is a real riskthat the contribution that targets and stan-dards have made to performanceimprovement has not been sufficientlyacknowledged by the Coalition Gov-ernment and that some of the progressmade since 1997 will be lost as a conse-quence. To make this point is not to arguefor the new government to simply con-tinue the approach taken by itspredecessor. Rather, it is to make the casefor policy learning in which governmentsbuild on what has worked rather thanalways returning to the drawing board.

REFERENCES

1. Thorlby R, Maybin J (eds). A High Performing NHS? A Review of Progress1997–2010. London: The King’s Fund,2010.

2. Connolly S, Bevan G, Mays N. Fundingand Performance of Healthcare Systems inthe Four Countries of the UK Before andAfter Devolution. London: The NuffieldTrust, 2010.

3. Propper C, Sutton M, Witnall C, Wind-meijer F. Did ‘Targets and Terror’ ReduceEnglish Waiting Times for Elective HospitalCare?Working Paper 07/179. Bristol: Centre for Market and Public Organisation, 2007.

4. Audit Commission and HealthcareCommission. Is the Treatment Working?Progress with the NHS System Reform Programme. London: The Audit Commission, 2008.

5. Dixon A, Robertson R, Appleby J,Burge P, Devlin N, Magee H. PatientChoice: How Patients Choose and HowProviders Respond. London: The King’sFund, 2010.

6. Ham C. Improving the performance ofthe English NHS. British Medical Journal2010;340:c1776.

7. Bate SP, Mendel P, Robert G. Organisingfor Quality. The Improvement Journeys ofLeading Hospitals in Europe and theUnited States. Oxford: Radcliffe Publishing, 2006.

8. Baker GR, MacIntosh Murray A, Porcel-lato C, Dionne L, Stelmacovich K, Born K.High Performing Healthcare Systems: De-livering Quality by Design. Toronto: Long-woods, 2008.

9. Enthoven AC. Competition made themdo it [commentary]. British Medical Journal 2002;324:143.

10. Pettigrew AM. Organising to ImprovePerformance. Warwick Business School HotTopics 1999;(1):5.

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Launch of new HiT TemplateThe European Observatory on Health Systems and Policies is excited to announce the launch of a new and improved template for the Health system profile (HiT) series. HiTs are country-based reports that provide a detailed description of a health system and of policy initiatives in progress or under development. They are produced by country experts in collaboration with the Observatory staff. The HiT template is designed to guide the writing of HiTs by setting out key questions, definitions andexamples needed to compile a country profile of the health system.

This new edition of the template is a revised version of the 2007 template and incorporates the many useful comments and suggestions from users and contributors. New features include: clear sign posting for ‘essential’ versus ‘discretionary’ sections; summary paragraphs for all chapters; a revised and extended chapter on performance assessment; and increased focus on public health and intersectorality.

The new template is available to download at: http://www.euro.who.int/__data/assets/pdf_file/0003/127497/E94479.pdf

HiTs now included in MEDLINEThe Observatory is delighted to announce that its HiT country profiles will now be included in MEDLINE, the US National Library of Medicine’s premier bibliographic database. This will increase dissemination and ensure health system information is available to all those who need and want it most. It will also reinforce the Observatory’s commitment to supporting and promoting evidence-based policy-making in health.

MEDLINE is available at: http://www.nlm.nih.gov/databases/databases_medline.html

Eurohealth Vol 16 No 3 26

PERFORMANCE

Although measuring quality of careremains a challenge for many healthservices, there is an increasing interest innot just assessing the quality of individualhealth system components but puttingtheir performance in the context of thehealth system as a whole. This holisticsystem approach was enforced by theWorld Health Organization (WHO)Regional Office for Europe through theTallinn Declaration in 20081 and morerecently, the health ministers of the Organ-isation for Economic Co-operation andDevelopment (OECD) countries came toconsensus that alongside access, costs andprevention, quality of care is a key com-ponent in judging the performance of ahealth system.2

Policy makers are no longer solely con-cerned with the costs of health care, buthave moved forward with genuine interestin health system performance. This asks,alongside information on structure,process and output measurement, for addi-

tional information on outcomes of care.The recent emphasis of the Minister forHealth in England to shift the focus tooutcome measurement underscores thisdevelopment.3

Measuring health system outcomes canbuild on the long history of population sta-tistics, but it is also challenged with thequestion of what outcomes can be properlyattributed to the actual performance ofhealth services. Apart from the challengeof measurement, the management chal-lenge remains of how to link outcomemeasures to policy initiatives, such asfinancing (associating resource allocationto performance) or national qualityimprovement programmes. Thus HealthSystem Performance Management asks fora clear conceptual model on what consti-tutes health system performance, datasystems that provide the necessary indi-cators, and a policy and managementsystem that actively uses this informationfor decision making.

Reasons for health system performancemanagementHealth system performance assessmentand comparability (both inter and intranational) have three primary goalsincluding: accountability, strategic decisionmaking and learning/improving.4 The firstof these reasons relates to a transparency

agenda and enables governments to justifythe resources allocated to health care andthe value generated. The second reasonfocuses on areas where countries identifyperformance problems and where specificattention is needed; examples include theneed for national cancer plans or primarycare strengthening. Comparative data canhelp countries identify areas for possibleimprovement. In order to realise and seeimprovement, more detailed informationon why certain countries perform betterthen others is needed. When all of thesecomponents are in place, benchmarkingand mutual learning becomes the man-agement goal.

This paper summarises some of the recentdevelopments in health system per-formance measurement by addressing theunderlying performance frameworks andthe various data sources, including mor-tality statistics, clinical registries,administrative databases, medical recordsand patient surveys. It also explores howthe measurement activities can then belinked to management, thus creating thebasis for health system performance man-agement.

Why performance measurement inhealth care is difficultBy nature, assessing the quality of healthsystems is not easy. In industry, per-

Health system performance management: Quality for better or for worse

Niek Klazinga

Summary: There is a growing interest in measuring quality of care to help increase the value of health systems. This paper addresses the reasons and difficulties of health system performance measurement. It stresses the need for athoughtful health system performance framework and illustrates the need of anadequate underlying information infrastructure with respect to mortality data,clinical registries, administrative databases and patient surveys.Various strategiesare discussed that can help to turn health system performance measurement intohealth system performance management.

Key words: quality, health system, measurement, management

Niek Klazinga is Professor of Social Medicine at the Academic Medical Centre, University of Amsterdam andCoordinator of the Organisation for Economic Co-operation and Develop-ment’s (OECD) Health Care Quality Indicator project. Email: Niek.klazinga@oecd.org

formance measurement is considered to bepossible when an organisation has concreteand simple products, when an organisationis product oriented or when there is anautonomous production process with iso-lated products. In this arrangement,causalities are known, quality can bedefined in indicators, products are uniformand the environment is stable. Comparedwith these conditions, health systems aredealing with organisations that havepatient-centred obligations and are highlyvalue oriented with multiple products,strong process orientation and a pro-duction process confounded by manyco-producers. Furthermore, health systemproducts are interwoven and the causalitiesare unknown. There are difficulties indefining quality in performance indicatorsand challenges arise in the variety ofproducts and the highly dynamic envi-ronment.5

The need for health system performanceframeworksAs a consequence, it should be clear fromthe beginning that a limited set of measureson the outcomes of a health care systemmost likely does not do justice to all theunderlying care processes and the qualitywith which these are performed. Outcomeindicators can help to signal potential areasof under performance, but it would benaïve to assume that any set of measuresexists, or will exist, that can be used in aone-to-one relation to manage the healthcare system.

It is not only the validity and reliability ofindividual performance indicators that areat stake here, but also the representativity(the volume of the underlying processes inthe health system that can effect this indi-cator), relevance (the relevance of thisoutcome in relation to all possible healthsystem outcomes) and usefulness (theability of the indicator to help identifypolicies that can improve performance).

To assess the performance of a health caresystem it is therefore advisable to have aperformance framework that considerscarefully the various performance domainsand assesses whether the indicators thatpopulate a certain domain actually meetthe criteria of validity, reliability, represen-tativity, relevance and usefulness.Constructing a health system performanceframework as such is not simply a neutralacademic exercise but captures manypolitical and managerial notions as well. Itis thus advisable that such frameworks, forexample developed in Canada, the United

States, the Nordic countries and theNetherlands are based on a developmentprocess that involves the main stake-holders.6

The health system performance frameworkused by the OECD is based on severalconstructs: it considers health care as oneof the determinants of health alongsideenvironment, lifestyle and genetics (theclassical Lalonde model). Four functions inthe health system are identified (stayinghealthy, getting better, living with disabil-ities and coping with the end of life, asbrought forward by the US Institute ofMedicine) and it operationalises quality inthree domains (effectiveness, safety andpatient-centeredness) alongside access, costand equity.7

The need for good databases: mortality dataLife expectancy and perinatal and maternaldeath have traditionally been consideredstatistics for health system performanceassessment. Although the intuitiverationale of the relationship between healthsystem performance and mortality seemsappealing, it is far more difficult toattribute improvements in mortality tohealth care performance without consid-ering other societal improvements in thewelfare state.

In the search for appropriate outcome indi-cators, avoidable mortality (or morepolitically correct – mortality amendableto health care) has recently becomepopular again after an initial wave ofresearch in the 1980s.8 Avoidable mortalitysurely holds a promise for measuringhealth system performance, but the studieson its factual validity and the ideal list ofindicators that should be used and includedis still ongoing (i.e., the Avoidable Mor-tality in the European Union study,AMIEHS). It seems therefore premature atthis time to link avoidable death indicatorsto financial policies such as regionalresource allocation.

