Sunday, September 21, 2008

20th September 2008, Liverpool
I had been invited by Michael Marmot to speak at the annual meeting of the
Academia Europaea. Michael had organised a session on Health and Wealth so I was presenting our work on the contribution of health to economic growth in Europe. It was my first opportunity to hear Michael speaking since the publication of the Report of the Commission on Social Determinants of Health, which he chaired.
The report begins by documenting, in great detail, the scale of the problem we face. Life expectancy at birth ranges from 54 to 82 years, not in the world as a whole but within a single city, Glasgow. The Commission states very clearly that "social injustice is killing people on a grand scale" and sets out a vision for closing the health gap between rich and poor in a generation.
The Commission made three broad recommendations:

  • Improve the conditions of daily life—the circumstances in which people are born, grow, live, work, and die Equity from the start; healthy places, healthy people; fair employment and decent work; social protection across the life course; universal health care;
  • Tackle the inequitable distribution of power, money, and resources—the structural drivers of the above conditions of daily life—globally, nationally, and locally Health equity in all policies, systems, and programmes; fair financing; market responsibility; gender equity; political empowerment—inclusion and voice; good global governance;
  • Measure the problem, evaluate action, expand the knowledge base, develop a workforce that is trained in the social determinants of health, and raise public awareness about the social determinants of health.

This is an ambitious but achievable agenda. The real question is whether the governments of the WHO’s member states will have the courage and determination to take it forward.

