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In their 2023 International Health Policy Survey, the Commonwealth Fund think tank has examined the variation between 9 high-income countries (both tax and insurance based) based on how income disparities are impacting upon the affordability of and access to services.
Overall, the UK performs best of the compared countries, with 16% of low- or average-income adults skipping or delaying the care they need due to cost, equal to the Netherlands, Germany and France. However, the UK fails to perform as well as these three nations on access to dental care, with 28% of low or average, and 25% of high-income adults reporting skipping dental care due to cost. This is likely due, in part, to the wide coverage of insurance for dental care in these countries.
To a lesser extent, and despite mental health care covered by the NHS, the UK also performs worse than comparator countries on cost posing a barrier to accessing mental health care, with 10% of low and average income and 7% of high-income adults not accessing care due to cost – double the instance seen in Germany.
For all countries surveyed, the access difference between high-income and low-income was most stark for social service needs, with the UK 35% of low-income adults requiring at least one service, with only 15% of high-income adults requiring social services.
In the latest of their health systems summaries series, the European Observatory on Health Systems and Policies has reviewed the often-lauded Swedish health system. A tax-based system that is devolved across Sweden’s 21 regions, the management of and outcomes achieved are routinely held up as examples of NHS aspiration. Of most interest to the NHS, will likely be efforts since 2018 to strengthen the patient-centredness and integration of the primary care system, as well as improving care coordination across the system more broadly.
The OECD has released the latest in their biennial "Health at a Glance" reports, which provides analysis of all OECD members' performance across a wide range of health system measures, ranging from health influencers such as smoking and alcohol consumption rates, to facilitators of modern healthcare, such as digital maturity and care coordination.
Because of the wide range of indicators used by the OECD, the number of included countries and the challenges of making direct comparisons between different systems, it is hard to draw firm conclusions from the report. Instead "Health at a Glance" can be used for insights into trends overtime, and to identify the top performing healthcare systems based on various metrics which can then be investigated further.
Public participation is increasingly being recognised as key to developing high-quality, equitable health services, both on the individual level where patients receive care, and at the collective level where patients and the public are engaged in groups to advise on topics such as quality improvement, policy development and research.
There is growing evidence on effective means for engaging on the individual level, but far less evidence of best practice exists at the collective level. A new paper published in "Health Policy", has developed five recommendations for collective patient participation based on the available literature. These are: the conditions for participation; strategy; preparation of the public and professionals; support for the public and professionals; and evaluation of the participation.
This new report from the European Health Management Association (EHMA) and the Health Policy Partnership (HPP) examines how implementation science can support the adoption of innovation designed to improve the affordability, effectiveness, and sustainability of health systems, in what is a constantly evolving, complex, and pressurised environment.
The report advocates for the use of implementation science as means for bridging the gap between research and practice, and investment in the infrastructure required for successful adoption.
The report advocates for healthcare managers and procurers to follow five guiding principles for successful implementation. These are: rigourous data collection; systems thinking; collaboration; understanding the local content; and iterative improvement. These five principles should be adopted into a framework that can provide structure for standardised data collection, and therefore simplifying stakeholder engagement and implantation evaluation.
James Maddocks, International Policy Advisor at the NHS Confederation, shares his thoughts on the October 2023 IHF World Hospital Congress.
Last week (Oct 25-27) I attended the International Hospital Federation’s annual World Hospital Congress (IHF WHC), for whom the NHS Confederation is the NHS’s representative. Historically an ‘association of associations’, the IHF provides a forum for healthcare leaders to connect with their international counterparts and exchange approaches to the mutual challenges and opportunities that are common across the globe, through a peer learning approach, as well as developing the executives of the future through the annual Young Executive Leaders Programme.
The epicentre of this connection is the annual World Hospital Congress, which is hosted by a different IHF member every year, with recent iterations taking place in Oman, Barcelona, and Dubai. The location of this year’s event was an uncharacteristically wet Portuguese capital, Lisbon.
