Switzerlands Health Care System from the viewpoint of the UK NHS Panos Kanavos, PhD London School of...
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Switzerland’s Health Care System from the viewpoint of the UK NHS Panos Kanavos, PhD London School of Economics Bern, 26 October 2012
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Transcript of Switzerlands Health Care System from the viewpoint of the UK NHS Panos Kanavos, PhD London School of...
Switzerland’s Health Care System from the viewpoint of the UK NHS
Panos Kanavos, PhDLondon School of Economics
Bern, 26 October 2012
Outline
• Stylised Facts: UK
• Stylised Facts: Switzerland
• Indicators & Performance Measurement
• A “Fair” Comparison?
2
1. Stylised Facts: UK NHS
• focus on the new Health & Social Care Act, 2012
• Spending trends in light of increases in demand
3
Summary
Health care financing in an era of austerity
Kanavos et al, 2011.
27. March 2012
Health and Social Care Act 2010-12
Progress and summary of the bill
“The Bill proposes to create an independent NHS Board, promote patient choice, and to reduce NHS administration costs.”1. establishes an independent NHS Board to allocate resources and provide
commissioning guidance2. increases GPs’ powers to commission services on behalf of their patients3. strengthens the role of the Care Quality Commission4. develops Monitor, the body that currently regulates NHS foundation trusts, into
an economic regulator to oversee aspects of access and competition in the NHS
5. cuts the number of health bodies to help meet the Government's commitment to cut NHS administration costs by a third, including abolishing Primary Care Trusts and Strategic Health Authorities. Source: Parliament 2012
Health and Social Care Act 2010-12
Evolution of commissioning in the UK
GP Fundholding
GP Commissioning groups
Primary Care Trusts (PCTs)
Practice based commissioning
19971991 1998 20051999 2012
Implementation of Health and Social Care Act
Health and Social Care Act 2010-12
Key policy components of the Act
• Clinically led commissioning• Provider regulation• Greater voice for patients• New focus for public health• Greater accountability• Streamlined arms-length bodies
Previously, clinicians negotiated service provision for their populations with the PCT.
Under the Act, clinical commissioning groups (supported by the NHS Commissioning Board) will commission services directly.
Source: DoH 2012
Health and Social Care Act 2010-12
Key policy components of the Act
• Clinically led commissioning• Choice & Provider regulation• Greater voice for patients• New focus for public health• Greater accountability• Streamlined arms-length bodies
Patients will be able to choose services from a broader variety of providers – including charities and independent providers – as long as they meet NHS costs.
Under supervision of the Monitor agency, providers will be free to innovate to deliver services.
Source: DoH 2012
Health and Social Care Act 2010-12
Key policy components of the Act
• Clinically led commissioning• Provider regulation• Greater voice for patients• New focus for public health• Greater accountability• Streamlined arms-length bodies
The Act establishes new Healthwatch patient organisations locally and nationally to drive patient involvement across the NHS.
Source: DoH 2012
Health and Social Care Act 2010-12
Key policy components of the Act
• Clinically led commissioning• Provider regulation• Greater voice for patients• New focus for public health• Greater accountability • Streamlined arms-length bodies
The Act provides the ground work for Public Health England, a new body to drive improvements in the public’s
health.
Source: DoH 2012
Health and Social Care Act 2010-12
Key policy components of the Act
• Clinically led commissioning• Provider regulation• Greater voice for patients• New focus for public health• Greater accountability • Streamlined arms-length bodies
The Act sets out clear roles and responsibilities, keeping Ministers’ ultimate responsibility for the NHS. It limits political micro-management and gives local authorities the responsibility for integrating local
services.
Source: DoH 2012
Health and Social Care Act 2010-12
Key policy components of the Act
• Clinically led commissioning• Provider regulation• Greater voice for patients• New focus for public health• Greater accountability • Streamlined arms-length bodies
Abolition of some administrative bodies (incl. General Social Care Council, Office of the Healthcare Professions Adjudicator, Alcohol Education and Research Council and others).
Re-establishment of NICE and the Information Centre in primary legislation. Extension of NICE’s remit to social care.