18th September 2008, Stockholm
To the
European Centre for Disease Prevention and Control. This was my first visit to ECDC, although we do work closely with colleagues there, most recently in our new book on the health system response to complex communicable diseases (primarily, but not only, HIV and TB). Unusually, this time we looked beyond Europe, drawing lessons from both Europe and another region undergoing political and economic transition, Latin America and the Caribbean.
I was there as a member of an expert advisory group on migration. The 2007 Portuguese EU presidency placed the health aspects of migration on the policy agenda and the ECDC is in the process of preparing a report on its consequences for communicable disease.
In some countries, in particular the UK, migration has become a highly politicised issue. Even though the UK has benefited enormously from migration (whether as assessed by the number of foreign born “British” Nobel Prize winners or the army of unrecognised workers who care for the elderly and disabled in our society), there are still shrill voices calling for ever tighter restrictions. These calls have, regrettably, been heard by the current government which has put in place a draconian process to limit the number of highly skilled migrants, as well as quite disgraceful treatment of asylum seekers fleeing persecution in other parts of the world. It has come under particular criticism for its inhumane treatment of children in families seeking asylum. These points are worth recalling as it is easy to overlook the reality that the major threats that migration poses to health are to the health of the migrants themselves.
The report is due out at the end of the year. It will focus on three areas, TB, HIV, and vaccine-preventable disease. However, what became clear from our discussions was the need for an extensive preamble, defining and categorising different types of migration and providing a conceptual framework to understand the health consequences of migration.
A major challenge will be collecting the necessary data. In part reflecting differences in laws on citizenship (at the risk of over-generalisation, there are two approaches – jus solis , where citizenship depends on where you were born, and jus sanguis, where citizenship depends on the nationality of your parents) and constraints arising from data protection legislation.
At the end of our meeting I gave a lecture on migration and health, entitled threats and opportunities. You can see a
short video on the ECDC website. It was an opportunity to recall that, even after the breaking down of barriers in Europe in 1989-91, we still live in a divided continent, inhabited by young and old and native-born and migrants. The European social system is, however, based firmly on solidarity. This solidarity owes much to the experiences of the 1940s, where even the most wealthy could be reduced to ruin when they became caught up in the conflict. Two recent books remind us that people of all nationalities suffered. These are Norman Davies’ Europe at War (in which he once again reminds us of the extent of Europe, in this case recalling the carnage on the Eastern Front), and Giles MacDonogh’s After the Reich (where he describes the horrors of the retributions visited on Germans after May 1945). The knowledge that you could go to bed rich but wake up poor ensured that the generation that survived would put in place arrangements to protect their fellow citizens from the consequences of illness and unemployment. This contrasts with the the USA, which has never managed to achieve universal health care coverage. There, those in power, who were overwhelmingly white, could be confident that they would never wake up black. The question we must face up to is whether our belief in solidarity is strong enough to survive the pressures of aging populations, increased migration (by those who are visibly different) and economic downturns. Unfortunately there are some worrying signs in many countries, with growth of extreme xenophobic parties. As Martin Niemoller reminded us over 60 years agoin his famous poem (First they came for...), this challenges everyone who believes in solidarity to speak out before it is too late.
17th September, 2008 Rotterdam
In Rotterdam for the initial meeting of our new EU-funded project Avoidable mortality in the European Union: towards better Indicators for the effectiveness of Health Systems (AMIEHS). Jointly led by Johan Mackenbach at Erasmus Medical Academy and us at LSHTM, with partners from France, Germany, Spain, and Estonia, it seeks to understand how the concept termed “amenable mortality” can be used as an indicator of health system performance.
The concept of amenable mortality was developed by Rutstein and colleagues in the 1970s. It was based on the premise that deaths from certain causes, and certain ages, that should not occur in the presence of timely and effective care. Subsequent work has expanded the list of causes of death considered amenable, reflecting advances in health care, and increased the upper age limit for these deaths, reflecting improvements in life expectancy. The concept has also been refined to include differentiation of causes amenable to the health care system and those to public health policy, while specific causes have been partitioned into the proportion to which reductions are attributable to primary, secondary, and tertiary actions.
In recent years, amenable mortality has undergone something of a renaissance. In part this reflects the much greater interest in performance of health systems, stimulated by the 2000 World Health Report, with improved tools being sought avidly by policy-makers seeking to determine whether they are getting value for money. An example was our
study showing that deaths from amenable mortality in the USA around the year 2000 had hardly changed at a time when other industrialised countries were experiencing substantial declines.
In its original conceptualisation, amenable mortality included some conditions where medical care could do little to prevent death once the disease process had occurred but where the onset of the disease could be prevented by health promotion activities. This is exemplified by lung cancer, where, it was argued, health professionals could be effective in preventing people smoking or encouraging them to quit. However, assuming they were successful, the deaths that would then be avoided would occur several decades later. Clearly, this is incompatible with the idea that contemporary rates of amenable mortality reflect the current performance of health systems. Hence, only those deaths than can be prevented by contemporary interventions should be included. The definition of contemporary is inevitably somewhat arbitrary but a period of five years has the attraction of consistency with the period used to assess what is popularly considered as “cure” in analyses of cancer survival.
The original list of amenable causes included causes of death that could be prevented entirely by health care and those from which some deaths would be inevitable but the number could be minimised. The former is exemplified by vaccine preventable diseases such as measles; the latter by ischaemic heart disease, where even in the best performing health care system, some deaths will be sudden and unobserved. However, there are also many causes of death not considered to be amenable where, in some circumstances, health care can be life-saving. This is true of many cancers for which a small proportion may be identified early, making possible curative treatment. An example is cancer of the pancreas. This begs the question of what proportion of deaths from a specific cause should be preventable for the cause to be considered amenable. This issue has previously been addressed only implicitly but it is now time to make it explicit. The figure is, again, somewhat arbitrary but we propose that a 50% reduction has the benefit of simplicity.
There are, however, a number of considerations to be taken into account. In some cases, reductions in mortality in this scale will be achievable with a single intervention. The term “magic bullet” recalls the dramatic benefits of penicillin when it was first given to patients with severe staphylococcal infections in the 1940s. More often, health care will prevent deaths through a combination of interventions that were introduced incrementally, perhaps over decades. In these cases it will be necessary to look at changes in death rates over considerable time, introducing the problem of attribution as it is necessary to exclude other explanations for observed changes.
It will be necessary to draw on a variety of sources of evidence. In some cases, there will be randomised controlled trials. However, these are most likely to exist for single interventions; they are much less likely where a combination of interventions is involved. Randomised controlled trials also face the problem of external validity, as they often exclude both children and older people, those with co-morbidities, and historically, women. Hence, it will also be necessary to draw on natural experiments, where it is possible to determine when new treatments were introduced. An example is the introduction of HAART for patients with AIDS, where death rates fell very rapidly. In other cases, even where detailed data are unavailable, it may be possible to infer the impact of health care where there has been wider system change. An example is the political transition in eastern Europe around 1990. The opening of borders to modern pharmaceuticals and ideas of evidence-based medicine made it possible to provide treatment that was previously denied to sufferers from many chronic diseases. Thus, in countries such as Estonia, there was a rapid decline in mortality from stroke, almost certainly as a result of better treatment of hypertension, at a time when such deaths were increasing in neighbouring Russia. It may also be necessary to look at historical evidence. Thus, conditions such as acute appendicitis became amenable to health care once the introduction of asepsis and anaesthesia made intra-peritoneal surgery possible in the late 19th century. Treatment of hypertension has a shorter history but has still been possible since the late 1950s.
In all previous studies, the definition of amenable deaths has had an upper age limit, reflecting the view that “everyone must die of something”. The age limit has increased over time, from 65 to 75, but this creates certain problems. The first is that it is explicitly ageist, as it devalues curative care for those aged over 75. The second is empirical, first because life expectancy in some countries now exceeds this figure but, second, as there is growing evidence that many types of health care are very effective in older people. If, however, the definition of an amenable cause is one where health care can reduce the death rate by 50% or more, then there is no intrinsic reason to have an upper age limit. Yet, while conceptually attractive, this also poses problems of obtaining evidence, first because older patients are often excluded from trials but, second, because the absence of an observed decline in mortality at older ages at a time when an intervention was being introduced may simply mean that this population was not offered treatment.
So far we have not addressed one of the most difficult definitional issues in assessing health system performance, how to define the borders of the health system. The
2000 World Health Report adopted an essentially pragmatic definition as it was necessary to include all of the WHO’s 193 member states, the majority of which had no functioning system f vital registration and certainly no possibility of ascertaining causes of death. As a consequence, it defined the health system extremely broadly. This included a range of inter-sectoral actions. It is, however, difficult t justify holding the health system to account for actions that others must take. For this reason, we propose that the boundaries must be drawn more tightly, to include interventions delivered by those working what is unambiguously the health care system but also those developed by public health agencies, such as immunisations and screening for cancer.
This is a three year project. What I have described above is only the first step, as we then need to show whether changes in amenable mortality actually do correlate with innovations in health care. If we are successful, this should be a valuable contribution to the debate on health system performance.
16th September 2008, Velden, Austria
Carinthia is a stunningly beautiful part of Europe. Its lakes, mountains, and traditional towns and villages make it an ideal holiday destination. Unfortunately my stay was for just over 12 hours but long enough to put it on the list for future visits. Situated in the south of Austria, it borders Italy and Slovenia and, since the 2004 enlargement of the European Union enlargement, links across these borders have strengthened greatly. This is especially true in the health sector, with the Carinthian authorities establishing a formal system of collaboration with colleagues in Slovenia and in the Friuli and Veneto regions of Italy. I was speaking at the
Austrian Health Economics Forum, sharing a session with my colleague Luigi Bertinato from the Veneto region. I was talking about the three way relationship between health systems, health and wealth (see Tallinn Conference) while he was discussing the changing nature of international health tourism. Veneto Region has been developing links with Dubai, where an international “medical city” is being built with the intention of attracting patients from across the world to what will be a first class medical facility.
Two weeks before I had been speaking about the Dubai venture on BBC World Service TV. I confess that I was not entirely optimistic. There is no doubt that there is a growing market for medical tourism but I’m not sure that Dubai can compete with the much lower costs in countries such as South Africa, India and Thailand. There is, of course, a potentially large American market, given the increasing unaffordability of care even for those Americans who have coverage. However, I’m not sure how many will be prepared to fly to he Arabian peninsula in the current political climate, especially when they can get care for rather less in Mexico.
Both in the presentations and discussions over coffee a key issue to emerge was that of quality of care. In Austria, as in many other countries with social insurance systems, it has proven extremely difficult t get the medical profession to engage in effective mechanisms to assess and improve the quality of the care they provide. There are, of course, lots of small scale individual efforts but there is still a lot of opposition to anything more systematic. As we have shown in our new
book reviewing the mechanisms to promote quality in all 27 EU Member States, Austria is not alone.
This is becoming an important issue at a European level. The proposed
framework directive on patients’ rights in relation to cross-border care will require that each country establish systems to ensure quality of care, and while they will be free to decide how to do this, future work is planned to monitor whether they are doing it (See our recent BMJ editioral). A further issue is the introduction, in a few countries of revalidation of the right to practice medicine. Again, this is something we have looked at in a recent paper and, in some more a detail, in a policy brief. Clearly this is an area where some discussion at a European level is needed, not least to ensure that the arrangements are workable (but also to ensure that they are not hijacked by bureaucrats who believe that the larger the pile of paperwork, the better the system (as seems to be happening in the UK)). Unfortunately, and as usual, the Commission’s DG Internal Market doesn’t agree. It invariably sees any attempt at regulation that would protect the public as a constraint on free movement. It is essential that its views are not allowed to prevail.
10-11th September, 2008 Tiberias, Israel
I was in Israel for a meeting of the International Advisory Board of the
Israel National Institute for Health Policy and Health Services Research and for the international conference that followed it. The conference was on the Public-Private mix in health care. The discussions were fascinating, reminding us of the many semantic difficulties in health policy. Specifically, could we agree on what we meant by public and private? This is of particular relevance in Israel, where the sickness funds are private bodies but operating within a statutory framework. Most of those representing them do not claim to be private organisations, rather seeing themselves as fulfilling a public role. Perhaps the only way to resolve the issue is to accept that some organisations have public and private dimensions and which predominates depends on the specific circumstances!
All health care systems are a product of history and, if one was starting from scratch it is unlikely that anyone would design them as they are now. Much of the discussion inevitably focused on issues facing the Israeli health system. Revital Gross provided a remarkably clear explanation of a highly complex financing scheme, where everyone is covered through the social insurance scheme yet where 80% purchase supplemental insurance from the sickness funds while 38% also pay for complementary private insurance. However, this was simplicity itself compared with the new Dutch insurance system, presented by Wynand van de Ven, which left many of us relieved that we didn’t have the choice that it offered, as the complexity of the many packages on offer seemed to test the comprehension of most of those present, that vast majority of whom had the benefit of tertiary education!
The conference was held in Tiberias, on the Sea of Galilee Its banks are steeped in history, from biblical times to the 20th century (it is overlooked by the Golan Heights). Over 200 m below sea level, the surroundings are beautiful and the warm water is fresh and clear (and I did manage to find some time to swim in it). Yet it also provides a warning. It is surrounded by jetties and harbours whose walls now tower over the stones that line its shores. Although it is difficult to tell, it seems to be about 8m lower than it once was, serving as a reminder that, ultimately, the survival of this region is dependent on one scarce commodity, water.

