Healthcare expectations are rising faster than national systems can keep up, but there are ways to tackle this global challenge effectively, says Penelope Dash.
Around the world, aging populations, increasing prevalence of long-term conditions, new treatments and altering consumer expectations mean that demand for healthcare is soaring beyond systems’ ability to pay. Most developed countries spend 10 to 16 per cent of GDP on healthcare and on present trends will need to spend 15-20 per cent by 2020.
The economic crisis is challenging health systems to cut costs while maintaining or increasing quality of care.
This article is the first in a series of three that will describe how health systems can tackle this dual challenge, and considers the English NHS’s response to the Liberating the NHS white paper, setting out the required changes. The second will examine how organisations can implement change, and the third will look at how change can be brought about in the present policy environment.
Developed countries have eight opportunities to reduce spending significantly while improving quality of care. The first four maximise the system’s allocative efficiency, the rest deliver efficiency gains in both hospital and out-of -hospital providers (see PDF).
All health systems must prioritise between populations, disease areas, and interventions. The clinical evidence base for efficient healthcare spending is not comprehensive, but there is sufficient information to allow robust prioritisation between different disease areas or within a care pathway.
Each intervention within a pathway can be quantified in terms of its expected impact on health and delivery cost. The resulting “cost curve” identifies which interventions deliver maximal health gain per amount spent, and which add lower value.
Improve long-term care
Better management of chronic or complex conditions in primary care can improve patients’ health status, prevent complications, and reduce hospitalisation. Some health systems use patient registries, performance monitoring and other tools. Germany, for example, uses performance management of dedicated disease management programmes to improve outcomes while lowering costs for diabetes and other long-term conditions.
Optimise settings of care
New treatments and technologies mean many services can move from hospitals to community settings. Often, quality is better, and – without hospitals’ overheads – cheaper. Equally, services that must be delivered in hospitals can be consolidated into fewer sites.
Focus on prevention
Reducing costly lifestyle diseases may take years, but many public health interventions produce quicker savings. Vascular screening helps prevent heart attacks. Encouraging breastfeeding markedly reduces hospital admissions in young children. Smoking bans have been linked to sharp drops in acute cardiac admissions. To prioritise and sequence interventions, health systems must be able to quantify their impact and assess the likelihood of success.
Ensure best practice
All health systems have providers with poor knowledge of (or adherence to) best practices. Few systems offer comprehensive guidance on best practice care or monitor adherence to guidelines.
Poor-quality care can cause significant errors: about 10 per cent of NHS inpatients experience an adverse event. This is both damaging for patients and expensive for the system. More systematic adherence to guidelines reduces errors.
Optimise clinical operations
All frontline clinical services can be streamlined to increase utilisation of staff and expensive assets, reduce duplication, increase throughput and capture scale benefits. Hospitals can decrease length of stay, increase utilisation, reduce headcount, and optimise the use of operating theatres, diagnostic kits, and estates. Analysis from Sweden found potential to increase individual clinicians’ patient-facing time (see PDF). Variations in out-of-hospital staff and estate use suggest similar opportunities.
Reduce back office spend
Back office spending – from procurement to support services – can be significantly reduced. A number of organisations have consistently achieved savings of 10-15 per cent.
Lowering healthcare spending requires a step change in delivery seen in other industries. Because we now pick our own groceries from shelves, support inventory management through online shopping, and scan our own items at the checkout, supermarkets have cut prices while earning higher margins.
Healthcare could see a similar change. Remote devices let patients monitor their own conditions and update their medical records; group consultations enable patients to support one another with practical information and advice.
Health systems must consider which actions to pursue and which tools (eg financial incentives, strong clinical leadership, and information) they should use to underpin and drive change. Next week’s article will look at these in more detail.
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