Source: DoH 2012
2. Stylised Facts: Swiss Health Care System
14
Swiss Health Care System Indicators – funding/allocation
Indicators of Health Care Costs (2010)
Costs of health care as a proportion of GDP 10.9%*
Health care budget funding
Social insurance 41.8%
Other social protection, means-tested schemes 4.5%
Private households 25.1%
State 19.0%
Health care costs by service provider
Hospitals 35.9%
Outpatient providers 30.8%
Nursing and residential facilities 17.2%
Retail sale of pharmaceuticals and therapeutic instruments 8.7%
Administrative costs and expenditure on prevention and accident provision
6.2%
Private non profit organisations 1.1%
Source: Swiss Statistics – overview: Costs, financing – Data, indicators 2010
*Share in GDP: 9.9% in 2000 and 10.9% in 2005
Statutory Health Insurance1996 Federal Health Insurance Act
• Regulated by law and supervised by the OFSP
• Universal coverage
• Statutory for all Swiss residents (exception for persons eligible for premium subsidies paid by the
canton or commune)
• Covers sickness, accidents and maternity
• Competing non profit health insurances: costs are redistributed among insurers by a central fund based
on a risk equalisation scheme adjusted for age, canton, gender, and recently whether the patient
stayed more than 3 nights in hospital or in nursing homes.
• Basic benefits package: established by the DFI/OFSP, with the support of relevant expert authorities
(e.g. Swissmedic), based on whether service is effective, appropriate and cost-effective.
• Complementary and supplementary health insurance also available (e.g. choice of hospital doctor,
improved accommodation): usually for profit
Source: Camenzind P, Squires D. The Swiss Health Care System, 2011. The Commonwealth Fund.
Statutory Health InsuranceWhat is covered?
Patient empowerment & choice (unless enrolled under a managed care plan):• Free choice of GPs• Access without referral to specialists in a private practice
What is covered?• General practitioner (GP) and specialist services (mostly all covered);• Pharmaceuticals (positive formulary), physiotherapy (if prescribed by
physician), some preventive measures, some complementary medecine (as of 2012);
• Mental illness (including psychotherapy, if prescribed by physician);• Costs of selected vaccinations, selected general health examinations, early
detection of disease among certain risk groups;• 15% of costs of long-term inpatient care (e.g. inpatient homes, institutions
for disabled and chronically ill): 2/3 being paid by OOP and the remainder by state subsidies and disability insurances.
• Dental care is generally not covered Source: Camenzind P, Squires D. The Swiss Health Care System, 2011. The Commonwealth Fund.
3. Performance Measurement (also based on survey data, CMWF, 2010-2011)
• Overall health spend (per capita and as % GDP)
• Cost sharing
• Efficiency
• Quality
• Responsiveness and access
• Affordability and access
• Care coordination
• Relationship with doctor
• Patient safety
• Management of chronic disease18
NZ (10.3%)
AUS (8.7%)*
UK (9.8%)
SWE (10.0%)
FR (11.8%)
GER (11.6%)
CAN (11.4%)
NETH (12.0%)
SWIZ (11.4%)
NOR (9.6%)
US (17.4%)
$0
$1,000
$2,000
$3,000
$4,000
$5,000
$6,000
$7,000
$8,000
$2,983$3,445 $3,487
$3,722$3,978
$4,218 $4,363$4,914
$5,144 $5,352
$7,960
Health Spending per Capita, 2009Adjusted for Differences in Cost of Living
* 2008.Source: OECD Health Data 2011 (June 2011).
% GDP
Dollars
Health spend per capita (US$): Escalation over time
20
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
0 1000 2000 3000 4000 5000 6000
Switzerland
United Kingdom
OECD AVERAGE
US$ per capita
Source: OCED health data June 2012.
Health spend as a percent of GDP: Sustainability?
21
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
0 2 4 6 8 10 12
Switzerland
OECD AVERAGE
United Kingdom
% of GDP
Source: OCED health data June 2012
Cost containment
• Switzerland has among the highest expenditures per capita in the world after the US and Norway (2009)
• Cost control measures• Regulated competition between insurers and providers
Inadequate risk equalisation, dual funding of hospitals by cantons and insurers, pressure on insurers to contract with certified providers
Þ Managed care plans could reduce such problems
• Pharmaceutical coverage decisions: based on effectiveness (Swissmedic) and on price (OFSP),
Efforts to reassess prices of older drugsPrice capping on generic drugs (50% less than original)Higher co-payment for branded drugs if original drugs available (20% instead of 10%)Flat dispensing fee for pharmacies
Þ Health technology assessment could increase efficiency in healthcare resource allocation
22
Responsiveness and access: Waiting times
Switzerland UK
Access to doctor or nurse when sick or needed care
• Same or next day appointment 93%* 70%
• More than days 2%* 8%
Waiting times for a specialist appointment
• Less than 4 weeks 82% 72%
• More than 2 months 5% 19%
Waiting times for an elective surgery
• More than 4 weeks 55% 59%
• More than 4 months 7% 21%
* Highest score across the 11 countries included in the study
Source: Schoen C, Osborn R. The Commonwealth Fund. The Commonwealth Fund 2010 International Health Policy Survey in Eleven Countries. November 2011.