18-22nd August, 2008. Auckland and Wellington, New Zealand
New Zealand holds a great deal of interest to anyone interested in health policy and living in the UK. In both countries the executive has almost unchallenged power to introduce laws, with no need to build supportive coalitions at other tiers of government or with civil society organisations. This has many attractions for politicians – after all, why explain your decisions if you don’t have to. However, the absence of detailed scrutiny also makes it easy to enact unworkable laws, and then to revise them with ever increasing rapidity.
New Zealand acted as a health policy laboratory in the 1980s and 1990s, introducing market reforms that went well beyond those then being contemplated in the UK. The word “hospital” was no longer acceptable, being replaced by Crown Health Enterprises. They were intended to work like businesses but to continue to be socially responsible. Inevitably, those running them failed to resolve the contradictions. Many chief executives left. Costs increased rapidly, as did waiting lists. By 1996 the Treasury concluded that ““The health reforms have yet to yield the original expectations. By a range of measures … the pace of performance seems, if anything, to have been weakened since the reforms.” However, lessons were learnt. Those bits of the system that had worked were retained, especially Pharmac, the pharmaceutical purchasing scheme that ensures that New Zealanders get low cost drugs. However the purchaser-provider split was abolished and a new system was put in place in which health care was delivered by 21 district health boards. The most important lesson was the destructive effects of what can seem like endless attempts at reform. Reform fatigue set it and even though there is widespread agreement that the current system is not perfect, there is little appetite for structural change.
I was in New Zealand for a series of meetings, concluding with a conference entitled
“Building tomorrow’s health services”, held in a spectacular community and conference centre built in the form of an upturned Maori boat.
My trip included several meetings at the Minstry of Health in Wellington and a masterclass in Auckland. New Zealand’s health system faces many familiar challenges, including an aging population and the rise of complex non-communicable diseases, as well as some that are less familiar, such as a long-term redistribution of population, away from the South Island and into the greater Auckland area. It also experiences a high level of emigration of health professionals although, as we learnt, the emigration rate is not significantly different to other graduates. There is, however, a remarkably clear vision of what needs to be done, embracing prevention (and especially action to reduce the persisting inequalities between Maori and European populations) to integrated delivery systems.
In 1948 Aneurin Bevan, when asked to speculate about the forthcoming introduction of the National Health Service replied “do I need a crystal ball when I can read the book”. He was referring to the successful introduction of a health service in New Zealand a decade earlier. Could it be that English politicians will once again learn a lesson from New Zealand and place major structural chage on hold for a while to allow people to just get on with the job of delivering better care. Somehow I doubt it, but we can but hope.
3-8th August 2008, Venice
This year’s European Observatory summer school is on the “Hospital re-engineering: New roles, tasks and structures”. It draws extensively on our forthcoming book and we have, once again, been able to assemble a first class team to teach on the course, which is held in the idyllic setting of the island of San Servolo, close enough to Venice to be inspired by the view but far enough away from crowds of San Marco to allow for the reflection and contemplation necessary to exchange and absorb new ideas. As always, one of the greatest assets is the range of participants, collectively bringing a vast range of experiences that they are willing to share.
3rd July, 2008, London
Among the hundreds of thousands of words written about different health systems (and I confess that I can account for quite a few thousand alone) there is remarkably little describing what health professionals in different countries actually do. Although we have statistics on how long patients stay in hospital (themselves increasingly meaningless in a world dominated by ambulatory care), we know very little about what happens when a patient with a common medical or surgical problem comes into a hospital. Well, we know what happens in our own country but unless we engage in participant observation, either as health professionals or as patients, in a hospital in another country, we know almost nothing about how things are done elsewhere. Yet without this crucial information, it is difficult to see how we can say anything meaningful about how different health systems perform.
This was what prompted the organisation of a meeting by the
NHS Confederation and the European Observatory that brought together health professionals from countries such as Sweden, Finland, France, Germany and Italy to talk through a series of scenarios such as acute myocardial infarction and deep venous thrombosis. As expected, there were many similarities in how patients are managed but also quite a few differences, reflecting the organisation of care in each country. In particular there were differences in the extent to which care was centralised in specialised hospitals or dispersed, in the roles of different health professionals, and the extent to which quality of care was monitored. This is only the beginning of what will be a long process. We will next be using this approach to understand the delivery of child health services at a workshop at the EUPHA conference in Lisbon in November. I hope anyone that is interested in these issues will join us there.
25-27th June, 2008, Tallinn
At last, the culmination of over two years’ work. Health ministers and their representatives from the 53 Member States of the European Region of WHO have come together in a major
conference to discuss the links between health systems, health, and wealth. I’ve been involved in many aspects of this process, including writing some of the background reports, but here my task is to give one of the opening speeches, along with Mary Robinson, former UN High Commissioner for Human Rights and President of Ireland, and Uwe Reinhardt, from Princeton University. Both extremely hard acts to follow. If you want to see whether I succeeded you can watch a webcast of the speech on the conference website.
The framework underpinning the conference is a series of reciprocal relationships between health systems, health, and wealth. The first set of relationships are between health and wealth. It is obvious the greater wealth, whether at the level of the individual or a country, provides greater opportunities for health. People with more economic resources can make healthier choices in terms of what they eat, where they live, and how they spend their leisure. Countries with more economic resources can provide healthier environments. However, there is now a large body of evidence that healthier individuals and healthier populations contribute to greater economic growth. Healthy individuals are more productive and more likely to remain in the labour force. Historical studies show that much of the wealth of countries today is due to improvements in health over the last 200 years.
Health systems contribute to health, by preventing death and alleviating suffering. We can I quantify this through research using the concept of avoidable mortality, which measures the number of deaths that should not occur in the presence of timely and effective care. However better health also contributes to health systems, as healthier people have less requirement to use health care. This was the basis for at the analysis conducted by Sir Derek Wanless in his report to the UK Treasury, when he was asked to look at future expenditure on the National Health Service.
Wealth can contribute to health care as wealthier countries clearly have more resources to spend on modern medicine. On the other hand, health care systems can contribute to economic growth, especially at a regional level, where the provision of high-quality health care and support inward investment. Investment in health facilities can benefit the local economy, reducing unemployment, and thereby improving the health of the population, but only if it is structured in a way that enables local companies to bid for tenders on a level playing field with multinational corporations.
What we were trying to convey at the conference was not the detailed prescription for action, but rather a vision of where policy should be heading. We believe that it is possible to create a virtuous circle, with benefits for everyone.
Although there was a large attendance at the conference, and the background material is available on the Internet, we had recognized that there was a need to reach out to a much wider audience. Fortunately, as at the
Oxford Health Alliance meeting in Sydney in February, we were able to enlist the invaluable support of Eddie McCaffrey and his team at JooseTV, who not only webcast the entire conference, but also produced a series of news bulletins at the end of each session and in-depth interviews with some of the key individuals who were at the conference. If you watch nothing else, check out the film shown at the end of the conference that really captures the atmosphere of excitement and enthusiasm there. Once again, I conducted many of the interviews and you can watch them on the conference website. The opportunities provided by webcasting also allowed us to connect with the European Health Management Association conference, taking place at the same time in Athens, with a specially tailored interview. If we really want to communicate messages to a wider world, this is definitely the way to go forward.
20th June, 2008 Leiden, The Netherlands
I was privileged to be asked to speak at a conference of the
EUPHIX consortium. This team, led by colleagues at RIVM in The Netherlands, has done a remarkable job in creating a portal for information on health in Europe. In my speech I asked, somewhat tongue in cheek, whether with EUPHIX we needed Interail to see Europe’s rich diversity. The portal is much more than a directory of information. It includes software for mapping data (down to regional level) and manipulating it graphically. However, crucially, it is supported by extensive guides, helping users to understand the strengths and limitations of the data they are using.
18th June, 2008 Belfast
In Belfast for the launch of the new
Centre of Excellence in Public Health, led by Frank Kee at Queen’s University, Belfast. As a graduate of Queen's University, have been delighted to see the remarkable progress in academic public health under Frank’s inspired leadership. I was particularly delighted to see that the launch conference was opened by Northern Ireland’s Deputy First Minister and Health Minister, two individuals from different political parties who, not so many years, would not have spoken to one another. The Centre’s research programme recognises the importance of interlinkages between different disciplines and the need to translate research into policy. This is just what Northern Ireland has needed for a long time and it is certainly something to watch.
8-10th June, 2008 Washington DC
This year’s
AcademyHealth conference was held in the sweltering heat of Washington in June, a city where summer is always hot and sticky but which this year was experiencing what was, for it, a heatwave. A strong disincentive to leave the conference venue! With my colleague Bernd Rechel, we had organised a session based on our forthcoming book on hospital. This is the product of a collaboration between the European Observatory and the European Health Property Network.. After introducing the scope of the study, which draws on the most innovative ideas in hospital configuration and design from across Europe, we looked in detail at some of the most interesting examples. One was Northern Ireland’s regional hospital plan, which will create a network of hospitals offering different levels of care, primary care and rehabilitation facilities, and care in patients’ homes. Another was the Orbis Medical Park, near to Maastricht, in The Netherlands, where a new hospital is being designed to support clinical pathways and processes rather than, as is more usual, ignoring them. The third was the Alzira Hospital in Valencia, Spain, which has implemented a new financing model that was initially quite problematic but is now working well, in contrast to the UK’s Private Finance Initiative, which is now suffering what seem to be terminal death throes.
As always, many of the presentations at the conference focused on the problems that arise when you fail to provide universal health coverage. A growing number of states are now taking initiatives themselves, typically by requiring people (and their employers) to purchase insurance schemes. However, for a European the overwhelming impression is of just how complex these schemes are, and also how many holes there seem to be in them. It is difficult to see how any of them will ever really work without addressing some of the reasons why health care is so expensive in the USA, in particular the high cost of pharmaceuticals and the huge administrative costs of maintaining a multi-payer system.
There is, of course, an election coming up but it is not obvious that either candidate has a solution. What’s more, we heard that health reform is not high on the concerns of ordinary Americans, and is training far below where it was when Hilary Clinton attempted to do something in the early 1990s. Instead they are concerned about the economy and the wars in Iraq and Afghanistan. Yet this may change, as manifest by the growing evidence that people are having to cut back on expenditure to meet health care costs. Something must be done sometime, but I suspect things will have to get a lot worse before they get better.
4-5th June, Izhevsk, Russian Federation
Izhevsk, a city on the European side of the Urals, is the setting for a major Wellcome-funded study we are undertaking to understand the high level of adult mortality in Russia. Readers of this blog will be familiar with our earlier work highlighting the role of alcohol. In our current work, and in previous work in other parts of Russia, it has become clear that we are facing an enormous problem of untreated hypertension. The Soviet Union never managed to deal effectively with chronic diseases. It never developed a modern pharmaceutical industry and, even if it had, it would never have been able to distribute the drugs that those in the west take for granted and which, when taken regularly, can be life-saving. Now the drugs are available and the distribution system is in place, but we still face two problems. First, those taking drugs as outpatients have to pay for them. As they are often much more expensive than in the west because of mark-ups along the supply chain they are often effectively unaffordable. Second, there are very low expectations as to what can be achieved, so that physicians seem content to leave patients untreated even with what we would consider dangerously high pressures. This should be an entirely soluble problem but I suspect it will take some time to resolve it.
27th May 2008, Lausanne
This was my second year teaching on the course run by Alberto Holly in Lausanne. The title of this year’s course was “Mastering the new challenges of health care”. There is a wonderfully diverse mix of students, making the discussions especially rich. My sessions were on health system performance and the future of health care. These are both topics I have spoken about many times before. Predicting the future is never easy. A few have managed it successfully, such as Jules Verne and HG Wells, but even they recognised their limitations and, as far as I know, never staked their fortunes on the outcome of a horse race! Yet there is one thing that we can be fairly certain about, and that is that health care in the future will be much more complex than it is now, with aging populations suffering from multiple disorders, each interacting with one another, with their ability to function secured by a complex mix of medicines that have never been tested in combination, and especially in people with impaired liver and kidney function. This poses real challenges for modern health systems, something Ellen Nolte and I will be looking at in our new book on the health system response to chronic disease, due out in September.