The same holds true for mortality statisticson hospitals. Hospitals Standardised Mor-tality Rates (HSMR) are increasingly usedin countries to assess the performance ofhospitals, but the debate on the validity ofthis measure is still ongoing.8,9

Not only for avoidable mortality andHSMR, but also for the development ofmore refined statistics on cancer survival,it is necessary that mortality data beadjusted for co-morbidity. This wouldassume either that in databases this infor-

mation is available, or can be madeavailable, though the linkage of databases.

However, mortality statistics poorly register co-morbidities without standardi-sation and linkages to mortality statisticsin administrative databases where any co-morbidity data could be assessed. Evenwith administrative databases, often themorbidity information is hamperedthrough data protection and privacy con-cerns, diminishing the possibilities ofmortality data use for meaningfulassessment of the performance of healthsystems covering representativeness, rele-vance and usefulness, as discussed earlier.

Unique Patient Identifiers (UPI) canprovide the linkage of necessary databases,but national governments will need tostrike the appropriate balance between theneed to obtain performance statistics andthe need (to fulfil justified expectations) fordata protection.

The need for good databases: administrative data and clinical registriesAdministrative databases and clinical reg-istries form major sources of performanceinformation about the health care system.Over the past few years the OECDthrough its Health Care Quality Indicatorproject has explored the availability andquality of administrative databases in itsmember states. Among the findings, infor-mation in mental health care and primarycare databases are often not standardisedand generalisable enough to serve as the basis for international comparable indicators on the quality of care.10

Hospital-based administrative databasesappear to be the best developed sources ofdesired data, partly through their directlinking with reimbursement systems.Reported indicators on primary care, suchas avoidable hospital admission rates fordiabetes, chronic heart failure, asthma andChronic Obstructive Pulmonary Disorder(COPD), are derived from hospital-basedadministrative databases, as are thereported indicators on 30-day case fatalityrates for acute myocardial infarction andstroke.10

More recently, the OECD has beenworking with a subgroup of eighteencountries on the calculation of PatientSafety Indicators following the work of theUS Agency for Health Care Research andQuality.11 Although this work is still con-sidered as research and development, it hasidentified some of the major challenges ofimproving administrative databases (and

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likewise clinical registries). Recommenda-tions to address these challenges include:

– advice to actively use Unique PatientIdentifiers to link administrative data-bases and clinical registries in order toenhance the possibilities of measuringthe outcome of hospital care and betteridentify disease co-morbidities that canbe used for case-mix adjustment in con-structing outcome measures;

– advice to include a ‘present onadmission’ code in the database tobetter identify whether a condition suchas a bed sore or an infection was alreadypresent at the moment of hospitaladmission;

– advice to have more extensive coding ofsecondary diagnoses (co-morbidities);the average number of secondary diag-noses codes per admission variesconsiderably between countries, thushampering the international compara-bility.

The need for good databases: Electronic Health RecordsPotentially an electronic version of themedical record would be an ideal basis forderiving information on quality of care.However even in the limited number ofcountries where this has been broadlyimplemented and is fully functioning,current use is limited. Most of the currentdebates on Electronic Health Records(EHRs) focus on data use for individualpatients. The debate on secondary data usefor population statistics, i.e., constructionof quality measures, is less prevalent.However, an increasing number of coun-tries, among them the US, Australia andthe Nordic countries, are trying to put reg-ulations in place that would facilitate theuse of the EHR for quality measures.

The need for good databases: patient surveysThe most direct source to obtain infor-mation on care quality is from the patient.Increasingly patient surveys are used as asystematic tool to obtain information onquality of care. This may be informationon the service delivery components ofhealth care, but also on the effectiveness(the Patient Reported Outcome measures).

For the return of data collection throughsurveys in a sustainable, valid and reliableway, a systematic and national approachtowards the measurement of patient expe-riences is warranted. The OECD hasformulated some principles for such an

approach.10 In the meantime, the surveyapproach in many countries remains tooad-hoc and is not institutionalised enoughto deliver a constant stream of comparativeinformation on performance.

From health system performance measurement to health system performance managementA comprehensive conceptual frameworkand sufficient databases to calculate qualityindicators are two of the three steps to turnHealth System Performance Measurementinto Health System Performance Man-agement. For this third step a direct linkageof measurement activities with policy anddecision making in the health care systemis necessary. This linkage is first andforemost to be found at the national levelin the health ministry. Are the data onhealth system performance actively usedfor assessing the system and does thisresult in strategic decision making andpolicies aimed at learning and healthsystem improvement?

The OECD discerns four areas where thelinkages can be made: health system inputs(professionals, organisations, tech-nologies); health system design (allocationof responsibilities, public health alongsidesocial care, primary, acute and long-termcare); monitoring (quality of the data-infrastructure and the various mechanismsfor monitoring services and professionals)and health system improvement (incentivestructures and national improvement pro-grammes). These linkages assume thathealth system performance serves as ananchor point in policies for the coordi-nation of care, patient-centred care, healthtechnology assessment and clinical evalu-ation, patient safety and pay forperformance.

Quality governance thus becomes far morethan issuing national reports on healthsystem performance. It is a systematicmanagement challenge to assess andimprove the performance of the system asa whole. These efforts can be strengthenedwhen measures used in health system per-formance frameworks are directly relatedto the measures used for assessing the per-formance of specific parts of the health caresystem, pertaining to both services andindividuals.

The agenda to develop performancemeasures should not be isolated frompolicies on certification and accreditation,guideline development, quality systemdevelopment, national audits and nationalimprovement programmes on quality and

patient safety. Only then will HealthSystem Performance Management becomea reality.

REFERENCES

1. WHO. The Tallinn Charter: Health Sys-tems for Health and Wealth. Copenhagen:WHO, 27 June 2008. Available at:http://www.euro.who.int/document/e91438.pdf

2. OECD. Final Communiqué of the Meeting of OECD’s Health Committee atMinisterial Level. Paris: OECD, 7–8 October 2010. Available at:http://www.oecd.org/ dataoecd/4/55/46163626.pdf

3. Department of Health. Transparency inOutcomes – A Framework for the NHS.London: DH, July 2010. Available at:http://www.dh.gov.uk/en/Consultations/Liveconsultations/DH_117583

4. Veillard J, Garcia-Armesto S, KadanwaleS, Klazinga N. International health systemcomparisons: from measurement challengeto management tool. In: P. Smith et al (eds.)Performance Measurement for Health System Improvement. Cambridge: Cambridge University Press, 2010:641–73.

5. de Bruijn H. Performance Measurementin the Public Sector. Strategies to cope withthe risks of performance measurement. International Journal of Public Sector Management 2002;15(7):578–94.

6. Arah OA, Klazinga NS, Delnoij DM, ten Asbroek AH, Custers T. Conceptualframeworks for health systems performance: a quest for effectiveness,quality and improvement. InternationalJournal for Quality in Health Care2003;15(5):377–98.

7. Arah OA, Westert G, Hurst J, KlazingaNS. A conceptual framework for theOECD Health Care Quality Indicatorsproject. International Journal for Qualityin Health Care 2006;18(Suppl.1):5–13.

8. Nolte E, McKee M. Measuring thehealth of nations: analyses of mortalityamenable to health care. British MedicalJournal 2004;328:494.

9. Black N. Assessing the quality of hospitals. British Medical Journal2010;340:2066.

10. OECD. Improving Value in HealthCare, Measuring Quality. OECD HealthPolicy Studies. Paris: OECD, 2010.

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Mythbusters

Eurohealth Vol 16 No 329

Pharmaceuticals save many human livesand improve the quality of numerousothers. For example, thanks to new anti-retroviral therapies, AIDS – once a rapidlyprogressive and deadly disease – is now amanageable chronic condition. Andchronic conditions such as diabetes can bemanaged with a range of medications tai-lored to patients’ needs. With theseadvancements in pharmacology, it’s nowonder that Canadians generally trust thatthe drugs they use are safe and effective.Furthermore, according to a recent poll,Canadians have confidence in publicauthorities and drug companies to keepthem healthy and safe.1

Despite the various measures in place toenhance drug safety, adverse drug reac-tions remain one of the top ten leadingcauses of death in Canada.2 Researchshows that hospital admissions fromadverse reactions are high and that manyare preventable.3,4 Experts estimate thatover 95% of adverse reactions go unreported.5

Out with the mould, in with the new?Drugs have been used for millennia, eversince certain plants were observed to havehealing properties. For example, extractsof willow bark have been used for cen-turies to reduce fever. These extractscontain a chemical similar to aspirin.However, pharmacology as a science hasexisted for just around two centuries.6

Some important discoveries wereserendipitous like the finding that peni-cillin – a by-product of a type of mould –can cure infection. However, in recentdecades drug research and development

has become increasingly sophisticated.Drugs can now be developed to isolatespecific protein molecules in target tissues(for example, Tamoxifen interferes with aspecific hormone receptor in breast cancercells).