Patient cost-sharing
• Patient cost sharing in the UK: approx 4.5% of total health spend• Patient cost-sharing in Switzerland: (out-of-pocket payments): approx.
30% of total health spend
• Deductibles (ranging between CHF 300-2,500.- / year depending on the health plan)
• Co-insurance of 10% on any costs exceeding the franchise (up to a maximum of CHF 700.- / year)
• Subsidies are available at cantonal level for persons who are not able to pay partly or entirely their premiums: • Approx. 1.6% of the population are not able to cover their
premiums• 30% of Swiss residents benefit from these subsidies
Þ Issues around affordability of premiums and financial burden to the population
25
Cost-Related Access Problems in the Past Year
Percent AUS CAN FR GER NETH NZ NOR SWE SWIZ UK US
Did not fill prescription or skipped doses
16 15 11 14 8 12 7 7 9 4 30
Had a medical problem but did not visit doctor
17 7 10 12 7 18 8 6 11 7 29
Skipped test, treatment, or follow-up
19 7 9 13 8 15 7 4 11 4 31
Yes to at least one of the above 30 20 19 22 15 26 14 11 18 11 42
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.
Out-of-Pocket Spending and Problems Paying Medical Bills in Past Year
Percent
0
10
20
30
40
50
60
15 6
11 12 1316
24
35 3639
More than US$1,000 in out-of-pocket costs
UK
SW
E
FRG
ER
NO
RA
US
CA
NS
WIZ NZ
NE
TH US
14 5 6 7 8 8 8
1114
27
Serious problems paying or unable to pay medical bills
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.
SW
IZ UK FR NZ
NE
THA
US
GE
RN
OR
US
CA
NS
WE
0
25
50
75
100
79 7975 75
7063
59 59 5951 50
Access to Doctor or Nurse When Sick or Needed Care
Percent
UK
SW
IZ NZ
FR
AU
SN
ETH
NO
R
US
SW
EC
AN
GE
R
2 4 5 8 10 12 14 1622 23 23
Same- or next-day appointment Waited six days or more
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.
UK
SW
IZN
ETH
NO
RG
ER NZ
SW
E
FR US
AU
SC
AN
0
25
50
75
100
2126
34 3540 40
52 55 55 5663
After-Hours Care and Emergency Room Use
Percent
GE
RN
ETH FR
SW
IZN
OR
UK NZ
AU
S
US
SW
EC
AN
31 32 3339 40 40
47 48 49 5058
Difficulty getting after-hours care without going to the emergency room
Used emergency room in past two years
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.
Waited Less Than a Month to See Specialist
SWIZ US NETH UK GER NZ FR SWE AUS CAN NOR0
20
40
60
80
100 9288
81 80 79
68 6763
5952
47
Percent
Base: Saw or needed to see a specialist in the past two years.Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.
Coordination Problems in the Past Two Years
Percent AUS CAN FR GER NETH NZ NOR SWE SWIZ UK US
Test results/ records not available at appointment and/or duplicate tests ordered
19 25 20 16 18 15 22 16 11 13 27
Providers failed to share important information with each other
12 14 13 23 15 12 19 18 10 7 17
Specialist did not have information about medical history and/or regular doctor not informed about specialist care
19 18 37 35 17 12 25 20 9 6 18
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.
Experienced Coordination Gaps in Past Two Years
UK SWIZ NZ AUS NETH SWE CAN US NOR FR GER0
20
40
60
80
20 2330
36 37 39 40 42 43
53 56
Percent
* Test results/records not available at time of appointment, doctors ordered test that had already been done, providers failed to share important information with each other, specialist did not have information about medical history, and/or regular doctor not informed about specialist care.Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.