Wednesday, May 07, 2008

I’ve been thinking a lot about two words, governance and stewardship, recently. In part this is because, with Josep Figueras, I’ve been working on the text for the Tallinn Ministerial Conference but also because I’ve been teaching about it to our MSc students. I’m grateful to one of my PhD students and to my MSc seminar group for the examples I’m going to use in a minute.
The problem with both of these words is that everyone seems to use them differently. A quick search on Google reveals dozens of definitions of governance; stewardship, a term that came into widespread use following publication of the 2000 World Health Report, has received less attention but it is also clear, listening to it being used, that it can mean all things to all people. As always with health policy, I take comfort from Lewis Carroll’s book, Alice’s Adventures in Wonderland, where Humpty Dumpty says “words mean what I choose them to mean”.
Yet maybe we can turn it round. We may not know what (good) governance and stewardship are but we do know when they are absent. Hence the two examples from my students. One concerns a new EU member state. As with any newly acceding country, its accession was conditional on putting in place an extensive body of modern laws. One of these laws concerned mental health. Yet although the law was passed, no resources or personnel were made available to implement it. No-one was accountable for failing to implement it. Indeed, it was very clear that it was never meant to be implemented. Simply passing it served a purpose and it could now be ignored. This is a failure of governance.
The second example is from the UK. A previous English Secretary of State for Health was confronted with a situation where, having put in place a new system of postgraduate medical training, it was clear that a flood of applicants from outside the UK would leave several thousand British doctors with no job. She issued an instruction that non-EU doctors would be ineligible to apply. The British Association of Physicians of Indian Origin sought judicial review and in a scathing
judgement the Law Lords supported them. They noted that the Secretary of State had it within her power to change the rules by bringing a motion before parliament. Clearly wanting to avoid controversy, she failed to do so, instead simply placing a notice on a web site of the NHS Employers organisation. This, Lord Bingham noted “was to suggest a degree of official formality that was notably lacking”, going on to state that “it is for others to judge whether this is a satisfactory way of publishing important government decisions with an impact on people’s lives”. This too is a failure of governance (and as I have argued before, far from exceptional in the UK in recent years).
Of course, these are not unique, and maybe we need to think about assembling a collection of such examples from across Europe. Even if we are unable to define what good governance and stewardship are, we will at least be able to know when they are missing.