Made up of 5 ‘tracks’, discussion at the IHF WHC this year focused on how healthcare executives are shaping, driving and supporting improvements in workforce wellbeing, the adoption and scaling of innovative approaches to delivering healthcare, the growing role of digital solutions, and the role of hospitals and health systems in environmental sustainability. Across all themes, there was an emphasis on shifting the focus of leadership and decision making from top-down process to one where communities and professionals are brought together at the beginning to determine ‘what problem are we trying to solve’ and ‘how are we going to get there’. This process was summarised best by Dr Pedro Delgado, Vice President of the Institute of Health Improvement, who has used this approach to support Newcastle Hospitals NHS FT and the Royal Free Hospital FT to increase staff satisfaction.
Traditionally an organisation focused on the delivery of care within hospitals, many IHF members are now finding themselves in the familiar reality where working in the historic hospital silo is no longer feasible. They, like the NHS, are increasingly seeking to deliver care outside of these traditional sector boundaries. This has led to the introduction of an Innovation Hub for the first time this year, with the remit of bringing together innovations that are enabling the delivery of care within the community. The NHS Confederation joined the steering committee on behalf of the NHS, shaping the hubs inaugural approach. The NHS’ experience of this direction of travel in care was reflected in the inclusion of three NHS and UK-based companies featuring in the final 16 selected innovations.
Given the diversity of membership and breadth of discussion, it is unsurprising that the IHF means many things to many people. Delegates may travel with the sole intention of learning something new from across the congress’ five tracks, or with the single-minded focus on gathering evidence to support specific policy developments back home. It may be a way to showcase to international colleagues the very best of your health system, or to identify potential collaborators for future research. Whatever delegates' primary intention for attending, it should not be understated how forums like these provide a space for healthcare executives, often scapegoated and demonised in the NHS, to take pride in their work.
The diversity of opportunities on offer fits perfectly with the growing UK participation in the congress. For HealthcareUK at the Department of Business and Trade, a sponsor for the second year and a key enabler of NHS participation internationally, the Congress provides the dual opportunity of learning about the priorities of our partners in other health systems – thus supporting the tailoring of the NHS’s offer to the world - whilst simultaneously presenting some of the current key offers of NHS exporting. A session on innovation and mental health included presentations from the Chelsea & Westminster Hospital NHS Foundation Trust, the Royal Marsden NHS Foundation Trust, Cambridge University Hospitals NHS Foundation Trust, South London and Maudsley NHS Foundation Trust, and Mersey Care NHS Foundation Trust. These are all organisations working internationally on a commercial and non-commercial basis to generate benefits for their organisation, workforce, and communities.
Whilst attending sessions over the three days it becomes clear how prevalent the challenges facing the NHS are; how they are forcing leaders of health systems to look beyond their traditional approaches to delivering for patients, and the opportunity this presents to include international experiences in our domestic NHS approaches.
This was perhaps best exemplified by the comments of John Haupert, President and CEO of Grady Health System in the USA, when he used his opening speech to call for a move from the treatment of illness to the promotion of wellness. A bold statement from the leader of a health system where the provision of care largely remains a for-profit, fee-for-service model – often considered the antithesis of the NHS approach.
Other highlights included hearing how executives from the USA, Singapore, Poland and Switzerland are fostering a culture of innovation within their organisations, systems and across their wider governments. Given the NHS’s current commitment to developing a culture of innovation, understanding the means by which each of these executives is leading the development of cultures that promote innovation could be key to improving the development, adoption and spread of innovation in the NHS. This includes understanding how professional roles in the USA are being updated to create space to innovate and how a cultural fear of failure can be removed in Singapore and Switzerland – something that exists across the NHS from single wards though to national transformation programmes.
