Mark Britnell has been scouring the globe for the perfect health system. Claire Read was there as he debated his findings with former health secretary Stephen Dorrell and HSJ editor Alastair McLellan
Global perspective: KPMG’s Mark Britnell has looked at healthcare in 60 countries for his new book
Six years ago, Mark Britnell began an extensive search for the perfect health system. It is a quest which brought him to 60 separate countries, and to what he says was an obvious conclusion: that what he was seeking simply does not exist.
‘The perfect health system doesn’t reside in one country’
“The perfect health system doesn’t reside in one country, but there are fantastic examples of great health and healthcare all over the world,” said Mr Britnell, global chair for health at KPMG.
“And although it’s not always possible to lift and shift systems from different parts of the world, it is possible to understand the dynamics and the ingredients of successful transformation.”
A recent discussion between HSJ editor Alastair McLellan, Mr Britnell and former health secretary Stephen Dorrell – now a senior adviser for KPMG – sought to build just that understanding.
Drawing on Mr Britnell’s newly published book, In Search of the Perfect Health System, the three talked about positive examples and cautionary tales from around the globe.
Primary care led
Israel, Singapore and South Korea were rapidly placed in the category of countries from which the NHS could valuably learn. “South Korea created universal healthcare in 12 years, which has to be a world record,” explained Mr Britnell.
“Singapore has just celebrated the 50th anniversary of its independence, and they achieve a life expectancy of 83 years of age for 4.9 per cent of gross domestic product. And Israel is the only country I’ve ever seen where talk of a primary care led health system is reality, not rhetoric.”
As Mr McLellan identified, the NHS is no stranger to arguments that it needs to look at the paths pursued by other countries. So were there, he wondered, actions which should definitely not be taken – those which might be judged potentially alluring but which are ultimately unhealthy and unhelpful?
“I would say that any system that primarily bases its healthcare on competition will end up paying a lot more money for those services,” Mr Britnell responded. “And that’s because of the asymmetries of powers that exist between the payer, the provider and the patient.
“Where competition works – and it doesn’t ever work perfectly in a healthcare system, nor should it – I’ve been quite surprised to see that it results in higher cost. Everyone, of course, cites the example of the United States, but when you look at some of the high performing European countries – if you look at say France, Germany, Netherlands – their health costs now are at least two, if not 2.5 percentage points, of GDP more [than the UK] and they’re not getting that much more out of their system.
“So I’m not saying we shouldn’t use competition judiciously, but I think a health system based on market forces will lead to much higher cost. So I would avoid that in the UK and the NHS example.”
Mr Dorrell agreed, suggesting that market forces are in some ways incompatible with truly universal healthcare. “Mark’s book references work that [Sir] David Nicholson did looking at how you introduce universal healthcare. His clear conclusion, rightly in my view, was that it doesn’t work if you think that what you do is allow the well off to secure the best and pull the rest up to the level secured by the best.
“Universal healthcare has to be a political commitment across a society as a whole, advancing on a broad front,” he continued. “That was something we did get right in the UK. The US is the best example of a country that has sought to follow the policy of deliver the best to those who can afford it and close the gap to the rest. That doesn’t work as a way of delivering universal healthcare.”
All of which lent a certain irony to Mr Britnell’s choice for best healthcare organisation: Pennsylvania based Geisinger Health System. “I’ve criticised the US because of its market foundations for healthcare, but Geisinger’s mission is to thrive and survive in spite of that marketisation,” he explained.
In 2000, the organisation was “in a terrible state”. He said: “They were in financial disarray, they had clinicians in revolt, and they had an insurance plan that nobody wanted to sign up to. So a perfect storm of failure. It may sound familiar to your readers in the NHS.”
Mr Britnell suggests a few factors turned this around: “If you’re asking me can they happen in the NHS and should they happen in the NHS, the answer is yes and yes.
‘The key is standardisation’
“They decided to say their sword and shield would be quality. So they built ProvenCare, which looks at 80 per cent of the highest volume procedures and care pathways, then looks at global best practices, has clinical caucuses, internalises those, systemises the processes through smart IT and then makes sure it’s run as leanly as possible.”
He added: “In terms of the English NHS, there is no reason whatsoever that we cannot construct fantastic Geisingers all over the country.”
The key, suggested Mr Dorrell, is standardisation. “The hint is in the title of ProvenCare: use the evidence where it’s available, don’t insist on reinventing it, if there’s a solution that works apply it.”
It is notable that, during the past two decades, Geisinger has increasingly provided care through hospital chains – the likes of which were proposed by Sir David Dalton in his eponymous review.
Mr Britnell expressed support for the rapid adoption of such set ups in England. “Having worked with the largest chains in the world, the sky does not fall on your head; there are real benefits in terms of clinical safety, there are real benefits in terms of clinical outcomes, and there are real financial savings to be made as well.”
The £22bn question
It was a comment that moved the discussion onto the scale of efficiency savings that might be possible in the NHS. Could the Five Year Forward View figure of £22bn by 2020 be delivered, asked Mr McLellan. Mr Britnell largely demurred: “The £22bn is a moving number, based on many assumptions. Look at what’s happening now in China, and the ripple effect on the global economy, just as one example of how things change.”