Tuesday, May 06, 2008

Copenhagen, 30th April
To Copenhagen, for the European consultation on the forthcoming Ministerial Conference on Health Research that will be held in Bamako, Mali, this November. I’ve been engaged with this process for a while, through WHO EURO.
The conference follows on from one held in Mexico City in 2004. It will be important as it will contribute to the agenda for global health research in the next number of years. Hence, it is essential to get it right.
My concern is that we risk losing sight of the fact that it is a global conference, albeit one that is, in part, focused on Africa. I don’t want to diminish for one second the enormous need for health research in Africa and, in particular, the importance of building research capacity there, but we should not forget the needs of the rest of the world.
Last November, we organised a consultation on European priorities for Bamako at the conference of the European Public Health Association (later published in the
Eur J Public Health). We highlighted three priorities for research in Europe (on top of the ones that will be included anyway because of their global reach, such as tobacco and HIV). These were migration, aging, and alcohol, while we also flagged up the contribution that Europe could make to the rest of the world in research on complex chronic disorders, which will be the real challenge for everyone in the future, whether we are talking of diabetes or HIV or something else.
This time we were looking more widely, and the Danish Foreign Ministry had brought together what seemed to be over 100 people in their very attractive conference on the sea front in Copenhagen. I was arguing, in a panel discussion, that the health systems framework we will be using in the forthcoming Tallinn conference bears closer inspection. It highlights the beneficial reciprocal relationships between health systems, health, and wealth. Beyond that, I think we have three questions about capacity that are of concern to those of us working in Europe.
  • First, how can we get the basic data in place, by which I mean regular health examination and health interview surveys, that are comparable across all of Europe? These are being developed but we are already so far behind the USA.
  • Second, how can we establish better links between research and policy? Obviously I would say that the European Observatory is a good model but we also need to learn much more from the Canadians with their knowledge brokers.
  • Third, how can we build up research capacity in our own neighbourhood. Research capacity in many parts of the former Soviet Union or in the Middle East or North Africa is far weaker than in countries like Uganda or Tanzania.
So at Bamako I hope that Africa does get attention – it deserves it. But we should not forget the rest of the world.
April 29th
To the Royal College of Physicians for their conference on Global Health. I was asked to speak about international trade and health so I chose as my title “Opium, tobacco and alcohol: the evolving legitimacy of international action”. My argument went as follows. We all agree that, in most cases, international trade brings great benefits. Each country does things where it has a competitive advantage. I enjoy mangoes but it would be a bit silly of me to try to grow a mango tree in my garden in north London (although with global warming you never can tell). Yet there is a down side. The problems arise when what are being moved around the world are not the usual “goods” but rather “bads”. Few people really think that flying tons of AK-47s into the Democratic Republic of Congo is a good idea (except of course those doing the flying and those supplying them from places like the Trans-Dneister republic – see Misha Glenny’s new book - McMafia: Crime Without Frontiers ). Similarly, landmines are now fairly universally regarded as a “bad”. But what is it that changes a “good” into a “bad”?
I began by looking at one of the best known examples. In the middle of the 19th century British forces went to war with China (twice) to protect our right to sell opium to China. China certainly didn’t want it – it realised that it was causing harm to its population and even threatened to retaliate by banning exports of rhubarb to Britain, in the hope that this would inflict widespread constipation. Yet it was the opium harvest that lay behind the economic success of now British Bengal. Over a century later we were still at it, as Christopher Bayly describes in his excellent
book on the British withdrawal from SE Asia, as we imported massive amounts of opium to ensure that the Malayan population kept working even though there was no food. Yet now the Royal Navy patrols the high seas, interdicting cocaine smugglers in the Caribbean (and anywhere else it can find them). What turned us from a trafficker to a policeman?
The same sort of change is taking place with tobacco. Here we have a product that has killed more people than all the wars of the twentieth century yet we (or at least our political leaders) still treat the manufacturers and distributors in the same way as people who make things that actually benefit us. It really is remarkable. These people are peddling their deadly products to children all over the world in a way that is really no different to the traffickers who hand around school gates trying to hook kids on heroin. Yet while no-one would invite the drug traffickers to be photographed with our political leaders, there seems to be no barriers for tobacco company executives. In the past, when countries such as Thailand stood up to the USA and said that they didn’t want tobacco imports, the USA threatened trade sanctions. Imagine what would happen if Bolivia took the USA to the World Trade Organisation for blocking exports of cocaine (although, again, anything is possible).
Except, there are some signs of hope. The
Framework Convention on Tobacco Control does make clear that tobacco is not just another product and that governments can put in place a range of measures to counteract the aggressive marketing of tobacco without being accused of erecting non-tariff barriers. So tobacco is steadily being transformed from a bad to a good.
What of alcohol? Obviously this is more difficult as moderate consumption is clearly good for you, providing you are at risk of heart disease (if you are under 40 you are just kidding yourself – the net effect is harmful, sorry). Yet the alcohol industry seems to be doing everything possible to move into the corner with the makers of “bads”. Recently (as I described in an
editorial in the BMJ) when discussions on a European alcohol policy were taking place, the Brewers of Europe published a remarkable report purporting to show that there really was very little evidence that alcohol was at all harmful. They commissioned it from the Weinberg Group, a consulting firm that had previous tried to convince us that the health effects of smoking were exaggerated and that Agent Orange was not such a bad thing after all. Their report argued that that "there is not enough evidence to substantiate a link between alcohol advertising and consumption," raising the question of why the industry spends so much money promoting its products, and that "violence is a subjective term which is fairly nebulous and elastic," a view unlikely to be shared by someone scarred by a bottle wielded by a drunk. Clearly, if the alcohol industry continues with tactics such as this, it cannot be surprised if we begin to consider the need for concerted international action, building on the experiences with narcotics and tobacco.

Sunday, April 27, 2008

My second trip to Brussels this week. I was with my colleagues Christian Haerpfer and Alexander Chorostov to begin negotiations with the European commission on our new FP7 project, Health in Times of Transition: Trends in Population Health and Health Policies in CIS Countries. This is a follow-up to our earlier project entitled Lifestyles Living Standards and Health. In it, we conducted household surveys in eight former Soviet countries, providing important new information on topics such as tobacco and alcohol consumption, access to safe water, and use of health services. In the new study, we will be expanding the household surveys to 11 countries, covering the entire Commonwealth of Independent States with the exception of Turkmenistan. We will also be undertaking a number of community profiles to understand better the circumstances in which people live, in particular their access to different forms of food, the extent and nature of tobacco marketing, and their access to healthcare. We are hoping that the project will begin in November 2008 with the first survey data being collected in early 2010.