Progress in drug science makes it temptingto assume that ‘newer’ means ‘better andsafer’. However, researchers cautionagainst this thinking, advising physiciansnot to prescribe new (and usually moreexpensive) treatments when existing oneswill do.7 In fact, new drugs have a one infive chance of being stamped with a ‘blackbox warning’ (required by the US Foodand Drug Administration if a drug mayhave serious or even fatal side effects), orbeing withdrawn from the market within25 years of approval (half of all with-drawals occur within two years ofapproval).7 Seen through this statisticallens, the newness of a drug does not guar-antee its safety.

Drugs on trial Before receiving regulatory approval, newdrugs undergo clinical trial research todetermine if the drug produces theintended effect. Trials also identify possibleside effects and their associated harms.This information helps regulators weighthe benefits and harms of drugs.

However, clinical trials have limitations.Certain people (such as those that are old,young, pregnant or suffering from othermedical conditions) may be excluded fromclinical trials meaning that their suscepti-bilities to adverse reactions are notuncovered .8 This is especially concerningsince the greatest users of pharmaceuticalsare the elderly.9 As well, participation isoften restricted to patients who would usethe drug only for its intended application,which isn’t always the case. These trialscannot anticipate a clinician’s decision toprescribe ‘off-label’ (prescribing anapproved drug for an unapproved

Myth: If a drug makes it to market,it’s safe for everyone

Mythbusters are prepared by Knowledge Transfer and Exchange staff at the CanadianHealth Services Research Foundation and published only after review by a researcherexpert on the topic.

The full series is available at www.chsrf.ca/PublicationsAndResources/Mythbusters.aspx This paper was first published in 2010. © CHSRF, 2010.

Progress in drug sciencemakes it tempting to assumethat ‘newer’ means ‘betterand safer’. However,researchers caution againstthis thinking, advisingphysicians not to prescribenew treatments whenexisting ones will do.

Eurohealth Vol 16 No 3 30

A series of essays by the Canadian Health ServicesResearch Foundation on the evidence behindhealthcare debates

application) or in opposition to clinicalguidelines. Furthermore, the internationalstandard suggested for the number of par-ticipants in trials10,11 is not large enough todetect very rare but nevertheless seriousadverse reactions.8

Because clinical trials do not mimic reallife, the occurrence of unexpected adversereactions is almost inevitable in the post-market setting. In fact, research shows thatpre-market clinical trials only detect abouthalf of all serious adverse reactions thatsurface once the drug is in widespreaduse.12

The ultimate trialOnce a new drug is approved (and only ahandful are approved annually), it is put tothe ultimate test of safety: application inthe market. However, it may require yearsof drug exposure before any safety con-cerns about adverse reactions becomeapparent.

In Canada and the US, drug companies arerequired to report adverse reactions to thefederal government, whereas health careprofessionals and the public areencouraged to report on a voluntary basis.The voluntary element leads to underre-porting, making it impossible to know thetrue frequency and severity of adversereactions. In addition, the typical pre-scriber often cannot identify or is unawareof the full spectrum of a drug’s harms dueto unreported adverse reactions. This lackof information can undermine efforts toprescribe only the safest drugs.

ConclusionIt cannot be assumed that progress in drugscience means that all drugs on the marketare safe for everyone. There is no ‘magicbullet’ drug that offers all benefit and noharm (for example, some people haveallergic reactions to penicillin that can befatal). Ultimately, it is up to patients andfamilies, in consultation with a health pro-fessional, to decide whether to take a drug.What’s most important is having athorough understanding of the potentialbenefits and harms of any drug so thatinformed decisions may be made. In thisrespect, the recent establishment of the

federally-funded Drug Safety and Effec-tiveness Network,13 which will fundresearch on the safety and effectiveness ofdrugs in the ‘real world’, is a step in theright direction. The bottom line is that themore information we have available, themore we are able to understand the impactof adverse reactions on individuals, thehealth care system and the economy.5

This issue of Mythbusters is based on anarticle by the 2010 Mythbusters Awardrecipient, Ms Tenneille Loo. Tenneille is amaster’s candidate at the University ofBritish Columbia, Vancouver, BritishColumbia.

Mythbusters are prepared by KnowledgeTransfer and Exchange staff at theCanadian Health Services Research Foun-dation and published only after review bya researcher expert on the topic.

REFERENCES

1. Decima Research. 2006 General PublicOpinion Survey on Key Issues Pertaining toPost-market Surveillance of MarketedHealth Products in Canada. Ottawa:Health Canada, 2006.

2. Rosenbloom D, Wynne C. Detectingadverse drug reactions. Canadian MedicalAssociation Journal 1999;161(3):247–48.

3. Sikdar KC, Alaghehbandan R, MacDonald D et al. Adverse drug events in adult patients leading to emergencydepartment visits. The Annals of Pharmacotherapy 2010;44(4):641–49.

4. Goettler M, Schneeweiss S, Hasford J.Adverse drug reaction monitoring – costsand benefit considerations. Part II: Costand preventability of adverse drug reactions leading to hospital admission.Pharmacoepidemiology and Drug Safety1997;6(3):S79–90.

5. Hazell L, Shakir SA. Under-reporting of adverse drug reactions: A systematicreview. Drug Safety 2006;29(5):385–96.

6. Scheindlin S. A brief history of pharmacology. Modern Drug Discovery2001;4:87–88.

7. Lasser KE, Allen PD, Woolhandler SJ,

Himmelstein DU, Wolfe WM, Bor DH.Timing of new black box warnings andwithdrawals for prescription medications.Journal of the American Medical Associ-ation 2002;287(17):2215–20.

8. Friedman MA, Woodcock J, LumpkinMM, Shuren JE, Hass AE, Thompson LJ.The safety of newly approved medicines:Do recent market removals mean there is aproblem? Journal of the American MedicalAssociation 1999;281(18):1728–34.

9. Morgan S, Kennedy J. Prescription drugaccessibility and affordability in the UnitedStates and abroad. Issues in InternationalHealth Policy, 1408. United States: TheCommonwealth Fund, 2010.

10. International Conference on Harmoni-sation. ICH Harmonised TripartiteGuideline: The Extent of PopulationExposure to Assess Clinical Safety for DrugsIntended for Long-term Treatment of Non-life-threatening Conditions, 1994. Available at: http://www.ich.org/

11. Health Canada. Guidance for Industry:General Considerations for Clinical Trials(ICH Topic E8). Health Products andFood Branch. Ottawa: Health CanadaPublications, 1997.

12. Moore T, Psaty BM, Furberg CD. Timeto act on drug safety. Journal of theAmerican Medical Association1998;279:1571–73.

13. Health Canada. Government ofCanada Works to Improve KnowledgeAbout the Safety and Effectiveness ofDrugs, 2009. Available at: http://www.hc-sc.gc.ca/

Eurohealth Vol 16 No 331

NEW PUBLICATIONSNEW PUBLICATIONS

Financial integration across healthand social care: Evidence review

Helen Weatherly, Anne Mason, Kath Wright and Maria Goddard

Edinburgh: Scottish Government SocialResearch, 2010

ISBN: 978 0 7559 7832-8

73 pages

Freely available online at:http://www.scotland.gov.uk/Publications/2010/02/19133206/0

This report looks at an Integrated ResourceFramework (IRF) which was jointly devel-oped between the Scottish Government,NHS Scotland, and the Convention ofScottish Local Authorities (COSLA). Theaim is to shift the investment away fromthe acute sector and towards health im-provement and prevention.

Presented in this report are the results of arapid review that was commissioned to inform an evaluation of the IRF, which isto be piloted at five sites in Scotland. Thereview assessed the international literatureon financial and resource mechanisms tointegrate care both within health care, aswell as across health and social care. Inte-grated resource mechanisms (IRMs) wereidentified and assessed from an economicperspective.

The review of empirical studies of IRMsidentified several factors critical for the suc-cess of the IRF. It also highlighted method-ological challenges that provide lessons forevaluating the IRF. Of primary importance

for the IRF pilot evaluations is an appro-priate choice of study design. This will helpensure that observed effects can be reliablyattributed to the intervention. Equally, theselection of an appropriate comparator(s)is critical. A common dataset, to which allHealth Boards can contribute, will facilitateanalyses of the effects, costs and unintendedconsequences of different IRF models.

The review found tentative evidence thatfinancial integration can be beneficial.However, still lacking is robust evidencefor improved health outcomes or cost sav-ings. Thus, appropriately designed pilotstudies of the IRF may help determine thepotential costs and benefits of financial integration in Scotland.

Contents:

Acknowledgements; Executive summary;Introduction; Objectives; Methods; Results;Discussion; Summary; Lessons from thereview; References; Glossary; Tables; andAppendices.

Funding and performance of health-care systems in the four countries ofthe UK before and after devolution

Sheelah Connolly, Gwyn Bevan andNicholas Mays

London: Nuffield Trust, 2010

ISBN: 1-978-1-905030-40-8

144 pages

Freely available online at: http://www.nuffieldtrust.org.uk/publications/detail.aspx?id=0&PRid=675

The health services of England, Scotland,Wales and Northern Ireland are all fundedby the UK taxpayer, but each country hasdeveloped different systems of governanceand different methods of providing healthcare. This report examines the impact ofpolitical devolution by studying key per-formance indicators for the NHS in thefour countries at three points in time. Thereport also undertakes a comparison ofNHS performance in the English regionsand the devolved countries.

Key statistics for the NHS in the four coun-tries are examined before and after devolu-tion. Performance is tracked against a num-ber of key indicators, includingexpenditure, staffing levels, activity, crudeproductivity of staff and waiting times.