Finally, as an NHS representative at the congress, it was refreshing to see and hear how well thought of the NHS is globally. Amid what can feel like unrelenting doom back home, it is inspiring to see the leading role the NHS plays in sustainability, as well as the comparatively advanced development of our integration across providers, and the maturity of our primary care. This NHS expertise was exemplified by the success of Alder Hey Children’s Hospital NHS Foundation Trust Staff Advice and Liaison Team (SALS), represented by Dr Jo Potier and Catherine Kilcoyne, winning in the Health Workers Wellbeing category, and Dr Phuoc Duong, Paediatric Consultant at Alder Hey featuring in the inaugural Innovation Hub to discuss the hospital's remote monitoring platform ‘Little Hearts at Home’ which enables proactive and preventative care for high-risk newborns and infants with congenital heart disease
As the NHS continues to work with the IHF, the annual congress will also continue to provide opportunities for the NHS to participate on the international stage. Whether you’re interested in commercial opportunities, global health, or learning more about international best practice on numerous topics, the international team at the NHS Confederation can support you to do this through the IHF.
A new article from the Health Foundation examines the complexities of using international comparisons as a means for guiding NHS reform, as well as the opportunities they hold when utilised correctly.
Anyone looking to make use of international examples, the article argues, should be aware of the nuances that influence health system design. These include recognising that the health system is not just health services and so comparing outcomes or performance between countries is rarely a like for like comparison; that the social and economic contexts countries find themselves in will influence what systems are able to deliver; and that performance is influenced by more than just money, with the training, recruitment and retention of the workforce, and the procurement and distribution of equipment all influencing variation in topline performance measures.
The article goes on to argue that whilst useful international comparisons cannot be taken at face value and viewed as simple, direct comparisons of system performance. Influenced by the variations outlined above, as well as significant gaps in the data sets used to make comparisons, means that more questions are likely to be raised than answers provided, at least in the early stages of comparative research. As such, time must be taken to ensure accurate and actionable results can be achieved. Read more.
A new study published in the Canadian Journal of Public Health explores the motivating factors and perceived impacts of centralisation reforms on public health systems and their essential operations - several Canadian provinces and territories have reformed their health systems by centralising power, resources, and responsibilities.
Motivators for centralisation included achieving greater value for money and consolidated authority, but this has also resulted in a negative impact on intersectoral and community collaboration, as well as a de-prioritising of public health systems that has contributed to greater challenges in the public health workforce. Read the study.
Commissioned by the Public Heath Physicians of Canada (PHPC), a new report from the North American Observatory on Health Systems and Policies (NAO) examines the breadth of relationships established between public health organisations and community-based organisations during the covid-19 pandemic in Canada, and the strategies they collaboratively developed and implemented to promote vaccine uptake.
Strategies ranged from those best described as ‘informing citizens’ which make use of communication materials tailored to the needs or circumstances of different groups and cultural competency training for healthcare and non-healthcare providers, through to methods of ‘consulting and involving’ citizens in vaccination programmes, research and broader community engagement. The most frequent examples identified by the NAO were population-specific vaccine clinics, informed by taskforces and community working groups. Strategies also made use of collaboration with trusted figures in communities to act as ambassadors and leaders in vaccination efforts.
Despite the success of these partnerships for developing and implementing vaccination strategies during the pandemic, gaps remain around the effectiveness, costs, and impacts on a range of outcomes that would help to develop “best practices” for strengthening and sustaining ongoing partnerships post-pandemic.
In March 2023, the Greek Ministry of Health introduced its National Action Plan for Mental Health, a 10-year plan (2021–2030) containing policies and interventions for the promotion, protection and enhancement of the mental health of the population, especially for vulnerable groups. The action plan aims to ensure universal access in mental health services and the eradication of stigma and social exclusion. The overall objective of the plan is to achieve de-institutionalisation, by establishing an integrated, holistic, recovery-oriented, community-based mental health services system. Read more.