Footnote: I read that the UK government is planning to introduce a new
facial recognition system “to reduce delays at immigration in British airports”. This news simply confirms to me that the Home Office is viewed as an incredibly soft target by anyone with a computerised gizmo that no-one else is stupid enough to buy. When it was introduced, I enrolled in the IRIS system, which was a complete waste of time. The system is frequently out of order and, even when it is working, it is so slow that it is quicker to use the ordinary queue. I was reading about the new system as I was getting on the Eurostar at Brussels, where one must show one’s passport to Belgian officials and then again, about 10m further on, repeat the entire process with the British (only more slowly as it is clear that their computers are creaking under the weight of data from the new biometric passports. If the government really is interested in reducing queues at immigration, there is an obvious solution. Join the Schengen Agreement like the rest of Europe!
To Brussels, for a meeting of the steering committee of the European Observatory. It has been an incredibly busy year, beginning with the publication of our book on cancer in Europe and continuing with intensive preparations for the Ministerial Conference on Health Systems in Tallinn in June.

It is always nice to know that one is appreciated, so it was a great pleasure for us all when the Observatory was recognized in an award schema that had been launched by the World Bank for initiatives that improve the lives of people living in Europe and Central Asia. A total of 19 awards were made, most for projects within countries, such as the restoration of the famous bridge in Mostar, in Bosnia, that was destroyed during the war, or an AIDS control project in Moldova. The Observatory was recognised by a multi-country award. The picture shows Armin Fidler, who had previously accepted the certificate from the president of the Bank, in Washington, handing it on to Charles Normand, the chair of our steering committee, and accompanied by Josep Figueras, Director of the Observatory.

Friday, April 18, 2008

17-18th April 2008, Riga, Latvia
We are here for a meeting of the
EURO-PREVOB project. This is seeking to develop a methodology to map policies, both “on the books” and “on the streets”, that can address the increasing problem of obesity in Europe. We are interested in policies that influence both energy intake and expenditure, in other words, nutrition and physical activity. With support from the WHO, we were joined by many of the leading experts on food and physical activity from across Europe, who provided extremely valuable inputs into our thinking.
We began with a series of presentations that brought us up to date with developments in this field.
Liz Dowler reminded us that, as we think about access to healthy food, we need to think about whether it is culturally appropriate food in an increasingly multi-cultural Europe. Mike Rayner reminded us that marketing involves 4 Ps: product, promotion, place, price. Effective action must address all of these. A key issue we need to address is food labelling. Although almost everyone has signed up to the need for labelling to inform the public, some companies are working hard to avoid the use of traffic light systems – red for danger, green for healthy – for the obvious reason that their products would have a line of red splodges. Instead they are pushing for more complex labels, often on the back rather than front of packs, that the public finds confusing (see link for UK Food Standards Agency evaluation). Mike also reported some very interesting evidence on the effects of so-called “fat-taxes”, or more generally increased taxes on unhealthy foods. In fact, in the EU, many foods are already taxed – in the UK there has been a very interesting legal action recently to decide whether a marshmallow is a cake or a biscuit, with very considerable financial implications for the Treasury. The question is whether the existing somewhat confused and contradictory regime can be refined to incorporate a health dimension. What the research showed was that simply taxing unhealthy foods would actually increase deaths. What is needed is an integrated policy that is linked to subsidies for healthy foods.
Tim Lobstein then took us through the tactics that are being used increasingly to market food to children. He reminded us of a study that looked at the range of foods marketed to children. Some products were low in fat (but high in sugar), some were low in sugar (but high in salt), so that only 1% of products were actually low in salt, saturates, fat and sugar. In other words, virtually all food aimed at children is junk.
Any parent will be familiar with some of the more obvious methods used to persuade children to consume energy dense foods, such as McDonalds’ Happy Meals, otherwise known as “edible entertainment”. Many of these products give away sets of toys, with the sets changing regularly to encourage children to eat enough to get the whole set. Then there are the links to “good causes” where companies distribute tokens that can be exchanged for school sports equipment and the like. We were reminded of Cadbury’s tokens, whereby, if one managed to consume 20,000 kcal of chocolate, one could get a netball. Then there are the companies offering free logos and ringtones for mobile phones, and of course once the numbers are logged, the children can be bombarded with advertising text messages. Or the books where children learn to count by placing M&Ms on pictures, no doubt eating a few as they do. It is clear that the regulators are many steps behind the industry.
So what is to be done? We were meeting in Latvia, a country where, unusually, the government has taken a strong stance against additives and colouring in food aimed at children. Leaving aside the emerging evidence that some additives may have harmful effects on children’s behaviour, we are faced with a situation in which colourings are used very extensively simply to make otherwise unattractive (and unhealthy) food attractive to children. There seems a strong argument for banning their use in food aimed at children.
So back to the project. Essentially, if we want to understand existing policies in a country, how they relate to needs, and the scope for further development, we need quite a lot of information. We will be focusing, first, on the “law on the books”. The idea is to identify a national focal point in each country who can convene a group of knowledgeable informants who can tell us about what policies are in place. Of course, that is just the first step, so we need them to tell us not only whether a policy exists but also whether it is written down , whether there are financial and human resources identified to implement it, and whether there are systems for monitoring, evaluation and accountability. The second focus is on “law on the streets”. Here we have to develop a means to capture what is happening in reality. Do the foods on sale in shops have nutritional labels? Can people afford to eat a healthy diet (and can they get to the shops that sell it)? Does the layout of the streets force people to use their cars or to walk of cycle? Finally, drawing on Marx’s comment that “the philosophers have only interpreted the world, in various ways; the point is, however, to change it”, we need to identify who the key stakeholders in a potential new policy might be, what their positions are, their interests, and their influence. We have a lot of work ahead of us!
17th April 2008, Flying from Tallinn to Riga
A short flight down to Riga. The Baltic States are now in the Schengen zone so no need to go through immigration, unlike the ridiculous situation when entering the UK, whose government continues to emphasise its semi-detached relationship with the rest of Europe.
I read in the in-flight magazine an article by Bertolt Flick, the CEO of
Air Baltic, that there is some prospect that the EU might get rid of the ban on liquids in hand baggage. He writes that he has serious doubts that they ever contributed to safety. So he should. As anyone with a moderate knowledge of chemistry will know, this policy is devoid of any basis in evidence (surely if it was so easy to make explosives from household liquids we would be seeing bombs going off in European capitals every week?). We must thank the European Parliament, whose members have been asking some quite penetrating questions (even if the European Commission has failed to answer them, citing secrecy – the argument of the truly desperate). The Parliament is pushing through long-awaited legislative measures to bring some basic common sense to the often bizarre array of security measures that simply serve to make air travel in Europe even more awful than it would otherwise be. However, I am not holding my breath. This will involve some governments admitting that they got it seriously wrong and, given that some still believe there are WMD in Iraq (and also presumably fairies at the bottom of their gardens), this may take some time.
15-16th April 2008 – Tartu, Estonia
Estonia has, in many ways, had a very successful transition from communism. Its economy is growing rapidly (somewhat faster than its neighbours Latvia and Lithuania), it has maintained a high level of fiscal stability, and its markets are now closely integrated with the rest of the EU. It has made remarkable progress in reforming its
health care system, introducing a very effective system of primary care, it has managed to restructure its hospital system very successfully, and has a health insurance system whose income and expenditure are in balance. These largely reflect the efforts of a number of extremely talented young Estonians (hope you are reading this, Maris and colleagues). Their achievements stand out in a region that has struggled, often unsuccessfully, to bring about much needed changes to health care systems.
Yet there is still some way to go, both in terms of economic progress but more importantly in terms of health. Life expectancy at birth for Estonian women lags behind that in Sweden by over 4 years; for men the corresponding figure is a massive 11 years!
Things are improving. Indeed, Estonia has managed to achieve sustained increases after 2005 at a time when Latvia and Lithuania have experienced what are hopefully only temporary setbacks. One area where there has been a marked improvement is in deaths from stroke, almost certainly reflecting the reform of Estonian primary care and resulting improvements in the treatment of high blood pressure. This is at a time when Lithuania has actually seen a slight worsening in death rates. There have been other achievements, most notably the successful implementation of a ban on smoking in public places (something I argued for in the Estonian paper Eesti Päevaleht in December 2004 (
Tubakasuits tuleb laiali ajada. Eesti Päevaleht). Yet there is one area that stands out because of the complete absence of a policy – alcohol. Like all countries that emerged from the USSR in the early 1990s Estonia has long had a problem with alcohol. Spirits are cheap and easily available (despite some local efforts to reduce the possibility of buying them late in the evening). As we showed in a recent study, aftershaves and medicines containing high concentrations of alcohol are sold widely, in the knowledge that they are being drunk. In a second study we showed that the main outlet is street kiosks, which sell an eclectic mix of aftershaves, pet food, washing powder, and condoms. One result is that, at a time when mortality overall has been falling, deaths from liver cirrhosis have been rising, to a level that is now three times higher than in 1990!
This provides the rationale for one of our research projects in Estonia. Working with Katrin Lang, Marika Väli, and Kersti Pärna and other colleagues at the University of Tartu, we are trying to understand better the role played by alcohol in premature deaths in Estonia and, in particular, the role of alcohol in sudden cardiac death, something that is still imperfectly understood. We should begin to have enough data to draw some conclusions in about 18 months.