The research suggests the NHS in Englandspends less on health care and has fewerdoctors, nurses and managers per head ofpopulation than the health services in thedevolved countries. Nevertheless, Englandis found to be making better use of the re-sources it has in terms of delivering higher

levels of activity, crude productivity of itsstaff, and lower waiting times.

Historical differences in funding levels mayhave been the cause of some of these trends,which are not directly related to policy dif-ferences following devolution. Some diver-gence reflects the different policies pursuedby each of the four nations since 1999, inparticular the greater pressure put on NHSbodies in England to improve performancein a few key areas such as waiting and effi-ciency. In England, there was extensive useof targets, strong performance management,public reporting of performance by regu-lators, and financial incentives towardsthese ends.

Contents:

Acknowledgements; Foreword; Summary;Introduction; Devolution: background,arrangements and their implications; Meth-ods, Cross-country comparisons; Compar-isons of Scotland, Wales and Northern Ire-land with English regions; Discussion;Appendix.

Eurohealth aims to provide information on new publications that may be of interestto readers. Contact Azusa Sato at a.sato@lse.ac.uk if you wish to submit a publication for potential inclusion in a future issue.

Please contact Azusa Sato ata.sato@lse.ac.uk to suggest web sites for

potential inclusion in future issues.

FEANTSA – European Federationof National Organisations working with the Homeless

http://www.feantsa.org

Eurocare – The European Alcohol Policy Alliance

http://www.eurocare.org

European Commission – Mentalhealth and wellbeing information

http://ec.europa.eu/health/mental_health/policy/index_en.htm

Eurocare is a network of some fifty voluntary and non-governmental organisations working onthe prevention and reduction of alcohol related harm across twenty-two countries in Europe.With a secretariat based in Brussels, it aims to raise awareness among European, national and regional decision makers of the harms caused by alcohol (social, health and economic burden),ensuring that these are taken into consideration in all relevant EU policy discussions. It also pro-motes the development and implementation of evidence-based policies aimed at effectivelypreventing and reducing this burden. The website includes detailed country profiles on alcoholuse and policy, a range of published papers and reports, key factsheets and links to European research projects.

HeRA – Norwegian ElectronicHealth Library Open ResearchArchive

http://hera.helsebiblioteket.no/hera

HeRA is the Norwegian Electronic Health Library's (Helsebiblioteket) open research archivefor hospitals and other health institutions in Norway. The archive contains research publicationsalready published (post print archiving), such as full-text peer reviewed journal articles, reviews,reports and other publications. The site contains advanced search options and in many cases linksto full reports and journal papers. Many of these reports and papers are published in English,with other material available in Norwegian.

Belgian Healthcare KnowledgeCentre

http://www.kce.fgov.be

The Belgian Knowledge Centre is a federal institution that has been operating since 2003. Itsmission is to produce studies and reports to advise policy-makers on health care and health insurance issues. It is active in three major research fields: analysis of clinical practice and devel-opment of recommendations of good practice; assessment of health technologies and drugs; andhealth care financing and organisation. The website provides full access to completed reports, aswell as information on current studies. The majority of reports are available in English, with others in Dutch and French. Summaries in Dutch and French are also provided.

The mental health section of the European Commission public health website contains a widerange of information on this topic and on activities undertaken as part of the European Pact forMental Health and Wellbeing. Recent additions include documents from the recent Pact con-ference on promoting social inclusion and tackling stigma held in Lisbon in November 2010.There are also links to a new Eurobarometer on mental health, as well as information on policydocuments, forthcoming events, consultations and projects.

FEANTSA is an umbrella group of not-for-profit organisations which participate in, or con-tribute to, the fight against homelessness in Europe. It has more than one hundred memberorganisations, working in close to thirty European countries, including twenty-five EU MemberStates. Most of FEANTSA's members are national or regional umbrella organisations of serviceproviders that support homeless people with a wide range of services, including housing, health,employment and social support. The website provides information on working groups, policywork, events and publications – the annual European Journal of Homelessness, the tri-annualmagazine Homeless in Europe and the monthly newsletter, the Flash. The website is available inEnglish and French.

Eurocarers – European Association Working for Carers

http://www.eurocarers.org

Eurocarers seeks to represent and act on behalf of all informal carers, irrespective of their age orthe particular health need of the person they are caring for. The organisation pursues philan-thropic, educational and scientific ends with regard to the representation of carers. The websitecontains a library with information on relevant EU policy documents, a factsheet, informationon good practice and past research projects, as well as links to past presentations by members ofthe organisation.

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WEBwatch

Eurohealth Vol 16 No 3

Press releases andother suggested information for future inclusion can be emailed tothe editor David McDaid d.mcdaid@lse.ac.uk

New

sNEWS FROM THE INSTITUTIONS

Conclusions from Employment,Social Policy, Health and Consumer Affairs Council The formal meeting of health andsocial ministers under the BelgianPresidency of the EuropeanUnion took place in Brussels on6 and 7 December. In respect ofhealth, ministers reached politicalagreement on a draft regulationon food information for con-sumers. They also exchangedviews on the follow up lessons tobe learnt from the A/H1N1 pan-demic, and in particular on thejoint procurement of vaccinesand antiviral products. Duringlunch, ministers exchanged viewson the joint report of the Eco-nomic Policy Committee onhealth care systems in Europe.Furthermore, the Counciladopted three sets of conclusionson: investing in Europe’s healthwork force for tomorrow; inno-vation and solidarity inpharmaceuticals; and innovativeapproaches for chronic diseases.

New labelling rules for food

The Council agreement on newlegislation on food labelling isdesigned to ensure that foodlabels carry essential informationin a clear and legible way,enabling consumers to makeinformed and balanced dietarychoices. One of the key elementsagreed by the Council is themandatory nature of thenutrition declaration: thelabelling of the energy value andthe quantities of some nutrients(fat, saturates, carbohydrates,protein, sugars and salt) shouldbecome compulsory.

As a general principle, the energyvalue and the amounts of thesenutrients would have to beexpressed per 100g or per 100ml,but could also be indicated as apercentage of reference intakes.However, food business oper-ators could also use additionalforms of expression or presen-tation as long as certainconditions are met (e.g. they donot mislead consumers and are

supported by evidence of under-standing of such forms ofexpression or presentation by theaverage consumer). All elementsof the nutrition declarationshould appear together in thesame field of vision but some ele-ments may be repeated on the‘front of pack’.

Many alcoholic products will beexempt from the new rules,although this decision will bereviewed within five years. Non-prepacked food would also beexempted from nutritionlabelling, unless member statesdecide otherwise. The text of thepolitical agreement reached bythe Council will be reviewedlegally and linguistically before itis formally adopted at one of theforthcoming Council sessions asits first-reading position. Thistext would then be forwarded tothe European Parliament for itssecond reading. The EuropeanParliament adopted its first-reading position on 16 June 2010

Pandemic A/H1N1

Ministers exchanged views on thefollow up to the Council conclu-sions on the lessons learnt fromthe A/H1N1 pandemic adoptedin September 2010 and in par-ticular on the joint procurementof vaccines and antiviralproducts.

Recalling the weaknesses of theindividual procurement of pan-demic influenza vaccines andantivirals during the A/H1N1influenza pandemic, in terms ofequitable access and purchasingpower, many ministers argued infavour of the joint procurementof pandemic vaccines andantiviral medication. A largemajority of delegations agreedthat framework contracts thatmember states may enter into ona voluntary basis constitute themost suitable form for a jointprocurement. It is expected thatthis would strengthen themember states’ negotiatingposition in discussions with thepharmaceutical industry andensure equitable access to vac-cines. The need to further clarifysome outstanding issues, such as

the question of product liabilityand the compatibility with com-petition rules before taking anydecisions, has been highlighted.

A broad majority of ministersalso recognised the need for acommon minimum coverage ofpandemic vaccines and agreedthat the vaccines for covering thiscommon minimum should bedelivered prior to all other addi-tional orders and on an equitablebasis. Ministers wished to targetthe common minimum coverageat strategic sectors such as healthcare workers, policemen and fire-fighters. The suggestions for sucha common minimum cover ratevaried between 2% and 20%,with many delegations stressingthe need to take account ofnational specificities as well.Some delegations considered thedefinition of a common vacci-nation strategy as a preconditionfor setting up a commonminimum cover rate.

The Council’s attention was alsodrawn to the fact that an indi-cation of the expiry date forvaccines can, if exceeded, furtherreduce citizens willingness tobeing vaccinated, even thoughthe vaccines in question wouldstill be safe and effective. Com-missioner for Health andConsumer Policy, John Dalli,announced that the Commissionwould take work on a joint pro-curement scheme further in theHealth Security Committee.With regard to the shelf life ofvaccines, Commissioner Dallisaid that he would ask theEuropean Medicines Agency(EMEA) to continue workingwith the industry on this issue.

The discussion was a follow-upto the conclusions adopted on 13September 2010 in which theCouncil invited the Commission,inter alia, to report on anddevelop, as soon as possible andno later than December 2010, amechanism for the joint pro-curement of vaccines andantiviral medication which grantsmember states, on a voluntarybasis, the right to common acqui-sition of these products orcommon approaches to contract

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negotiations with the industry, clearlyaddressing issues such as liability, avail-ability and price of medicinal products aswell as confidentiality.