Patients’ and citizens’ perspectives and their active engagement are critical to making health systems safer and more people-centred, and are key for co-designing health services and co-producing good health with healthcare professionals, as well as building trust in health systems. Patients, families, caregivers and citizens can contribute towards improving patient safety at all levels from clinical, local, institutional (e.g. hospital , nursing home), community (e.g. primary care, home care) and national levels of healthcare systems.
This report, the sixth in the OECD series on the Economics of Patient Safety, looks at the why, what, and how of patient engagement for improving patient safety and includes detail on:
- the economic impact of patient engagement for patient safety
- the results of a pilot data collection to measure patient-reported experiences of safety
- the status of initiatives on patient engagement for patient safety taken in 21 countries
- recommendations for countries to enhance patient engagement for patient safety.
When we think of payment models of healthcare in the United States, we are probably more likely to think of the ‘fee for service’ model than an outcomes-based payments approach; however, as this report from the Commonwealth Fund attests, outcomes-based payment models do exist.
The issue with the design of value-based payment models (VBP) is that they are often designed to take inequality into account, which can result in unintentional harms being created in three ways:
- value-based schemes have historically lacked a requirement for the inclusion of reporting and non-financial instruments, such as the collection of demographic data by providers that could identify inequalities in access and outcomes
- some providers have been penalised by VBP models because they are expected to achieve the same outcomes regardless of varying levels of inequality within populations, meaning that they are penalised when outcomes are worse, instead of being provided with the necessary resources to manage the higher rates of inequalities and the associated negative impacts on health
- thirdly, providers in communities where a higher percentage of the population is black, living in poverty, uninsured, disabled or has less than a high school education are less likely to adopt a VBP model, meaning that those more likely to suffer from health inequalities will miss out on the benefits that these models offer.
A new article published in the International Journal of Integrated Care documents the reorganisation of public health services working with youth social and emotional development in Quebec, Canada.
The reorganisation had the ambition of acknowledging the increasing volume of evidence that suggests a public health approach is required to promote positive mental health in children, and the role that the socio-educational environment has in delivering this. To this end, a collaboration was established between the regional public health authority, schools, school boards, and parents from which developed an Integrated Community Care (ICC) framework. Across the 46 participating schools, it was observed that in just 6 months of implementation, encouraging improvements in the level of integration between schools and public health services could be observed. Read more.
As in the UK, Australia is challenged by the increasing demand for social care services for its older population. In this current financial year, these services are likely to cost the tax-payer A$35 billion.
Despite the variation in design of our respective public services, the UK and Australia are alike in sharing the cost of social care between government and individuals. Most crucially, demand and expenditure have been identified by the Australian treasurer as the government's biggest challenge. In response, the government has set up an aged care taskforce that will advise on how and by whom social care should be funded in the future. This article has all the details.
In an effort to inform future health system reform, the European Observatory on Health Systems and Policies convenes health systems' experts from the 31 high-income countries represented in their Health Systems and Policy Monitor (HSPM) Network. Through surveys and workshops, the network maps the planned, implemented and abandoned reforms in each country, identifying trends in reforms across nations, and ultimately providing a space for national policy-makers and health systems' researchers to learn from their international counterparts.
In 2018 alone, there were 81 healthcare system reforms reported across 28 high-income countries. In 2019, this increased to 86 reforms across 30 countries. This new paper, published in the Health Policy Journal, has mapped these reforms and identified the most popular in each country and across various categories.
Interestingly for the UK, in the same year primary care networks were introduced, 13 other countries reported reforms to primary care provider networks, with six of these aiming to increase the size and role of primary care, so that they are able to provide more multidisciplinary and integrated care.
Possibly of most interest to the UK are the reforms in Norway, Finland and the Czech Republic. Norway sought to replace doctor-led practices with a team-based model; Finland has taken steps to integrate health and social care services into ‘health and social care centres’; and the Czech Republic has expanded the focus of primary care to include the management of chronic conditions.