And he expressed concern about the impact of the figure on morale. “With the £22bn, I think Simon [Stevens] was right to focus attention on the size of the challenge. My own view at the moment is people are becoming crushed by that number, and it’s not liberating enough energy and focus for us to be able to achieve the savings. I think people need more help and support, and I hope that will be forthcoming.”
Some feel new sources of capital might need to be forthcoming too. Here, Mr Britnell suggested the UK could once again draw on the experience of other nations.
‘New sources of capital might need to be forthcoming too’
Option one: direct state investment in new facilities, as in Singapore. Option two: the US model, where there are clear incentives for care transformation – the national “meaningful use” programme, for instance, which rewards the adoption of electronic health records.
Option three – and the most common in Bismarck/Beveridge-type systems, Mr Britnell said – is to have a conversation “about which are the most critical parts of infrastructure to be transformed”, and then to find specific solutions to funding them. When it came to “bricks and mortar and cable, you could go to the pension funds to create a different form of public/private partnership”, he suggested.
“I think the pension funds are certainly interested, but they need clarity and certainty over a long period of time.”
He also spoke of the possibility of joint ventures, specifically with IT firms. “The NHS would always be the dominant force, I think, because you’re controlling care processes, but you would have joint ventures between say the foundation movement or [clinical commissioning groups] and [information and communications technology] suppliers.”
He added: “I think there is more than enough space in the English NHS to raise the capital to transform using one of those methods. And I think they should
But he was concerned about the lack of clear local plans over 5-7 years. “I’m still working 20-30 per cent of my time in the UK, and the English reforms of 2012 have created a great degree of fragmentation. At the moment we’ve got individual fiefdoms, be they CCGs, local authorities or hospitals, who are all trying to do their very best in terms of the world in which they live.”
But, he said: “No one really has got an overarching plan locally for 5-7 years of transformation based around better health, better care, and better value.”
Wisdom of the global crowd: answers to some key questions
To write In Search of the Perfect Health System, Mark Britnell says he ‘worked in 60 countries on just under 200 occasions, and circumnavigated the world 70 times over’. Here, he answers questions currently facing the NHS, drawn from those experiences and journeys
How long does it take to implement real and sustainable change in healthcare?
“The quickest changes I’ve ever seen that make sustainable progress in terms of quality, finance and access take about a decade. Some have done it in seven years, many have done it in 12.”
Where is the NHS on that journey to lasting change?
“To use the analogy of a crop, I believe that we’ve broken the soil and the soil is being properly cultivated. We now have to actually grow and harvest. And therefore I think we’re probably in year four or year five.”
If we introduce accountable care organisations, quite how should they be held accountable?
“At Geisinger, accountability on better health, better care and better value applies at three levels. On better care, clinicians are held to account for adhering to protocols that have been evidenced as best practice. I asked [then chief executive] Glenn Steele a very direct question: if clinicians don’t like playing with these protocols, if they think that ProvenCare is some management technique to make them fail in their jobs, what happens? He said they’re invited to reflect on their practice and then invited to leave the organisation.
“On better value – if Glenn and his board are not making acceptable rates of return on investment, be it in buildings, in human beings or in IT, they are held to account.
“And then I asked him the most difficult question, on population health, and his answer to me was thank goodness for Obamacare. Because with Medicare and Medicaid shifting to the states – the equivalent of our local government but at much bigger scale – they of course are very interested now in the determinants of ill health and wellbeing.”
Will devolution work?
“I think the start in Manchester has been promising. Clearly we have learnt from Norway, from Sweden, from Denmark, that it’s possible to have local authority inspired and directed healthcare. But of course they’ve been doing it for decades and decades. I think it’s too early to say how all this will pan out [in Manchester]. I’d prefer them to start and bump into problems than to spend the next two years having a perfect wiring diagram about accountability and responsibility.”
From which non-European countries could the NHS learn most?
1) South Korea
“I was impressed by South Korea because it started in the 1950s after civil war with no industrial or service base to talk of and created universal healthcare in 12 years. There is an umbilical link between what it means to be Korean and also what it means to be a great industrial country, and they’re now linking that to healthcare.”
“It’s a small country but as the state was being created, they sent all of their civil servants to look at the best and the worst parts of health systems both in North America and Europe. And they created something that is distinctly Singaporean.”
“It’s the only country I’ve ever seen where talk of a primary care led health system is reality. That stems from the health maintenance organisations that were created by the Zionist Labour movement in the second decade of the 20th century. These four [health maintenance organisations] are basically grounded in the community, and so everything that’s been built in Israel was built from a primary care and community care bedrock. They only spend 7 per cent of GDP for a life expectancy of 83 years of age. It’s a phenomenal system.”
How do we avoid a scenario where the NHS is lurching from deepening deficit to even deeper deficit, and where bailouts become the norm rather than the exception?
“I’ve seen very distressed systems in Portugal, in Italy, in Spain, in Ireland - so countries where they have literally run out of money.
“When you get into that situation, pensions are slashed, jobs are made redundant, and there is no healthcare reform or development whatsoever. In a sense you place your health service in the dark ages.
“The NHS has to be respectful of the fact that we are trying to anticipate interest rate rises to make sure that our economy is placed on a very sturdy footing over the next 10 years. We don’t talk about that in health, but it’s very important to acknowledge.”