National Health Care Services

in Europe – an insider perspective

Frank RöhrichtMD, FRCPsych

Consultant Psychiatrist & Clinical Director ELFTVisiting Professor University of Hertfordshire

Honorary Professor University of Essex

Setting the scene (Andreou et al 2010: Cost and Value of Health Care in Cyprus)

• “A public-private mix which is the case of most health care systems combines the pros and cons of public (free) and private provision.”

• “ …while 85%-90% of the population is eligible for free or reduced cost services…, many population groups…..do not use this benefit. Instead, they resort to purchasing health care from the private sector. This implies that the health care system in Cyprus is not efficient,….creates a wasteful duplication”

• Explanation: waiting time/quicker access, lower perceived quality, more attentive health care

Money matters, but does not explain it all (WHO statistics):

Country Total expenditure on health as % of GDP, 2006

Government expenditure on health as % of total expenditure

Per capita total expenditure on health, 2006 ($)

Life expectancy at birth, 2007 (years)

Cardiovascular mortality rates, 2004 (per 100,000 population)

UK 8.4 87.3 2784 80 175

USA 15.3 45.8 6719 78 179

China 4.5 40.7 342 74 279

Russia 5.3 63.2 698 66 645

Germany 10.4 76.9 3328 80 199

Cyprus 6.4 45.6 1696 78 ??365

Healthcare Costs Around the WorldAccording to Reuters, “The United States spends more on healthcare than any country in the world but has higher rates of infant mortality, diabetes and other than many other developed countries.”

Prejudice: there is no perfect “one size fits all” solution

However:

• New investment and strict policy implementation in UK 2000-10:

• High levels of evidence based care• Waiting times for all major interventions

down to max. 18 weeks• Surveys demonstrated highest level of

patient satisfaction for 25 years (BMJ)• Doctors from all over EU seeking

employment in UK

Examples of personal experience as doctor/patient in different healthcare systems

• Germany: The hospital morning conference: waste of resources

• Germany: The specialist practice quarterly review: incentives to spend

• UK: The “revolving door” and the suicidal patient: lack of continuity

• UK: The slipped disc: lack of resources• UK: The skin lesion

Advantages of NHS systems

• Central control (e.g. re gate keeping to specialist care, prevention, education)

• Implementation of national quality standards (guidelines), guided by evidence-based medicine (NICE)

• Easy to direct, manage conflict of interest• Clinicians are directly involved in

management

• Equity of access and care provision

Disadvantages of NHS

• Systems tend to be under funded due to adverse spending preferences of governments

• Lack of innovation, access to new treatments

• Long waiting lists for most medical specialties

• Often limited choices for patients

Inefficiencies in private HC• Prone to overuse health services,

encouraging over-investigating and treatment

• Only those who can afford it will access health care (lack of prevention)

• Insurance excludes pre-conditions and chronic disease

• Ageing and rising HC cost (scientific progress) exacerbate inefficiencies further

• Its unethical to exploit health care needs according to profit orientation

The money issue: example

• Cyprus mail 9th April 2011: “Health minster: stop feeding your children antibiotics”

• “It is notoriously easy in Cyprus to walk into a pharmacy and be given antibiotics instead of going to a doctor.. private doctors are the biggest culprits when it comes to dishing out the drug in liberal doses. “

Can investing into a NHS be cost effective?• Evidence: insurance systems with competition more

generous and expensive (e.g. Germany) than NHS• Central mechanism with purchasing opportunities

(i.e. mass ordering of pharmaceuticals etc.)• Guidelines re-directing care provision (e.g. PT

versus medication AD/AP)• Control mechanism avoids wasting resources• Prevention reducing long term cost pressures (e.g.

Obesity/diabetes, vaccination, unemployment cost)

• Single point of entry provides coordination of care • Gate keeping to delivery of expensive specialist

care, regulating (GP/family doctor)

Managing change during austerity

• NHS chief tells trusts to make £20bn savings• For ELFT £8mill. per year for 2011 and 2012;

£3.5mill. from general adult services (total £82m)• First steps: whole system review, recruitment

freeze, renegotiate targets, risk assessment• Agree on set of principles underpinning change

process: e.g. integrated pathways, core provision, evidence base, avoid “salami slicing”

• Explore synergism with other providers, and immediate savings opportunities (i.e. “Risperdal”)

• Reconsider necessary skill mix for new system and review job plans accordingly

Suggested principles underpinning new system development:• Working together in partnership: Open dialogue with

professionals, patients, management, commissioners • Involving academic institutions at early stage• Limited resources require priorities, low bureaucracy• Clinical leadership, decentralised decision making • Focus: quality, equity and in the community• Integrated pathways of care• Integrated strategies for prevention, patient

participation and treatment/care provision• Integration of physical, psychological and social care• Primary care gateways, stepped care approaches

Finally: the unique case for Cyprus

• Opportunity: learn from mistakes made elsewhere (e.g. UK/Germany)

• Position: centred in the middle between three continents, integrating best practice

• Resources: rich in education levels, history, culture, nature, space and sunlight

• Experience: professionals trained across the world in centres of excellence

• Attitude & Dedication: there is a spirit of innovation and a dynamic drive for change

Thank you!

www.frankrohricht.com

Prevention strategies• cross-fertilisation: create integrated pathways,

with experts providing sessional input into non-healthcare settings and employees from wellbeing initiatives providing input for MH services

• create well-being centre as community hub for health prevention and self-helping initiatives (provided by third-sector, voluntary organisations), including: health/dietary advice, exercising and physical health groups such as yoga/relaxation and counselling (Mental Health professionals input from DPS)

Polysystems Polysystems Detection and Detection and Prevention Prevention Services Services (DPS)(DPS)

CMHT AAT/BTT in

Primary Care

Network clinics

PersonalityBehaviour

DPS(DBT)

Anxiety andDepression

DPS(IAPT)

MUSDPS

(SDC/NUH liaison)

EarlyPsychosis

DPS (EIS)

Community well-being

centre

The Third SectorThe Third Sector

Voluntary Voluntary OrganisationsOrganisations