Wednesday, April 09, 2008

Five years ago the University of Crete established a postgraduate training course in public health. I’m here at the invitation of the course director, Professor Anastas (Tassos) Philalithis, to join in a review of the course, accompanied by colleagues from the UK, Sweden, and Canada.
Public health has not, traditionally, been strong in Greek universities (the Athens School of Public Health is part of the Ministry of Health, not Education). The creation of the course was therefore a very welcome development. In the short time that it has been going, it has attracted large numbers of students (and also attracted some very talented staff who had been working abroad). The Medical School here at the University of Crete has a spectacular modern campus, with a view of the mountains and sea that must inspire great thoughts! Although we are only half way through the process, we have had a chance to talk to the extremely motivated students and to look at their dissertations , all of which are very impressive.

Crete has a special place n the geography of public health. Cretan researchers participated in the landmark
Seven Countries Study. The study recruited men aged between 48 and 59 and followed them up from 1958 to 1970. At that time, remarkably little was known about the causes of cardiovascular diseases. The Seven Countries Study was far ahead of its time, using standardised data instruments and analyses. It included countries with some of the highest and lowest mortality rates known anywhere at that time. By comparing risk factors in Karelia with those in Crete, the research team discovered the key role played by diet, in particular lipids, in the genesis of this disease. In due course this study, along with others, would confirm the status of the traditional Cretan diet, with its olive oil and high levels of fresh fruit and vegetables, now considered the healthiest anywhere in the world.

Of course, Crete is a Mediterranean island, benefiting from the Mediterranean climate and culture. The main square in Heraklion has a reminder of this shared culture, with a bust of one of it’s most famous sons, Doménicos Theotokópoulos, better known as El Greco. Although born here, he spent time in Venice and Rome before finally settling in the Spanish city of Toledo, where many of his greatest works were painted.

Unfortunately, as in other parts of the Mediterranean, the traditional Cretan lifestyle is under threat from the forces of globalisation. The diet is giving way to fast food, the growth of motor vehicles is reducing the amount of physical activity that people take (and leading to an enormous number of premature deaths from traffic injuries, in part because of a widespread rejection of the concepts of seatbelts and motorcycle crash helmets), and obesity rates are increasing rapidly. However, perhaps the greatest problem, and the one that can be addressed most easily, is the high rate of smoking.
I watched someone smoke three cigarettes, one after the other, at breakfast in the hotel yesterday morning. Every bus shelter has large advertisements for cigarettes, clearly designed to attract new smokers among Cretan adolescents. As the pictures here show, there are health warnings but they are very difficult to see. The result – death rates from cardiovascular disease and cancer are now rising in Crete and, as we showed in a recent paper looking at regional patterns of mortality in the Mediterranean countries, in many other places that traditionally had a health advantage.
The tragedy is that many Greek politicians do not seem to have understood what is happening to the health of their population. The public health service remains focussed on traditional hygiene. There is still no proper career structure for public health professionals. Although there are some world class public health researchers, they have so far had to go abroad for their postgraduate training and many have not returned. There are few funds for research training, except those available from the European Union. The health insurance funds, that might be expected to show some interest in preventing illness and ensuring that the care they pay for is effective, take little interest as, when faced with rising costs, they simply increase their deficits and from time to time ask the government to bail them out. Until now the gods have been kind to the Greeks, blessing them with a long life expectancy. It was easy to believe that a modern public health workforce was a luxury. Hopefully, before it is too late, Greece’s political leaders will realise that it is not. When they do, the University of Crete is well-placed to rise to the challenge.

One of the things I enjoy about Greece, as a non-Greek speaker, is spotting the many words of Greek origin that have made it into English. The emergency exits in the university bear signs labelled “exodus”. The labels on the fire extinguishers begin with “pyros”. The wings of the university building are Pteriga (as in Hymenoptera – bees and wasps – or Pterodactyl (wing/ fingers)). I was therefore fascinated to learn from Tassos that, back in the 1950s, Xenophon Zolotas, an eminent Greek economist, had developed the art of making speeches to the international financial bodies, ostensibly in English but using virtually entirely words of Greek origin. One of his speeches, to the IBRD, is reproduced here. Another can be found by clicking on his name above.
I always wished to address this Assembly in Greek, but realized that it would have been indeed "Greek" to all present in this room. I found out, however, that I could make my address in Greek which would still be English to everybody. With your permission, Mr. Chairman, l shall do it now, using with the exception of articles and prepositions, only Greek words.
Kyrie, I eulogize the archons of the Panethnic Numismatic Thesaurus and the Ecumenical Trapeza for the orthodoxy of their axioms, methods and policies, although there is an episode of cacophony of the Trapeza with Hellas. With enthusiasm we dialogue and synagonize at the synods of our didymous organizations in which polymorphous economic ideas and dogmas are analyzed and synthesized. Our critical problems such as the numismatic plethora generate some agony and melancholy. This phenomenon is characteristic of our epoch. But, to my thesis, we have the dynamism to program therapeutic practices as a prophylaxis from chaos and catastrophe. In parallel, a Panethnic unhypocritical economic synergy and harmonization in a democratic climate is basic. I apologize for my eccentric monologue. I emphasize my euharistia to you, Kyrie to the eugenic and generous American Ethnos and to the organizes and protagonists of his Amphictyony and the gastronomic symposia.