Gaps in Hospital or Surgery Discharge in Past Two Years
Percent did NOT AUS CAN FR GER NETH NZ NOR SWE SWIZ UK US
Receive instructions about symptoms and when to seek further care
16 16 33 23 22 17 29 27 13 11 7
Know who to contact for questions about condition or treatment
12 11 20 9 9 10 13 16 9 5 6
Receive written plan for care after discharge
30 27 33 26 44 31 44 46 28 19 7
Have arrange-ments made for follow-up visits
31 26 47 47 22 31 38 36 32 12 16
Receive clear instructions about what medicines to be taking
15 11 27 15 20 11 19 14 14 9 5
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.
Medical, Medication, or Lab Test Errors in Past Two Years
Percent reported: AUS CAN FR GER NETH NZ NOR SWE SWIZ UK US
Wrong medicationor dose 4 5 6 8 6 7 8 5 2 2 8
Medical mistake in treatment 10 11 6 8 11 13 17 11 4 4 11
Incorrect diagnostic/lab test results*
4 5 3 2 6 5 4 3 3 2 5
Delays in abnormaltest results*
7 11 3 5 5 8 10 9 5 4 10
Any medical, medication, or lab errors
19 21 13 16 20 22 25 20 9 8 22
* Base: Had blood test, x-rays, or other tests in past two years.Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.
UK SWIZ CAN US GER NZ AUS NETH SWE FR NOR0
20
40
60
80
100
1625 28 28 29 31 34
41
55 5862
Percent
Pharmacist or Doctor Did Not Review and Discuss Prescriptions in Past Year
Base: Taking two or more prescriptions.Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.
Doctor–Patient Relationship and Patient Activation
Doctor–Patient Relationship and Communication
Percent reported regular doctor always/often:
AUS CAN FR GER NETH NZ NOR SWE SWIZ UK US
Spends enough time with you 85 77 82 86 87 87 71 70 88 87 81
Encourages you to ask questions and explains things in a way that is easy to understand
69 59 53 64 54 67 31 41 77 77 71
Always/often to both 66 54 50 61 52 65 27 37 73 72 65
Base: Has a regular doctor/place of care.Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.
Shared Decision-Making with Specialists
SWIZ UK NZ NETH US AUS CAN GER SWE NOR FR0
20
40
60
80
100
80 7972
67 67 64 61
50 4840 37
Percent reporting positive shared decision-making experiences with specialists*
* Reported specialist always/often: 1) Gives opportunities to ask questions about recommended treatment; 2) Tells you about treatment choices; and 3) Involves you as much as you want in decisions about your care.Base: Seen specialist in past two years.Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.
Patient Engagement in Care Management for Chronic Condition
Percent reported professional in past year has:
AUS CAN FR GER NETH NZ NOR SWE SWIZ UK US
Discussed your main goals/ priorities
63 67 42 59 67 62 51 36 81 78 76
Helped make treatment plan you could carry out in daily life
61 63 53 49 52 58 41 40 74 80 71
Given clear instructions on symptoms and when to seek care
66 66 56 64 64 63 44 49 84 80 75
Yes to all three 48 49 30 41 42 45 23 22 67 69 58
Base: Has chronic condition.Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.
UK
US
SW
E
NZ
NE
THS
WIZ
NO
RC
AN
AU
SG
ER FR
0
25
50
75
100
8177
73 71 70 6863 62 59
55 54
Between Doctor Visits, Has a Health Care Professional Who . . .
Percent
US
UK
SW
IZ
NE
T
NZ
SW
E
AU
SC
AN
GE
RN
OR FR
31 2924 22 22 22
16 16 14 12 9
You can easily call to ask a question or get advice
Contacts you to see how things are going
Base: Has chronic condition.Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.
Blood Pressure Under Control Last Time CheckedHas Heart Disease, Hypertension, and/or Diabetes
CAN NOR US NZ SWE FR AUS GER NETH SWIZ UK0
20
40
60
80
100
85 85 85 84 84 8379 78
7469 69
Percent yes, under control
Base: Has heart disease, hypertension, and/or diabetes and blood pressure checked in past year.Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.
4. A Fair Comparison?Cross-Cutting Themes and Implications
• Room for improvement in all countries– Improving care coordination and system integration– Engaging patients in care and self-management– Using information better and in a cleverer way
• Efforts to make health care system more patient-centric, encourage choice and improve access
• Further competition needed to increase efficiency and improve performance (both UK and Switzerland)– Better purchasing– More competition in insurance markets and fewer barriers
• From a quality of care perspective, no single health system model stands out– U.K. and Switzerland very often lead but have very different systems– Very high co-payments in Switzerland & frequent calls for more
affordable health insurance premia– UK and Switzerland lead on perceived quality indicators
