Atlantic drift

Published: 09/06/2005, Volume III, No. 5959 Page 18 19

First it was Beverley Malone. Now another US policy export from the Clinton era, Professor Donna E Shalala, former secretary of health and human services, is to take a look at the UK. She is a speaker at next week's NHS Confederation conference - but Andy Cowper got a sneak preview

Maybe it was infectious anglophilia: something inhaled in the 1960s Oxford air by Rhodes scholar and former US president Bill Clinton.

First, Beverly Malone, who was deputy assistant secretary for health in his administration, moved to the UK to become general secretary of the Royal College of Nursing. Now Professor Donna E Shalala, who served as Clinton's secretary of health and human services from 1993-2001, is coming to the UK to address next week's annual NHS Confederation conference.

As professor of political science and president of Miami University, she is a woman in a hurry. HSJ catches her just before a meeting and gets straight to business: what are her key messages for managers?

'There are three themes that apply to healthcare reform internationally. One - we are all in this together, trying to find a way to provide high-quality care at an affordable cost for government in the case of the UK, and for government, individuals and corporations in the case of the US.

'Two - we are all trying to figure out how much technology and information we can absorb to update health professionals on the latest techniques, and how we can get a culture of continuous improvement.

'Three - how do we organise all of this? How do we bring on board the new ideas for organisations about stronger roles for nurses and other professionals?' Professor Shalala has considerable knowledge of reform on a grand scale. The US Health and Human Services department that she ran had a budget of nearly $600bn and covered such programmes as welfare, social security, Medicare, Medicaid, child care, the public health service, the national institutes of health, the centres for disease control and prevention, and the Food and Drug Administration - enough acronyms to give her impeccable NHS credentials. The Washington Post described her as 'one of the most successful government managers of modern times'.

Professor Shalala is also now a director of UnitedHealth Group, whose Evercare programme has heavily influenced recent UK policy on the case management of longterm conditions.

Interim evaluation of Evercare pilots by the UK's National Primary Care Research and Development Centre in February found no firm evidence that it is yet reducing hospital admissions. However, it did discover that Evercare was popular with patients, and reported improvements in patients' quality of life. Likewise, the Picker Institute Europe's study found that GPs, nurses and patients all perceived it to be beneficial.

What lessons does she think Evercare possess for the UK?

'Evercare is an attempt to provide better care using other professionals working with doctors. It is also client-oriented, and more tailored to the individual, which may be the future of healthcare. People with long-term conditions seem to like this model. The question is, is it affordable? Everybody is learning.' Was it not the case that managed-care programmes like Evercare were introduced in the US largely in response to the rising costs of healthcare, including the socalled 'tariff creep' that affected the US version of payment by results?

Cost and competition

Professor Shalala demurs. 'We have known for some time in the US that we would need more co-ordinated care as new drugs and technologies are introduced. US medicine has become so technologically oriented that we had to have all the new 'stuff' organised by one person - to oversee the technology and ensure patient safety and quality.

Insurers were looking at their costs per treatment; why they were rising and what they could do about that.

But now the focus is back on quality, particularly for patients with long-term conditions.' Given the differences between the UK and US health systems, what does she see as the strengths and limits of competition? 'Healthcare markets are different from everything else. When you're talking about competition, are you talking about competing on the grounds of quality? Competition on driving down costs is not good enough - but driving up quality is valid'.

Demand management is the twin brother of commissioning, metaphorically speaking. In the US, United is responsible for commissioning at a population level far bigger than those covered by primary care trusts. Many commentators think the UK would benefit from this kind of approach.

HSJ columnist Simon Stevens - now United's European president - championed a similar idea while serving as the prime minister's adviser on health, although he proposed that the highestperforming PCTs might take on commissioning in other 'failing' areas on a franchise basis.

Does Professor Shalala think that United could and would be interested in tendering for that kind of work in the UK? Her response is diplomatic. 'Trying out new ideas is always good, if It is carefully studied and you report back locally on effectiveness. I am very much in favour of trying new ideas.

Healthcare has changed, and we ought not to be afraid of new approaches to provision.' Another new approach, being explored both here and in the US, is more intensive use of data to determine how well healthcare systems are performing.

In particular, now that activity will increasingly drive payment for healthcare services in the NHS, there is a growing argument that development of necessary data should focus more on outcome measures than relative mortality rates - such as those proposed to indicate the performance of cardiac surgeons. Which would she favour?

'Outcomes are a better measure, ' says Professor Shalala. 'But unless you can measure the health status of patients when they started treatment, they do not tell you much.

You have got to know what has changed.' What does Professor Shalala believe are the distinctive US health issues?

'In the US, our priorities are to try to get a consistent standard of care, as opposed to a very decentralised standard, mostly based on where you went to medical school.

'We [also] have large numbers of patients passing from doctor to doctor with no co-ordination of their care, but That is changing and We are focusing on obesity, tobacco, exercise - the 'low-tech' issues.

'If we can sort those out, we can definitely get on top of the high-tech issues.' Professor Shalala is not only visiting the UK to teach: she feels the US has 'much more to learn from some of your stuff'. Does she think the US could benefit from the NHS's gate-keeping GPs?

'Absolutely. In the States, we reward our primary care physicians much less well than our consultants, so we have a very specialist-oriented system. And specialists always find work for themselves. We have got a highquality system, but It is uneven.'

Universal coverage

Professor Shalala was in government when the Clinton health reforms failed. What lessons were learned from the battery of opposition that shot down those proposals to introduce universal coverage?

'I think we'll only get change to the US health system if the [members of the] American Medical Association were to get together and decide they want some kind of universal coverage system.

'To bring about a giant step change in social policy in the US, you have to get everyone to throw up their hands and say 'this is not working'.

Without a consensus on both the problem and the solution, you will fail. We had a consensus on the problem - but not on the solution.' Like jokes, the old questions are still the best: given all the differences between the US and the UK systems, how transferable are lessons between the two?

Professor Shalala is clear: 'Transferability is about attitude - can we share new ideas, are we open to new approaches, or will it be 'we have always done it this way round here'? The challenge is to find the specific improvement needed for each system'.

The CV

2201-: professor of political science and president, Miami University

1993-2001: US secretary of health and human services

1987-93: chancellor, University of Wisconsin-Madison

1980-1987: president, Hunter College, City University of New York