Innovation and solidarity in pharmaceuticals

The Council also adopted conclusions oninnovation and solidarity in pharmaceu-ticals, calling upon member states to takeinitiatives to promote the rational andresponsible use of valuable innovativemedicinal products with a view toobtaining an optimal clinical outcome andan efficient management of expenditure.The European Commission and EUcountries should continue to worktowards a stronger prioritisation in theallocation of resources for pharmaceuticalresearch to increase the probability ofvaluable innovations. They should alsogive priority to revising the clinical trialsdirective with the aim of ensuring animproved regulatory framework fordeveloping medicinal products. Furthermore, they should examine thepossibilities of enabling an efficient cross-border exchange of clinical data, and takeappropriate initiatives to establish inter-operable registries, for instance on rarediseases. They should also examine howto facilitate availability to innovativemedicinal products throughout the EU.

Chronic diseases

The Council adopted conclusions oninnovative approaches for chronic dis-eases in public health and health caresystems, inviting the member states tofurther develop patient-centred policiesin the field of chronic diseases. The EUcountries and the Commission are calledupon to start a reflection process with aview to optimising the response to thechallenge of chronic diseases. Thisreflection should cover inter alia healthpromotion and prevention of chronic dis-eases, health care, research into chronicdiseases and comparison of chronic dis-eases at European level. The outcomes ofthe reflection process should be sum-marised in a paper by 2012. Theconclusions take into account the resultsof the conference organised by theBelgian Presidency in Brussels on 20October 2010. Chronic diseases are oneof the presidency’s priorities in the fieldof public health.

Council conclusions are available atwww.consilium.europa.eu/uedocs/cms_data/docs/pressdata/en/lsa/118254.pdf

Council of Ministers acts against adverseeffects of medicinesOn 29 November the EU Council ofMinisters adopted a regulation and adirective aimed at strengthening the EUsystem for the safety monitoring ofmedicinal products for human use (phar-macoviligance), to better protect publichealth. The EU pharmacovigilance systemseeks to detect, assess and prevent adverseeffects of medicinal products placed onthe market in the European Union. It alsoensures that any product, which presentsan unacceptable level of risk, can berapidly withdrawn from the market.

Member states will remain central for theoperation of a pharmacovigilance system,but their responsibilities are clarified.Under the new rules they will collectinformation on suspected adverse drugreactions, not only if the product wasused within the terms of the marketingauthorisation, but also in case of overdose,misuse, abuse and medication errors.

A new scientific committee within theEuropean Medicines Agency (EMEA),the Pharmacovigilance Risk AssessmentCommittee, will also advise the EMEA’sCommittee for Medicinal Products forHuman Use, which remains responsiblefor issuing an opinion, on the risk-benefitassessment of centrally-authorisedmedicinal products for human use. Pro-vision is also made to allow adequatefunding for pharmacovigilance activitiesthrough the collection of fees charged tomarketing authorisation holders forobtaining and maintaining EU marketingauthorisations and for other services pro-vided by EMEA and national competentauthorities.

The existing EU pharmacovigilancedatabase, the “Eudravigilance database”,will be strengthened and become a singlepoint of receipt of pharmacovigilanceinformation for medicinal products forhuman use authorised in the EU, thusfacilitating early discovery of adversereactions. In order to ensure transparencyin pharmacovigilance issues the EMEAwill also create and maintain a Europeanmedicines web portal.

In terms of the pharmacovigilance obliga-tions of industry, as under the currentrules, the marketing authorisation holdermust establish a pharmacovigilancesystem to ensure the monitoring andsupervision of its authorised medicinalproducts. The requirements for applica-tions have been simplified. Marketing

authorisation holders will have to submitonly key elements of their pharmacovigi-lance system, rather than a detaileddescription of the system. On the otherhand, they will have to maintain adetailed file on site for possible inspec-tions by the competent authorities.

For more information about the directive,www.consilium.europa.eu/uedocs/cms_data/docs/pressdata/en/lsa/118080.pdf

EU health strategy undermined by failureto draw on wealth of experience at sub-national level, warns CoREurope’s regions have a wealth of expe-rience in developing and implementinghealth strategies that remains untapped atthe European level, the Committee of theRegions (CoR) warned on 2 December2010. The failure to fully involve sub-national authorities as legitimate partnersin the development of future initiativeswill undermine the European Com-mission’s efforts to improve the quality ofhealth care and health services across theEU.

Speaking after the adoption of hisopinion on the role of local and regionalauthorities in the implementation of theEU Health Strategy at the CoR PlenarySession in Brussels, rapporteur AdamBanaszak said that “local and regionalauthorities are still insufficiently involvedin the implementation of the Europeanhealth strategy despite the key role thatthey play in, for example, providinghealth care services or developing pre-vention campaigns. The EuropeanCommission could do much more toinvolve local and regional actors whiledealing with health issues, such as invitingthem to take part in working groups, andshould build on their experience in areassuch as assessing health inequalitiesbetween regions. But above all it needs tomake sure that there is sufficient financialsupport for local and regional authoritiesin the field of health care, not least bymaking it easier for them to accessexisting European funds for health-related programmes, in particular thoseinvolving cross-border cooperation. Forthe CoR it is also important for healthobjectives to be included in the Europe2020 strategy with a view to achievingintelligent and balanced development thatcan help combat social exclusion.”

One of the clear messages for EU Healthand Consumer Policy CommissionerJohn Dalli, who was invited by CoRPresident Mercedes Bresso to present the

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European Commission’s position in thePlenary Session, is the need for moreeffective indicators to assess the level ofhealth inequalities across Europe. “TheLisbon Treaty makes territorial cohesionone of the key pillars of the EU, yet inthe field of health care there are still substantial differences across regions,even within countries. European-fundedprojects have, for example, established aset of regional indicators that give a farmore accurate picture of health inequal-ities than the methodology currently inuse. The Commission should supportsuch projects and ensure that theirfollow-up helps regions to tackle inequal-ities in health care and meet other futurechallenges,” said Banaszak.

The Committee of the Regions is com-mitted to working closely with theEuropean Commission on key issuessuch as disease prevention and healthpromotion, through the recently estab-lished technical platform, which bringstogether officials from local and regionaladministrations, experts and stakeholders,EU officials as well as interested CoRmembers to discuss a wide range ofhealth-related issues with policymakers.

The opinion can be downloaded athttp://tinyurl.com/2fc8ekx More information on the Committee of theRegions at http://www.cor.europa.eu/

Commission launches consultation on active and healthy ageingThe European Commission is seeking theviews of public and private organisations,companies and individual citizens on howEurope could scale up innovation to meetthe challenges of the ageing population inEurope, and in particular on a pilotEuropean Innovation Partnership (EIP)on active and healthy ageing, as set out inthe Innovation Union Flagship Initiative,launched on 6 October. Between 2010and 2030, the number of Europeans agedover 65 will rise by nearly 40%, posinghuge challenges but also offering greatopportunities for Europe’s society andeconomy. The EIP, which the Com-mission has proposed should be launchedin 2011, would seek to meet three goals:to improve the health and quality of lifeof older people, enabling them to liveactive and independent lives; to con-tribute to the sustainability and efficiencyof health and social care systems; and tofoster competitiveness and businessopportunities. The online consultationruns until 28 January 2011.

John Dalli, European Commissioner forHealth and Consumer Policy said:“Europe needs to prepare for the futureageing of its society and the use of inno-vation shall be one of the tools at ourdisposal. This is why I am very pleasedthat the very first of the Partnerships ison Active and Healthy Ageing: it willimply a close cooperation across differentpolicies covering public health, research,digital and industrial policy.”

Neelie Kroes, Commission Vice-President for the Digital Agenda said:“People are living for longer – and shouldbe able to do so as actively and independ-ently as possible, with the help ofinnovative solutions such as fall-detectionand prevention devices, easy to use socialinteraction services to overcome lone-liness, and smart use of information andcommunication technologies in the home.We need input from stakeholders to makesure the future Innovation Partnershipcan help to make these ideas a reality forEurope’s senior citizens.”

The consultation invites interested stake-holders, such as organisationsrepresenting older people and patients,hospitals and care service providers,health and care professionals, insurers,ICT and health companies, public author-ities and individual citizens, to helpidentify current barriers to innovationand opportunities in the field of activeand healthy ageing. Contributors can alsoshare existing and future initiatives whichcould be undertaken at European leveland advanced in a collaborative way.These should focus on how innovativesolutions can bring promising and tan-gible outcomes to benefit the elderly.

The European Innovation Partnership onActive and Healthy Ageing, as a headlinetarget, aims to increase the averagehealthy lifespan in the EU by two yearsby 2020. It seeks to improve olderpeople’s quality of life and to lead tomore efficient care solutions. It will focuson applying innovation on a larger scalethan today in areas such as health pro-motion, prevention, early diagnosis andtreatment, integrated and collaborativehealth and social care systems, inde-pendent living and assistive technologiesfor older people.

The Commission will analyse theresponses to the consultation, in order toobtain a clear view of the innovationpotential and capacity in the multipleareas that affect ageing today. The

responses will help the Commission toplan the next steps for the EIP.

The consultation document is available athttp://tinyurl.com/2asqav8

European countries urge greater actionon chronic disease prevention and controlOn 26 November ministers and officialsfrom around 40 European countriesended a two-day consultation on globaland regional efforts to prevent andcontrol the increasing deaths and suf-fering caused by non-communicablediseases (NCDs), as well as their effectson economies and development.