Given the sustained funding pressures the NHS faces, there are now regular calls for the funding model used to finance healthcare to be reexamined. As the Kings Fund outlined in their recently published report ‘How does the NHS compare to the health care systems of other countries’ healthcare can broadly be defined as being financed through one of three models; taxation (Beveridge), social insurance (Bismarck), or market-based private insurance or out of pocket spending (Private). Very few people are calling for the adoption of the private model we associate with the USA, thus leaving us with the option of exploring a model of social insurance.
In a new blog for the Health Foundation, Ruth Thorlby examines the choices policy-makers would face if such a model were to be adopted and asks the question, would it actually make anything better? The source(s) of funding and their impact on the overall available budget, management and regulation of insurers, the overall benefits package available to NHS patients, and the process for deciding who and how the costs of care should be decided would all need to be agreed.
All social insurance-based models make use of general and targeted taxation to fund their services, with France funding 77% of health spending from general taxation, while the Netherlands supplement their health spending to the tune of 13%. In these scenarios, general and targeted taxation is used to ensure financial sustainability and minimise inequalities for those unable to afford insurance. Therefore, it is unclear to what extent the tax burden would fall in the UK if the model were changed.
The UK consistently comes out on top of international comparisons on administrative efficiency - we spent just 1.9% of the overall health budget on administration in 2021, compared to 5.5% in France, 4.4% in Germany and 3.7% in the Netherlands. If a model of social insurance akin to Germany or the Netherlands were to be adopted, where citizens have a choice of 24 and 105 insurers respectively, the requirement for additional layers of management and regulation to efficiently administer the system could undermine the NHS’s position as an efficiency frontrunner.
Despite the differences in their method of funding, administration, management and choice of insurer, there is no clear evidence that either insurance or taxation-based systems deliver more cost-effective care or better outcomes. Policy-makers advocating for an insurance-based model would be committing themselves to delivering reform that requires significant upheaval, could increase administrative costs and bureaucracy, but with no evidence base for improving care for NHS patients. The blog concludes by arguing that policy-makers must instead focus energy on the sustained investment, innovation and incremental reform the service needs.
Writing in the Harvard Business Review, Press Ganey, a US-based company specialising in patient satisfaction surveys, has published findings of their work to engage 1.6 million healthcare employees from US healthcare organisations between 2020 and 2022.
The survey results show that whilst there is a widening gap between the best and worst performing healthcare organisations when it comes to workforce morale and retention, common themes emerge across the best performers of which less well performing organisations could take note.
The findings show that top performing organisations where able to improve engagement with and resilience among their workforce through implementing seemingly simple steps, such as a policy called GROSS (getting rid of stupid stuff) where leaders develop processes that listen to the needs of frontline staff and commit to implementing their solutions. Read more.
New research from the Australian Sax Institute has identified the impact of various suicide prevention interventions on the adult population aged over 20 in New South Wales. The interventions, which include community-based outreach teams, peer-led support groups, and counselling in rural communities, reduced suicides by 6.8% and suicide attempts by 6.3% over 5 years. Learn more about the research results.
A study undertaken by the Australian Institute of Health and Welfare has found that a partnership between the University of Queensland and Goondir Health Services (an Aboriginal Community Controlled Health Service) to develop a student-led dental clinic in rural Queensland improved the oral health of Aboriginal and Torres Strait Islander people by providing access to culturally appropriate and timely care.
Rural populations in Australia suffer from worse access to dentistry and poorer oral health due to a lower density of dentists and the resulting need for longer travel times, which are compounded by limited transport options. The UQ Dental Clinic – run by supervised fifth-year dental students – opened 10 years ago and has since treated 800 rural patients each year. The clinic makes use of a co-location model that sees the dental service placed in Goondir’s facilities, allowing easy access and onward referral to other services. The hope now is that the model can be expanded across specialities and the wider Australian health system.