Thoughts from abroad: A prescription for Finnish health care in the 21st

century

Martin McKeeLondon School of Hygiene and Tropical Medicine

European Observatory on Health Systems and Policies

@martinmckee

The challenge

• Fragmentation– 320 municipalities,

although down from 444 in 2005

– Challenges of co-ordination

– Dis-economies of scale and scope

• Domestic politics

18 (15) regions but…

• The Government has decided that there will be 12 units (hospitals and associated 24-hour intensive social welfare services points) operating on a broad basis around the clock.

• All the other existing central hospitals will continue as units providing a more limited range of 24-hour services

Co-ordination with higher education and research sectors: Great idea, but how?

• “The appropriate criteria will be formulated for the operation and development of university hospitals and dedicated centres of expertise in the social sector. Similar criteria will be drawn up for pertinent research and teaching carried out in universities and polytechnics to be utilised in the practical development of healthcare and social welfare services.”

Research infrastructure

• BBMRI.fi, Biobank Infrastructure• Biocenter Finland• EATRIS (Finland), European Infrastructure for

Translational Medicine• ELIXIR (Finland), European Infrastructure for

Biological Information• EuBI (Finland), European Research Infrastructure

for Biomedical Imaging (Bioimaging)• EU-OPENSCREEN (Finland), European

Infrastructure of Open Screening Platforms for Chemical Biology

• INFRAFRONTIER (Finland), European Research Infrastructure for the Analysis, Archival and Distribution of

• Genetically Modified Mice• Instruct (Finland), ICVIR, Integrated Structural

Biology Infrastructure• NaPPI, National Plant Phenotyping Infrastructure• NVVL, National Virus Vector Laboratory

Information technology

• “An important practical task of the autonomous regions’ joint national data management and ICT service will be to implement the single ICT platform necessary for the integration of data and the smooth functioning of services.”

• NHS IT system abandoned after spending £11.4 billion (€15 billion)

• “patchwork of fragmented systems”

Data

• “Quality and cost data on public and publicly-funded private healthcare and social welfare services must be publicly available in order to facilitate open comparison. “

“Private provision exacerbates geographical inequalities. Those responsible for commissioning care fordefined populations must have access to consistent data on provision of treatment wherever it takes place.”

Seamless care• “The autonomous regions’ data

management and electronic services will be organised such that they are seamlessly incorporated into the national service channel and other related services. The interface and architectures of the autonomous regions’ information systems will be specified and the information systems implemented such that the interoperability of information and information systems with other private and public sector information systems is ensured. “

• When you find out how to do it, please tell the NHS in England!

Problem: lost needle in haystackSolution: get more hay

“…data were so variable in quality and so incomplete as to render “any attempt at commenting on trends and comparisons between schemes and with any external benchmarks, futile.””

Independent Sector Treatment Centres

• Intended to increase competition with publicly provided NHS• Paid additional premium to encourage market entry• Able to select patients, so only those without complications

of co-morbidities• No requirement to train staff• No effective monitoring, so paid according to numbers in

contract, not numbers actually treated• “Commercial in confidence” so real activity unknown, but

some evidence that, for certain conditions, >10% of what was paid for

Making comparisons

• Insist on provision of comparable data

• Impose strong penalty clauses for failure to provide data

Comparability of public and private

• “Further preparation will address comparability between different service providers in terms of the costs, cost-effectiveness, quality and impact of publicly and privately provided services that fall within the scope of the public service pledge. “

Intention in England was to encourage small & medium enterprises and charities to bid

• Transaction costs extremely high– Failed bids for 2-3 tenders can bankrupt a small organisation– Massive economies of scale for large corporations writing

bids• Payment in arrears– So small organisations face cash flow problems

• Performance bonds required– Which small organisations cannot afford

• Reputational risk– Charities should not be fronts for corporations

Money

• Large corporations saw prospects of vast sums coming their way

• US health sector immensely profitable• They were major donors to politicians

supporting the NHS reform• BUT• UK spends 9.8% of GDP on health, US 17%

Business model

• Drive down costs– Reduce level of provision– Cut wages

• However– major service failures and public scandals– inability to recruit and retain staff– mounting complaints– Regulatory action

• Withdrawal from market when business model seen as unviable

• “Serco agreed to end its contract 17 months early after failing to meet national standards and reports of some staff falsifying data.”