The meeting, held in Oslo, Norway, wasa critical step in Europe’s build-up to nextSeptember’s first-ever United NationsGeneral Assembly High-level Meeting on the Prevention and Control of Non-Communicable Diseases. “NCDs arebecoming a major health challenge allover the world, and the cost of not takingaction is unacceptable,” said NorwegianMinister of Health and Care ServicesAnne-Grete Strøm-Erichsen. “Countriesin the European Region need to share ourown domestic experience with othernations on what does and does not workin the fight against NCDs.”

Key outcomes of the Oslo meetinginclude the following.

– National health plans will give higherpriority to NCDs.

– Many countries called for theinclusion of NCDs into global development initiatives and relatedinvestment decisions. The officialdevelopment assistance currentlyreceived is insignificant for the fightagainst NCDs.

– The participants concluded that NCDsare a threat to development thatneither the developed nor developingworlds can afford. Additional researchis needed to halt and reduce prematuredeath from this cause. Cost-effectivepolicy interventions need to be imple-mented to reduce people’s exposure toNCD risk factors and strengthenhealth care services for those withchronic diseases.

The United Nations summit will focus onthe four main types of NCDs: cancer,diabetes, cardiovascular diseases andchronic lung diseases. They are respon-sible for more than 60% of global deaths(35 million); nine million of these deaths

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are premature (in people aged under 60years). Deaths from NCDs can largely beprevented by low-cost measures targetingfour key risk factors: tobacco use,harmful use of alcohol, poor diet andphysical inactivity.

Globally, NCDs heavily affect developingcountries, particularly the poorest, whichhave weaker health systems, poverty andlower protection against the risk factors.As a result, marked increases in preva-lence are projected. In Africa, deathsfrom NCDs are expected to increase byaround 25% by 2020.

In the WHO European Region, NCDsannually account for more than eightmillion deaths (over 80% of all deaths in the Region), including 1.5 million premature deaths. Three out of four premature deaths from NCDs in theEuropean Region (1.1 million) occur inlow- and middle-income countries.

“The challenge posed by NCDs is notone just for the health sector alone totackle, but for all sectors to fight together,including foreign affairs, developmentcooperation, urban planning, finance,education and transport,” stated Dr AlaAlwan, Assistant Director-General forHealth Action in Crises at WHO head-quarters in Geneva. “More and morepeople are dying and suffering from thesediseases, which are causing enormoushealth and economic impacts globally. Inparticular, poor and vulnerable people areaffected in the world’s poorest countries.”

More information on the meeting athttp://www.euro.who.int/en/home/con-ferences/regional-high-level-consultation-on-noncommunicable-diseases

Landmark declaration signed on thehealth of children with intellectual disabilitiesOn 26 November health policy-makersfrom the 53 countries in the WHOEuropean Region signed a declarationexpressing their commitment toimproving the lives of children and youngpeople with intellectual disabilities byimproving their access to high-qualityhealth care. The declaration was signed atthe WHO European Conference BetterHealth, Better Lives: Children and YoungPeople with Intellectual Disabilities andtheir Families in Bucharest, Romania.

Despite tremendous efforts in recentyears, major challenges remain in helpingintellectually disabled children leadhealthy lives. Intellectual disabilities affect

about five million children and youngpeople in the Region, the majority livingin poorer countries. More than 300,000live in institutions, often remaining forlife. Unless urgent action is taken, thisnumber is expected to rise by about 1%per year over the next ten years.

“Children with intellectual disabilitieshave the same rights to health and socialcare, education and protection as otheryoung people. They should have equalopportunities to live stimulating and ful-filling lives in the community with theirfamilies, alongside their peers,” statedZsuzsanna Jakab, WHO RegionalDirector for Europe. “The declarationthat our Member States have adoptedtoday in Bucharest recognises that thesechildren have greater health needs yetthey encounter major barriers in gainingaccess to effective health promotion andcare. If they gain access to services, theirneeds are often either missed or neg-lected. The declaration maps out concreteactions that will empower these childrento achieve their full potential in life.”

The declaration builds on some funda-mental principles. Children withintellectual disabilities and their familiesneed effective and comprehensive carefrom community-based services. Pro-viding this entails a major shift frommodels based on institutional care tothose that give priority to community-based living and social inclusion. Peopleliving in poverty have a disproportion-ately high incidence of disability. Familieswith vulnerable members, includingchildren with disabilities, are all too oftentrapped in chronic poverty.

The declaration also challenges the publichealth community to draw a true pictureof the problem and its scale. Accurate andmeaningful data on disabled children arehard to find. Official statistics rarelyreveal much about their situation or theproblem’s extent. “Supporting the reformof child care systems has been a priorityfor UNICEF (United Nations Children’sFund) in eastern Europe and central Asiafor the last twenty years. We can reportpartial success. The reforms havedelivered many new services across theregion, especially alternative family-basedcare, and this is a significant achievement.But, sadly, what we are seeing is thatchildren with disabilities are usually thelast ones to benefit from these services.Most disturbingly, the institutionalisationof children with disabilities continues as astable trend, untouched by any reform. In

many countries, children with disabilitiesrepresent as many as 60% of all childrenin institutions. For us, this is an indi-cation of the failure of systems to providetailored responses to families with dis-abilities and children with disabilitiesthemselves,” underlined Steven Allen, theUNICEF Regional Director for Centraland Eastern Europe and the Common-wealth of Independent States.

National legislation and policies needfurther development. Few Europeancountries have policies that explicitlyaddress the needs of intellectually disabledchildren and young people. To fill thesegaps, the declaration includes an actionplan covering ten priority areas with con-crete interventions for groups of youngpeople differentiated by their age, vulner-ability and evolving capacities. The firstresults of carrying out this plan areexpected towards the end of 2015.

The declaration is supported byUNICEF, the European Commission,representatives of intellectually disabledyoung people and their families,providers of social and education services,and non-governmental organisations.

More information at http://www.euro.who.int/en/what-we-do/health-topics/diseases-and-conditions/mental-health/activities/intellectual-disabilities

European Court of Human Rights rulesthat Ireland’s abortion laws breachhuman rightsOn 16 December the European Court ofHuman Rights ruled in the case of A, Band C versus Ireland (application number25579/05) that Ireland’s laws banningabortion breach European human rightslaw. In a landmark and binding case thatcould have implications for otherEuropean countries, the court ruled thatIreland had breached the human rights ofa woman (case C) with a rare cancer whofeared it would relapse if she becameunintentionally pregnant. The womanwas unable to find a doctor willing tojudge whether her life would be at risk ifshe continued her pregnancy to term.

The court concluded that neither the“medical consultation nor litigationoptions” relied on by the governmentconstituted an effective or accessible pro-cedure. “Moreover, there was noexplanation why the existing constitu-tional right had not been implemented todate,” the court ruled. The woman wasawarded €15,000 in damages.

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While abortion in Ireland remains acriminal offence under 1861 legislation, atechnical constitutional right to abortiondoes exist following a 1992 SupremeCourt ruling. In a controversial judgmentknown as the “X case”, the court estab-lished the right of Irish women to anabortion if a pregnant woman’s life was at risk as a result of the pregnancy.However, successive governments havenot legislated on the issue, and severalconstitutional referenda variously aimedat either enacting or revoking thejudgment have proved inconclusive.Ireland and Malta are the only member-states of the Council of Europe in whichabortion remains illegal.

The European court case was filed in2005. In 2009 it had an oral hearingbefore the court’s grand chamber. This17-judge court is reserved to hear casesthat raise serious questions affecting theinterpretation of the European Con-vention of Human Rights. As a signatoryto the European Convention on HumanRights – now incorporated into Irish law– the government is obliged to remedyany breaches of the convention.

The two other Irish women (A and B)who took cases before the court in Stras-bourg, France, were unsuccessful in theirbids. The first woman, who was claimingthe right to an abortion because she wasliving in poverty and felt unable to raisethe child, had her case struck down. Hercase, if successful, would have forcedIreland to legislate for abortion ondemand. The second of the two unsuc-cessful candidates ran the risk of anectopic pregnancy, in which the foetusdevelops outside of the womb. Her casealso was rejected because there was noclear medical certainty over the diagnosisof an ectopic pregnancy.

All three women were among an esti-mated 4,000 Irish women who travel toGreat Britain for an abortion each year(Abortion is also not available inNorthern Ireland). The Irish governmentdefended its laws and said Ireland’sabortion laws were based on “profoundmoral values deeply embedded in Irishsociety”. It argued that the EuropeanCourt of Human Rights has consistentlyrecognised the traditions of differentcountries regarding the rights of unbornchildren. However, it maintained that thewomen’s challenge sought to underminethese principles and align Ireland withcountries with more liberal abortion laws.

Reacting to the judgement, the Taoiseachstated that the judgement would have tobe carefully studied. In practice, anyresponse will be delayed until after theimminent general election early in 2011.Both main parties – the current governingFianna Fail party and the main oppositionFine Gael – have policies opposed toabortion. Ireland’s third party, the LabourParty, supports the introduction ofabortion. Welcoming the judgement,Senator Ivana Bacik, the Labour Party’sJustice Spokesperson said that “theEuropean Court ruled that we must havegreater clarity in our law, through passinglegislation which will ensure that the rightto a life-saving abortion is put into effect.I very much welcome the ruling and urgethe Government to introduce legislationnow as Labour has already recommended,to provide clarity about the conditionsunder which the X case judgment may beimplemented by doctors.”

