Saturday, December 16, 2006

To Jerusalem. Two reasons. The first is a meeting of the International Advisory Committee of the Israel National Institute for Health Policy and Health Services Research. This is an organisation established in the early 1990s, in preparation for the introduction of a national health insurance system in 1995. This introduced universal coverage with contributions paid from taxation and distributed according to a weighted capitation formula to one of four Health Maintenance Organisations (HMO). The full story of how this came about, despite opposition from powerful vested interests, is told in the Israeli Health System in Transition report. One element of this reform was the creation of the Israel National Institute for Health Policy and Health Services Research. It was funded by “up to 0.1%” of contributions to the HMOs. It is always important to get the wording of legislation absolutely correct, a point that the UK government consistently fails to grasp. In this case it was the “up to” that caused the problem as it was too easy for this to be clawed back when the economic situation was unfavourable. Yet notwithstanding budgetary cuts, the Institute has supported a wealth of mainly small but useful studies providing answers to practical problems. Looking ahead, the Institute faces the same issues as any policy-relevant research funder. Do you wait for investigator instigated research or do you take a more proactive stance, identifying emerging issues and seeking to encourage proposals that will address them in a timely way so that the answers will be available when needed.
The second reason was to speak at the Institute’s international conference on health care reforms. We had an almost complete participation from the European Observatory’s senior staff at the conference and there were lots of excellent presentations. I especially enjoyed Steven Schroeder’s critique of the US health care system and learned a lot from Naoki Ikegami’s presentation on long term care insurance in Japan. Hans Stein gave a superb speech on globalisation.
There were four parallel streams and I was giving the plenary introduction to the one on chronic disease. It had been organised superbly by Leon Epstein, with lots of really good papers (I leave others to comment on my own of course!). With my colleagues Ellen Nolte and Dina Balabanova, we have been thinking a lot about this over recent years. We have a new book coming out from the Observatory in 2007 and have contributed to the World Bank’s new strategy on non-communicable diseases in low and middle income countries. Complex chronic diseases are clearly the main challenge facing health systems in the 21st century yet many politicians simply don’t get this. They persist in their simplistic ideas of individual patients making one-off trips to a health professional for a self-limiting condition. Of course they never make this model explicit but it is clear that it underpins the paradigm they inhabit, dominated by attempted to measure individual encounters, patient treatment episodes, and the like, as well as, at least in England, to promote “patient choice” as a value above all others, including the more usual ones such as equity, effectiveness, and efficiency. Yet it is all too clear, from even the most superficial review of the literature, that the key to effective management of chronic diseases is integration, not fragmentation. Ellen Nolte and I have highlighted how, in a country characterised by fragmentation of care, the USA, outcomes, in the form of death rates from diabetes and other chronic diseases among young people, are many times higher than in Europe, although even here we could often do better. Yet bizarrely those advising English ministers seem determined to attract American providers of chronic disease programmes, persisting in this goal even in the face of recent evidence from the early examples in England that they are no better than what was already there.
Of course you need to do more than simply integrate services. You need to establish mechanisms that allow them to respond to patients’ needs, to adapt to changing technologies, evidence, and expectations, and to find ways to develop the new types of workers that will be needed for these changing models of care. Yet the introduction of market-based reforms in many countries is actually making this more difficult. Unfortunately, these reforms are driven by ideology rather than evidence. In my talk I drew initially on some examples from other sectors in the UK, where apart from the USA (and to a lesser extent, The Netherlands) this paradigm has taken root most firmly among the political elite. These were the break-up of the telephone directory enquiry service, long seen as a natural monopoly and run cheaply and efficiently by British Telecom. The government, in its wisdom, decided that the service would be improved by competition. There was a feeding frenzy as companies, many with no experience in telecommunications, moved into the market. Like any market there were winners and losers. The winners were the advertising companies who were the beneficiaries of vast campaigns to attract customers to the different providers. Of course everything has a cost and this was recouped by higher charges (albeit somewhat opaque as they developed incredibly complex pricing structures) and cuts in those providing the service. The result? Service quality and later calls to directory enquiries have plummeted and the leading provider is now abandoning its main product in favour of a computerised “voice recognition” model. Prepare to receive even more wrong numbers! The second example was railway privatisation, where the government’s subsidy to the private operators is now double what it was under state ownership. A reduction in expenditure on track maintenance was associated with some high profile crashes, in which people died. The company owning the track failed and was taken back under state ownership, since when quality has improved and it has turned a loss into a £750 million profit! Yet still we are told that market solutions are needed so that the private sector can sort out the inefficiencies of the public sector! Given that one of the UK Prime Minister’s former health advisers was also speaking at the conference, extolling the virtues of patent choice, it was perhaps a little insensitive of me to compare Mr Blair’s campaign of modernisation with Mao Tse Tung’s Great Leap Forward. However I leave it to others, especially those who have the misfortune of trying to implement the constant stream of contradictory initiatives emanating from Whitehall, to decide whether the analogy is valid.
The final reason for being in Israel was to move forward on our existing collaborations with Israeli colleagues. They have been developing an important new initiative entitled Healthy Israel 2020, in which a number of committees have been established to design a health strategy linked to achievement of health targets. A key goal has to be the reduction of smoking. There is a ban on smoking in public places but it is not enforced, something I called attention to in an op-ed in Haaretz where I argued for a smoke-free Israel earlier in the year. One obvious way forward is to levy large fines on bar and restaurant owners who allow smoking on their premises. At last it seems that the Knesset will support such a move. The next challenge is to get the Finance Ministry to provide the funds that are needed for the Healthy Israel programme to move forward.
I can’t finish a blog about a trip to Israel without addressing the political situation. A number of people invited to the conference refused to attend because of their political beliefs, a view I can understand, even if I disagree with it. After a lot of thought I’ve taken the decision to work with Israeli colleagues because many of those I work with have done a great deal to bridge the divide with their Palestinian colleagues. They are as horrified as I am by the atrocities by both sides in this ongoing tragedy. What’s more, I can hardly blame others for the actions of their government, given some of the things mine does. Unfortunately as in my own Northern Ireland, those advocating mutual understanding on both sides are in the minority.

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