• “where skulduggery has come to light, the contracts have been so poorly framed – or the officials so timid – that fines and sanctions are either not applied at all or are so lenient as to amount to little more than a slap on the wrist.”

• “When a whistleblower revealed that Serco was fiddling figures on an out-of-hours GP service contract in Cornwall, a subsequent audit found that poor performance had been disguised by more than 250 manipulations of data over a six-month period. Yet Serco continued to receive regular payments and remained entitled to bonus payments under the terms of its contract. And when Capita failed to deliver enough properly qualified interpreters to the Courts, they were fined a meagre £2,200. The far larger bill for adjourning and delaying these cases had to be met by the taxpayer.”

Financial Times

The real problem

• Outsourcing companies were able to make good profits by cream-skimming

• Typically took ~5% of market• Insisted on a premium for market entry• Passed anything difficult back to NHS• Impossible to do this when you have to

provide 100%

Managing contracts

• Substantial transaction costs

• Contract monitoring often totally inadequate

• Penalty clauses weak• Enforcement lax• Significant power

imbalance

• “The Finnish Consumer and Competition Authority will supervise the implementation of competition in the healthcare and social welfare services market and, as part of this, also the opportunities for small and medium-sized enterprises to participate.“

• “…the contradictions within the regulations and with the act create a magnet for competition lawyers, including some of the peers who supported the act. The result is that the future of healthcare in England lies in the hands not of politicians and professionals but of competition lawyers.

the NHS could be forced to spend millions on competition lawyers after the UK’s biggest private healthcare provider demanded an immediate investigation into a decision to award an elective care contract to a local health trust.

Care UK has been branded a bad loser after lodging a complaint with the NHS watchdog Monitor over the management of a contract by commissioners in north London.

Freedom of choice• “legislation on freedom of

choice will be enacted, enabling customers to choose between public, private or third sector service providers. Freedom of choice will be the main principle at the basic service level. Where appropriate, the same principle will also be applied in specialised healthcare and social welfare services.”

• UK experience suggests– Patients prioritise good local

service above freedom to choose

– Information basis for choosing superficial and has little meaning to most people

– In most cases, patients ask general practitioners to make choices for them

• Choices are only meaningful when there is spare capacity

Informed choices?

• Massive efforts have been made to generate performance measures for hospitals

• Hospital standardised mortality ratios heavily promoted by government

• But recognised to be largely meaningless• “There is little correlation between how well a

hospital performs on one standard of safe effective care and how well it performs on another” – Academy of Medical Royal Colleges

Future challenges facing all health systemsI: Organisation

• Increasing multi-morbidity• Need for integrated care, spanning health and

social sectors (but how to resolve with increased choice?)

• Need for networks of care, with management at lowest appropriate level but rapid upward referral where needed, including shared protocols (but how to resolve with increased provider fragmentation)

Source: Barnett et al. Lancet 2012

Future challenges facing all health systemsII: Delivery

• The modern concept of the hospital arose in the 19th century, for 3 main reasons– Physics – discovery of x-rays so need to

concentrate imaging equipment– Chemistry – development of laboratory medicine– Biology – safe anaesthesia/ germ theory and

asepsis so need for operating theatres• Linked to rise of scientific medicine, and need

to concentrate training

Future challenges facing all health systemsII: Delivery

• Antimicrobial resistance– Is the era of safe surgery drawing to a close?

• New interventions– Some enabling care to be dispersed

• Minimally invasive surgery• Portable ultrasound

– Some requiring greater concentration• Trauma centres• Combined medical/surgical management of GI haemorrhage• Advanced cancer care• Genomic medicine

Some specific challenges for Finland

• Highly dispersed rural populations in north• Challenge of recruiting and retaining health

workers– Declining birth rate– Language barriers when recruiting abroad

My prescription for Finland (since you ask…)

• The real challenges for the future involve how to deliver integrated care for patients with complex disorders and multi-morbidity

• While ensuring basic care is available as near to patients’ homes as possible

• Debates about patient choice/ increased role for private sector are an unhelpful distraction and, except in Helsinki, largely irrelevant

You mean the contract failed to

specify we needed ambulances that

can go on beaches!

@martinmckee