The Irish Family Planning Associationhas said that the ruling ‘leaves no optionavailable to the Irish State other than tolegislate for abortion.’ The Association,which represented the three applicants inthe case, has said the move is necessary inorder to protect women at risk. Earlier,the Catholic Primate Cardinal Seán Bradysaid that the judgment does not obligeIreland to introduce legislation autho-rising abortion. The Cardinal has said theStrasbourg Court decision ‘raises pro-found moral and legal issues which willrequire careful analysis and reflection.’He stated that the judgement leaves futurepolicy in Ireland on protecting the lives ofunborn children in the hands of the Irishpeople. Meantime the National Women’sCouncil of Ireland has welcomed theruling and called on the Government tolegislate for a woman’s right to have anabortion if her life is at risk.

The full text of the judgement is availableat www.echr.coe.int/echr/ homepage_EN

COUNTRY NEWS

England: The Internet is first choice forhealth adviceNHS Choices (www.nhs.uk) is theofficial website of the National HealthService (NHS). In addition to providingthousands of pages of NHS accreditedcontent on conditions, treatments andhealthy living, it allows the public tocompare and comment on the per-formance of hospitals, general

practitioners (GPs) and many other NHSservices. More patients than ever beforeare now going online to find health infor-mation and self-diagnose, saving theNHS millions of pounds a year,according to two separate reports published on 9 November.

The NHS Choices 2010 Annual Reportshows there has been a 10% increase inthe number of visits to the NHS websitein 2010 compared to 2009, taking thenumber of times people logged on to thesite to well over 100 million. On averagethis was more than 200,000 visits per day.During the height of the flu pandemicnineteen million people turned to NHSChoices to find information on swine flu,while over 40,000 patients have postedcomments about hospitals and GP prac-tices. The site is now the biggest healthinformation site in Europe, regularlyattracting nine million users a month.

Separately, Paul Nelson, Joanna Murrayand Muhammad Saleem Khan at ImperialCollege London surveyed 4,200 peopleand found that 70% of patients use theinternet to search for health information.37% of those who logged on towww.nhs.uk reduced their GP call-outsand appointments as they found theinformation they needed before con-tacting their doctor. Given that an averageGP visit costs £32, this is the equivalentof saving the NHS £44 million a year. Thereport’s authors noted that these savingswere conservative: there are likely to beother considerable savings associatedwith the opportunity users have to act onhealth advice offered by NHS Choices.

NHS Choices has now partnered withover 170 external organisations, such aspatientopinion.org.uk and mumsnet, toallow patients to access reliable healthinformation across the board. This has ledto twenty-five million people viewinginformation on NHS Choices via partnerwebsites. NHS Choices also topped theconsumer magazine Which? recent inves-tigation into medical websites, saying thesite “excelled for its breadth of infor-mation” and that the site contained“medically robust information”.

The reports come at a time that the gov-ernment in England has recently launcheda consultation on how information andtechnology can help people take morecontrol of their health and make the bestchoices for themselves and their families.

Commenting on the two reports, JuniorHealth Minister Simon Burns said that

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“every day we use the internet and tech-nology to organise our lives, andincreasingly when it comes to our health.For example, more and more people aretaking the information they have foundonline with them when they consult theirGP. It is important they can find accurate,trusted information from sources such asNHS Choices. It is vital that every pennyspent on the NHS counts, and theImperial College research shows thattools like NHS Choices can help deliversavings.”

The NHS Choices annual report and theImperial College London research reportcan be found at www.nhs.uk/annualreport

UK: Government decides against genericsubstitution of medicinesFollowing the Government’s consultationon proposals to implement generic substi-tution entitled ‘The proposals toimplement ‘generic substitution’ inprimary care, further to the Pharmaceu-tical Price Regulation Scheme (PPRS)2009: Consultation Document’, whichwas open during the period January toMarch 2010, the new Coalition Gov-ernment has now abandoned plans to putthis scheme in place. The consultationproposed to allow for medicines thatwere prescribed by brand by the pre-scribing practitioner, to be dispensed as ageneric medicine where that prescribingpractitioner consented.

The main driver behind the consultationwas that of cost savings to the NHS, tosave the additional expense of brandedmedicines wherever possible. By implementing generic substitution, thepharmacist would have the option to dispense a cheaper generic medicine insituations where patients’ health wouldnot be compromised. Other reasons givenin support for generic substitutionincluded giving patients greater access totheir medicines, as the pharmacist wouldbe able to substitute the branded medicine for a potentially more readilyavailable generic alternative.

Secondly, it was suggested that by pre-scribing and dispensing generically, thehealth care professionals involved wouldbe more acutely aware of the treatmentregime for each patient, as the genericname gives health care professionals agreater indication of the mode of actionof each medicine. This would, it wasfurther mooted, lead to a decrease in anypotential risk of prescribing a secondincompatible medicine or duplicating the

prescribing of the same medicine.

The Government has now published itsresponse to the consultation, stating thatthe generic substitution proposal will notbe going ahead. The analysis of responsesshowed no clear consensus on the wayforward. The consultation reported astrongly held perception by respondentsthat generic substitution posed a threat topatient safety. If the proposals were to beimplemented, these concerns would arisein the delivery of frontline services,impacting on the workload of profes-sionals. The consultation did notconclusively establish the cost effec-tiveness of generic substitution. Therewas also a strong sense that the effortinvolved was simply too great for thepotential gain.

Health Minister, Lord Howe, said that“we know that there are valuable savingsto be made from the use of generic medi-cines where it is clinically appropriate.However, we believe that national plansto enforce generic substitution in primarycare are too prescriptive.” He didhowever add that “we want patients toget the drugs their doctors recommend atthe best price for the taxpayer. Patientsshould be reassured that we are looking atmore appropriate ways of supporting theuse of generic medicines and, in the longterm, value-based pricing will help toensure we pay a price for drugs whichbetter reflects their value.”

More information on responses to the con-sultation atwww.dh.gov.uk/en/Consultations/Responsestoconsultations/DH_120431

Germany: Health minister highlights benefits of health promotion to businessOn 8 December at an event on workplacehealth promotion in Berlin, GermanFederal Health Minister Dr PhilippRösler highlighted the importance ofhealth promotion as a factor in the eco-nomic success of companies. He stressedthat these benefits could be realised bysmall and medium sized enterprises,pointing to recent scientific studies sug-gesting that better workplace healthpromotion could reduce health care costsand sick leave by about one quarter. TheMinister recognised that more needs to bedone to raise awareness of the benefits ofworkplace health promotion. Many com-panies only rarely benefit from effectivestrategies. He encouraged healthinsurance funds and companies to workhand-in-hand in this task.

Investing in workplace health promotionis a voluntary activity for employers, butit is mandatory for health insurance tomake provision for such services. As anincentive for employees to invest inmeasures to improve health in the work-place income tax breaks are in place to thetune of €500 per annum. The event sawthe presentation of different goodpractice examples covering a range of dif-ferent areas including diet and physicalactivity, stress management, leadershipand tackling mental health problems suchas depression and burn-out.

Thematic Conference: Promoting MentalHealth and Well-being at Workplaces

In related news, the EU German FederalMinistry of Health will organise, in coop-eration with the European Commission’sDirectorate General for Health and Con-sumers and the Directorate General forEmployment, Social Affairs and EqualOpportunities, a EU-conference ‘Pro-moting Mental Health and Well-being atthe Workplace’ on 3–4 March 2011. Theconference will create an opportunity toraise awareness about the relevance ofmental health and well-being for work-places and exchange and improvecooperation on challenges and opportu-nities in workplace mental health andwellbeing. It will also contribute to awider dissemination of good mentalhealth practices in various workplacesettings and present state-of-the-artresearch findings, highlight leadershipexamples and good practices in mentalhealth promotion at workplaces, and itwill discuss the role of policymakers, andhealthcare and social security systems inthis context.

A German language workplace healthpromotion brochure produced by the Ministry of Health can be downloaded athttp://tinyurl.com/34amxdr. More infor-mation on the European conference onPromoting Mental Health and Wellbeingat the Workplace is available athttp://ec.europa.eu/health/mental_health/events/ev_20110303_en.htm

Ireland: Unique cross border hospitalservice establishedA unique model for planning and man-aging a cross border hospital service hasbeen established between the HealthService Executive Dublin North East andthe Southern Health and Social CareTrust in Northern Ireland. This crossborder collaboration has seen Ear, Noseand Throat (ENT) waiting lists in the

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HSE Dublin North East (HSEDNE) areasignificantly reduced by facilitating ENTconsultants from Northern Ireland’sSouthern Trust to work in MonaghanHospital. It is also enabling HSE DNEENT patients to access inpatient care inNorthern Ireland’s Daisy Hill andCraigavon Hospitals. Funding for the‘start up’ period of this scheme has beenprovided by the European Union’sINTERREG IVA programme which wassecured by Co-operation and WorkingTogether (CAWT), the cross borderhealth and social care partnership. Thepartnership comprises the Health andSocial Care Board and the Public HealthAgency in Northern Ireland, the bordercounties of the Health Service Executive(HSE) in the Republic of Ireland and theSouthern and Western Health and SocialCare Trusts in Northern Ireland. As partof the initiative Monaghan Hospital hasbeen collaborating with the acute hos-pitals in the Southern Health and SocialCare Trust in Northern Ireland over thepast twelve months, to get the crossborder service up and running. Theamount of funding secured for crossborder ENT services is €3.77 million forthe whole of the CAWT border region.

