November 2013

Sustainable Health Systems for Inclusive Growth in Europe:
Session IV Overview

A conference organised by the Lithuanian Presidency of the Council of the European Union, Vilnius, 19-20 November 2013.

Improving health systems productivity: scope for reform

Efficiency improvements are needed to get more and better health care from dwindling budgets - to justify the claim on taxpayer funding and make health systems sustainable.

In response to the financial crisis many governments have cut spending on health care, forcing up waiting times, shifting demand from primary care to acute services, increasing health inequalities, demotivating health care staff and putting a stop to new investment. These undesirable consequences highlight how across-the-board decisions can set off a spiral of decline whereby a high level of public spending is devoted to health care, yet the value extracted from the investment diminishes.

This situation points to the need to confront the new financial reality – that healthcare budgets are unlikely to bounce back to pre-crisis levels – and to acknowledge the need to start reshaping services and applying technological and social innovations with the explicit aim of increasing productivity and making systems more efficient and resilient.

The recognition that budgets will remain constrained should also be the impetus for a concerted action to confront the challenges of ageing and burgeoning chronic disease and begin making the changes to established systems and ways of doing things that are required to deal with these problems.

The need to measure healthcare productivity

As the Chair of Session IV, Peter C. Smith, Co-director of the Centre for Health Policy at the Institute of Global Health Innovation, Imperial College London, points out in the interview accompanying this overview, the idea of measuring productivity in health care is an anathema to many. But a daunting and difficult task though it may be, such assessments are critical to squeezing as much value as possible out of shrinking budgets.

One place to start is by making comparisons of expenditure and outcomes in different member states. The European Collaboration for Healthcare Optimisation (ECHO), a Framework Programme 7 project which reaches its end this month, has gathered patient-level data from public hospitals in six member states and used this to deliver insights into unwarranted variations in the effectiveness, quality and efficiency of these health systems.

Researchers involved in ECHO are meeting to report their conclusions in Brussels on 13 November, when they will highlight differences in hospital performance, length of stays, and socioeconomic inequality in access to health care, amongst other measures of comparative effectiveness.

While comparisons like this are a good way of highlighting best practice and giving health care staff models to which they can aspire, they do not provide the means for systematically and routinely measuring outputs and using the information to improve performance.

Restructuring health systems certainly has a part to play in attempts to extract the maximum value from budgets. While the ageing population and rising levels of co-morbidities may result in increasingly complex clinical care and support needs, there is no reason why this care must take place in a hospital setting.

An ethos of shared responsibility

Specialist care could be administered in the community, with medical teams cooperating with primary care doctors and social services, to deliver care in, or close to, patients’ homes. For patients who do need to stay in hospital, there should be systems in place to ensure they can be discharged as soon as their clinical needs allow, not dictated by the 9 – 5, Monday to Friday regimes that currently exist in health and social care.

There is a need to pull down barriers between the different tiers of health and social care to create an ethos of shared responsibility that is reflected in, and supported by, more appropriate and transparent budget allocation and improved information management systems.

Removing the walls between different tiers will have the effect of making health systems more receptive to productivity-boosting innovation – which increase costs at the point of implementation, but reduces cost elsewhere in the system.

The push to improve productivity by centring health systems around primary care underlines the need for workforce training. Staff must look beyond narrow specialisations to empower patients through effective communications and support patients in self-management of disease.

It is clear that information technology can play a critical role in improving health system productivity in terms of improving administration; in the collection, analysis and dissemination of performance data as the foundation for evidence-based policy; and in supporting new methods of service delivery in telehealth, assisted living and mobile health.

‘Infrastructure-lite’ health care

Currently, health lags way behind other sectors in the use of information technology. Targeted investments in computer systems would provide the comparative effectiveness data needed to run health systems more efficiently and to justify and implement efficiency measures.

Coupled with the reconfiguration of health care systems in favour of primary care, assisted living technologies will allow older people to remain independent for longer. At the same time, the rise of mobile health will be a major opportunity to reduce costs by delivering health through ‘infrastructure-lite’ systems.

To give one example of the power of mobile health to improve treatment of chronic diseases, it is now possible to monitor wheezing in asthmatics via smart phones. While this is obviously very convenient, it also provides a better way of monitoring wheezing than existing manual devices. Similarly, smart phone-size diagnostic devices about to come on the market can process pinprick blood samples to isolate, amplify and sequence DNA, and then use this information not only for diagnosis of infections such as malaria, tuberculosis and HIV, but also to recommend the correct drug treatments. In other words, one portable device has the potential not only replace huge amounts of expensive equipment and fixed infrastructure, but also to deliver superior health care.

Mobile health is now primed to boost the productivity of health systems by giving European citizens greater control of their health. This is not only a route to reduce the cost of managing chronic conditions; it will be an important tool for disease prevention, health promotion and wellness.

In summary, it will take an intricate mix of cultural change and structural reforms, coupled with sensitive deployment of innovation, but the means are at hand to improve the productivity of health systems and to buy more health with our money.