Thursday, March 13, 2008

12th March: Ljubljana

Slovenia will have a general election in September. Health care is rising rapidly on the political agenda, largely because of the high share (about a third) of health expenditure now being paid directly. The Slovenian health financing system has a large co-payment element, which many people cover through complementary insurance but others pay out of pocket (See HiT profile).

I was invited to talk about the roles of planning and markets in health care, with particular reference to the UK. My host was the Friedrich Ebert Stiftung, a German foundation that supports dialogue on public policy issues.

The starting point was that markets have clearly delivered many benefits. No-one now would want to go back to the centrally planned system for distributing food in the Soviet Union. The question is whether the conditions for markets to operate apply in health care? Another issue to consider is the differing goals of the various actors. Governments seek to improve the health of their populations, to respond to their legitimate needs, and to do so fairly (or at least they should – this is the WHO definition). Private companies are legally obliged to maximise the returns to their shareholders. These goals may overlap, but it is unlikely that they will overlap completely.

Health care is not a commodity like baked beans, apples, or widgets. It has certain features that make it special. Many people who need care don’t realise it. Even if they know they need something, they may not know what. They are easy prey for unscrupulous providers. This is what we call information asymmetry. It is not only people who are ill who have an interest in being treated. The rest of us also have an interest. This is obvious where they are suffering from infectious diseases, which may infect us, or mental health problems that may lead them to harm us. But simple concern for others also leads us to want to see their suffering relieved – what we call externalities.

Then there is the changing nature of disease. Markets are fine where the transactions are simple, as was once the case in medicine, where an individual patient would go for a single visit to a doctor, who would make a diagnosis (often wrong) and prescribe treatment (often ineffective). The patient either got better or died. The situation now is quite different. A typical older patient may have arthritis, Parkinsons Disease, heart failure, bronchitis, diabetes, and depression. They go to their family doctor. They are then referred to a series of medical specialists, nurses, other health professionals, all working together in a network, collaborating with each other. They receive multiple powerful and effective medicines, all of which are affected by their organ function and by the other drugs they are taking (which will never have been evaluated in combination). They remain under continuing review for the remainder of their now active and fully engaged life. This is seriously complex and someone has to manage it. Unsurprisingly, private providers will run a mile from patients like this. Instead they concentrate on straightforward non-urgent surgery, where the costs are largely predictable, and if they do venture into chronic disease management, they select those people who only have one disease and are otherwise healthy. The public sector picks up the rest – what we call cream-skimming.
But does this matter, as long as everyone can get treatment somewhere? It can do. Think of situation where a family is injured in a high speed car crash. They arrive at an emergency department. There is no paediatric service – it has been moved into the community. Their eye injuries cannot be treated as the ophthalmologists have been relocated to an independent treatment centre to concentrate on waiting lists for cataracts. The complex hip fracture cannot be treated, because the orthopaedic surgeons have been relocated to an independent treatment centre to concentrate on waiting lists for knee replacements. There is no microbiologist to speak to about the wound infection because the service has been privatised and moved 200 km away.
However, perhaps the greatest challenge relates to preparing for the future. As Donald Rumsfeld famously said “there are known knowns; there are things we know we know. We also know there are known unknowns; that is to say we know there are some things we do not know. But there are also unknown unknowns, the ones we don’t know we don’t know. And … it is the latter category that tend to be the difficult ones.” So when we are thinking about the competing strengths of public and private provision, a key issue must be which allows more flexibility to adapt to future challenges. Then there are the things that we can predict, such as the need to train the next generation of health professionals and the need to engage in research and development to generate new knowledge. Again, we need to ask which is better at investing in these future needs.

Taken with the conventional questions such as value for money, this then gives us a framework for looking at two of the developments that have taken place in the UK, the Private Financing Initiative (PFI) (as a means of funding new hospitals) and Independent Sector Treatment Centres.

It is now apparent to all but the most ideologically driven commentators that the UK PFI scheme has been a failure. Allyson Pollock has provided most of the evidence in a series of papers, in the process exposing herself to vicious personal attacks from the supporters of PFI (or in some cases from backbench Members of Parliament who probably never understood the issues but were doing what they thought might be appreciated as they sought to advance their careers). She has shown how the procurement process is expensive, complicated, and prolonged. One result is that several projects have been abandoned at an advanced stage, wasting millions of pounds. Several of the hospitals that have been completed have suffered major quality problems. However, for us the real problem is the inflexibility (see our paper in the Bulletin of the WHO). Because the contracts are negotiated in so much detail, it is virtually impossible to change the specifications, even though we know that the nature of health care is changing rapidly. One example is the ratio of operating theatres to beds. With short acting anaesthetics and minimally invasive surgery we need more of the former and less of the latter. Yet some recently completed hospitals (including one close to where I work) are already obsolete in his respect by the time they open. The accompanying picture illustrates the problem. Given the declining need for beds, a newly built hospital now may have too few (an example is the now notorious Norfolk and Norwich hospital PFI scheme). However, in 30 years time it will have too many. The situation is worse for schools. There are now quite a few examples of schools built under the PFI scheme that are now surplus because of falling birth rates (see article in the Guardian). Yet the local governments still have to pay for them to be maintained for the next 30 years, at a cost of millions of pounds each.

The Independent Sector Treatment Centres raise different issues. Here the evidence is rather less, largely because they have consistently failed to supply the data that were required from them. Consequently, a cartoon accompanying one of Allyson Pollock’s paper in a recent issue of the BMJ compared them to a black hole, with money and patients being swept into them but no idea what happened afterwards. One problem is cream-skimming. They only take the straightforward cases, leaving the NHS to look after the rest. Yet bizarrely, give the lower costs that result, the government pays them 11% more per case! (and this is on top of various other subsidies plus a guarantee to buy back the premises at the end of the contract). It then doesn’t even check whether they have performed all the procedures they have been paid for – a reasonable estimate is that they have performed about 70% of the contracted work but of course they received 100% of the payment.
Now I am not saying that markets have no place in health care. Of course they do. All that we have to do is ask whether, in a particular set of circumstances, the prerequisites for a market exist and then whether it will actually deliver what it promises. Fortunately, I don’t have to answer that question for the Slovenian population!

Footnote 1: Credit where credit is due. On Tuesday evening I passed through Terminal 2 at Heathrow. This is normally a deeply unpleasant experience, reminiscent of Douglas Adams’ comment about being drunk, as experienced by a glass of water. Amazingly, I got through security in only a few minutes because there was a security supervisor who was actually managing the process. No-one should underestimate the importance of this development. Could it be that the executives of the British Airports Authority have finally realised that they are meant to be managing an airport, rather than a shopping mall? Somehow I doubt it. Terminal 5 opens in a few weeks and we already know there will only be enough seats for about two jumbo jets’ worth of passengers, presumably with the intention of forcing people wanting a seat to buy food and drink from the many commercial outlets. No. I suspect that this was just an individual who takes pride in his job. I fear he won’t last long.

Footnote 2: I returned through Terminal 2 at Frankfurt. A 20 minute queue to get through security, having been screened only 90 minutes earlier at Ljubljana. It’s close, but in the competition to become the most incompetent airport operator, Frankfurt seems to be drawing ahead.