To date, under this cross border scheme,2,270 people living in the Dublin NorthEast area have received ENT outpatientappointments in Monaghan Hospitalwith day case treatment also available ifrequired. Additionally, 859 SouthernTrust patients have been seen in ENTclinics in either Craigavon or Daisy HillHospitals. CAWT’s Chief Officer, MrsBernie McCrory outlined the significanceof this new cross border ENT service.She said “CAWT is managing twelveEuropean Union funded cross borderhealth and social care services andprojects and the biggest portion of ouractivity is focused on acute hospitalservices. This unique partnership servesas a model for other cross border hospitalservices currently in the planning stages.Both partners to this cross border ENTservice, the Southern Trust and the HSEDNE, are committed to its longer termcontinuation, which is already bringingreal health benefits to the local borderpopulations.”

To support the establishment of this crossborder ENT service, nurses from Mon-aghan hospital engaged in observationaltraining in the Southern Trust, with theapproval of the Nursing and MidwiferyCouncil (NI) and An Bord Altranais

(Irish Nursing Board). The two SouthernTrust consultants, Mr Kaluskar and Mr Farnan, already registered with theGeneral Medical Council in NorthernIreland, are now registered with the IrishMedical Council, which enables them totreat patients in the Republic of Ireland.Once the EU funding period has elapsedthe cross border ENT service will con-tinue as a permanent collaborative servicebetween the HSE DNE and the SouthernTrust.

More information atwww.cawt.com/acute

Hungary: Dissolution of the Health Insurance Inspectorate On 26 September 2010, the HealthcareInsurance Inspectorate (EBF) was dissolved. The tasks that had been performed by the EBF for more thanthree years have been taken over by otherauthorities. The EBF had come into existence on 1 January 2007. One of itsmain tasks was to supervise promotionalactivities related to medicinal productsand therapeutic medical devices directedat health care professionals. It was alsoresponsible for the supervision of theactivities of health care service providersto ensure that patients’ rights were pro-tected during the performance of suchactivities. In addition, the first instancedecisions of the National HealthcareInsurance Administration (OEP) – theresponsible authority for the inclusion of medicinal products and therapeuticmedical devices in the public reim-bursement scheme – could be appealedbefore the EBF.

As a consequence of the dissolution ofthe EBF, the tasks pertaining to the supervision of promotional activitiesrelated to medicinal products and thera-peutic medical devices directed at healthcare professionals have been transferredto the Chief Medical Officer’s Office(OTH). The supervision of the operationof health care institutions is now the taskof the Regional Institutes of the NationalPublic Health and Medical Officer’sService, which, together with the OTH,will continue to pursue ongoing pro-ceedings previously initiated by the EBF.Further, the Act abolished the possibilityof making the administrative appeals theEFB used to hear against OEP decisionsrelated to the inclusion of medicinalproducts or therapeutic medical devicesin the public reimbursement scheme.Consequently, these decisions can now

only be challenged before regular courts.During its existence, the EBF was particularly active in supervising the promotion of medicinal products andtherapeutic medical devices, maintaining arather strict interpretation of the relevantlaws.

Spain: Stricter rules on prescribingFrom 2011 doctors in Spain will be ableto prescribe the exact number of pills ofcertain drugs. Initially 25 drugs will becovered by the scheme. Pharmaceuticalcompanies will have to start graduallychanging the format in which theymarket these drugs, so that quantities ofpills contained in the packets or boxes canbe adapted to the most common treat-ments. Patients will receive the exactnumber of pills they need to treat theirdisease, avoiding an accumulation ofproducts in their homes, while improvingthe quality of the service they receive.

The savings achieved with ‘single-doseprescriptions’ combined with the fall inthe price of medicines manufacturedunder patent, will reduce the gov-ernment’s drug bill, which in 2009reached approximately €12.5 billion. Themove will save Spain €300 million perannum according to Health MinisterLeire Pajín.

In December 2010, the Health Ministryalso started promoting generic drugs witha campaign to raise awareness of thequality and efficiency of the genericoption. In 2010 generics accounted forjust over 10% of cost of drugs in phar-macies, compared with 6% in 2003. Akey objective of the new campaign is toimprove the image of generic drugsamong the public and promote their use.Community pharmacies will be activelyinvolved in the strategy, whilst trainingand information for doctors and othermedical professionals on the safety, effectiveness and quality of generic medications will also be improved.

The way in which reference prices fordrugs are set is also to change. This willnow be based on the cheapest drug ineach medication group rather than beingbased on an average of the prices of drugsin the group. In future drugs costingmore than this reference price may bereplaced by a generic version, unless thepatient pays the difference in price.

More information in Spanish athttp://www.msc.es/gabinetePrensa/notaPrensa/desarrolloNotaPrensa.jsp?id=1934

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Eurobarometer on mental healthReleased to mark World Mental HealthDay, a new Eurobarometer surveyreveals that 15% of respondents acrossEU Member States sought professionalhelp for psychological or emotionalproblems and 7% took antidepressantsover a twelve month period. It also illus-trates the continuing discriminationfaced by people with mental healthproblems, noting that those with themost negative experiences have mostsocioeconomic difficulties, while thoseaffected by physical or emotional prob-lems tend to be those under social andfinancial stress.

The survey can be accessed athttp://ec.europa.eu/health/mental_health/eurobarometers/

New EU Health at a Glance reportThe European Commission (DG Healthand Consumers) jointly with the Organ-isation for Economic Cooperation andDevelopment (OECD), has issued thereport Health at a Glance: Europe 2010.This report provides a useful insight intothe current situation of health in the EU.

The report compiles data from theOECD, Eurostat and the WHO andpresents key trends on health, healthsystems and health spending in the 27EU Member States, plus the three Euro-pean Free Trade Association countries(Iceland, Norway and Switzerland) andTurkey.

The report notes that life expectancy atbirth in the EU has increased from 72years in 1980 to 78 years by 2007.Health spending has risen in all EUMember States, often increasing at afaster rate than economic growth. In2008, EU Member States spent, onaverage, 8.3% of their GDP on health,up from 7.3% in 1998.

The report is available atwww.oecd.org/health/healthataglance/europe

European regions launch health technology consortiumOn 7 October some of Europe’s mostadvanced regions in health care tech-nology launched a consortium toincrease and accelerate health care inno-vation. The Health-Ties consortium,supported by a three year grant from the

European Commission, has been set upto strengthen the research potential ofEuropean regions through encouragingresearch driven clusters of universities,research centres, companies and regionalauthorities. The consortium consists ofMedical Delta (the Netherlands), LifeScience Zurich (Switzerland), Oxford &Thames Valley (United Kingdom),BioCat (Spain) and the mentoring regionÉszak-Alföld (Hungary).

The consortia will map what is neededto speed up the transfer of idea-to-product and analyse regional researchand development needs. It will focus onfour major disease areas: cardiovasculardiseases, cancer, neurodegenerative dis-eases and infectious disease. In addition,it will involve medical doctors andpatient groups in the development of thenew technologies and will share innova-tions with other EU regions.

Further information about the consortium is available athttp://www.oep.org.uk/?p=930

Sweden: the future need for careBy 2050 the proportion of older peoplein the Swedish population is expected tohave increased from the present level of17% to 25%. The population is ageing,health is improving and life expectancyis rising. In response, the Swedish Min-istry of Health and Social Affairs hascompiled a description of how demo-graphics, health, morbidity and mor-tality will develop over the next fortyyears, and what impact this will have onthe need for health and social care ser-vices for older people. A unique modelis used to simulate how a statisticallyrepresentative population of 300,000individuals age year by year up to 2050.

The report can be accessed athttp://www.sweden.gov.se/content/1/c6/15/36/57/d30b0968.pdf

New Health Evidence Network policybriefsTwo joint HEN-European Observatoryon Health Systems and Policies policybriefs and two policy summaries wereprepared at the invitation of the BelgianFederal Public Service – Health, FoodChain Safety and the Environment, forthe Belgian EU Presidency MinisterialConference on ‘Investing in Europe’shealth workforce of tomorrow: scope

for innovation and collaboration’ thattook place at La Hulpe, from 9 to 10September 2010. The publications reflectkey priority areas for Europeanpolicy/decision-makers in respect offuture health workforce needs, andwhere learning from comparative experience is crucial to informing futurepolicy choices.

One brief looks at how to create condi-tions for adapting physicians’ skills tonew needs and lifelong learning and thesecond at how to create an attractive andsupportive working environment forhealth professionals. Policy summariesfocus on future health workforce needs,and the use of audit and feedback tohealth professionals to improve qualityand safety.

The publications are available athttp://tinyurl.com/3xuazhp

New web publication series givesoverview of ECDC’s disease surveillance for EuropeA new European Centre for DiseasePrevention and Control (ECDC) seriesof web publications presents anoverview of surveillance activities,explains the finer points of disease sur-veillance and shows how data are col-lected and used in order to provide max-imum protection for European citizensand their families. The web publicationsfeature three main messages:

1. Surveillance is essential to under-standing the epidemiology of infectious diseases;

2. European surveillance supports otherEU and national public health efforts;and

3. Surveillance data provide scientificevidence, allowing for a better targeted public health response.

More information athttp://ecdc.europa.eu/en/healthtopics/spotlight/spotlight_surveillance/

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