Once again we were addressing in this conference a subject on a comparative basis which superficially at least has been tackled in such different ways in different countries that comparison may be impossible. Nevertheless the underlying issues are common to all and while history and culture shape the solutions, it seemed possible and useful to try to derive some common principles.
The first point that emerged was that while it was prima facie attractive to distinguish systems funded from direct taxation from those funded through insurance schemes, whether state-managed or private, in reality all expenditure must be regarded as coming from the pockets of the people. Even the apparently wholly private system in the US was largely supported by federal funds, through Medicare, Medicaid and tax reliefs. It would be more useful, it was suggested, to distinguish between different methods of provision, i.e. between those systems where provision is managed directly by agencies of the state and those where it is in private hands. The Canadian system could properly be regarded as a private system, funding coming from provincial taxation (with some federal support), but provision being privately managed.
One working group in particular addressed the fundamental question: what should be the objective of a health care system? Equal access for all regardless of means? Equality of treatment for all? A situation in which no treatable ailment went untreated? Personal responsibility, with freedom of choice within the individual’s means? If equity was the preferred objective, how could the tension between it and cost-efficiency be managed? Competing objectives necessarily involved trade-offs, the balance depending on the history, culture and values of each society. It was noted that when health care was last discussed at Ditchley in November 1985, the emphasis had been on equity: in this weekend’s discussions the emphasis had been more on efficiency and effectiveness. It was noted also that in Canada and Europe the emphasis tended to be on equity which had been more or less achieved, and in the US on personal responsibility.
The point was made that in most countries the system was demand-driven; but whose demand? Hitherto, it had been the demand mainly of the profession, but there was a case for shifting the bias towards the patient (or, better, the consumer). That called for better informed consumers, able to exercise choice between treatments, and brought out the importance of the family doctor at the primary level. There was some evidence, it was claimed, that informed consumer choice did not necessarily lead to more, or more expensive, treatment: it could lead to a reduction. Such an approach however also emphasised the importance of education, not only about disease but about healthy living and in that area the media had not always been helpful, preferring the sensational. Moreover there were dangers in too paternalist an approach. Screening was perhaps an example: the cost-efficiency of blanket screening, or the screening of a group, for example the elderly, was questionable. Intervention, presumably the object of screening, might often do more harm than neglect. Similarly, the latest, more expensive, treatments might not produce a better outcome than earlier, cheaper ones: there was a great need for systematic evaluation of such “advances” and the dissemination of the results.
This led to a discussion of how wide an ideal health care system should spread its net. The line between treatment of disease and long term care of the infirm or the handicapped varied in different countries and the link between the two, responsibility for which often fell to different departments and budgets, was blurred. In the UK, for example, health care provision was free at the point of access (with some relatively minor contributions for prescriptions etc, though it was suggested that in all systems co-payments would increase), but home-care and other social services were means-tested. The Belgian insurance system was comprehensive, but in many countries the cost of long-term care was growing, especially of the elderly, and was being shifted on to the individual or private charities. Better coordination between the health care system and the social services could lead to more home care (which many of those concerned preferred), greater efficiency at lower cost and the freeing of facilities for acute cases, thus serving the overall aim of efficiency and effectiveness.
In a comparison of international costs, the US stands at one end of the spectrum, devoting some 12% of GDP to health care and the UK, of the developed countries, at the other, with a figure of a little less than 6%. Most developed countries are grouped in the bracket 7-9%. If there was an ideal level of expenditure, which all doubted, that bracket seemed to be about right. However in some countries the figure was rising relatively fast and containment was becoming an issue. It was suggested that ideally health care should be removed from politics, but in a democracy that was impossible, and choices had to be made between health and other calls on the national income. Indeed the health care industry was itself a major employer and made a significant contribution to the economy as a whole. That said, it seemed that the issues generated less heat in systems which were insurance-based, whether or not the premiums were regulated by government, and provision was privately organised, although costs might be more difficult to control. (In British health politics however “privatisation” was taboo.) Decentralisation of budgetary control in systems of private provision, or in the British reforms, called for more sophisticated management, as opposed to administration. The Canadian or German systems might well be models here, although in a discussion of what advice we should be giving to East Europeans, it was generally agreed that we should be cautious in commending any system: rather we should encourage them to build on what they had, recognising their current strained resources; and beyond that, should, with proper humility, point to our own mistakes. Above all they should come and see for themselves and not blindly accept the nostrums offered by visitors.
In a discussion of pharmaceuticals, it was pointed out that the proportion of budgets devoted to drugs was relatively small and shrinking. Nevertheless there was much unease among consumers at the costs, some of which could be attributed to improper use (over-prescription was the obvious culprit but under-prescription leading to inefficient treatment and mis-application were probably more serious). The removal of some drugs from the requirement of medical prescription would economise on doctors’ time. The industry should supply credible, independently certified, cost-efficiency evaluations, based on agreed protocols. This was happening. Regulation was necessary but the procedures were too slow. The problem of dissemination of information to the medical profession was noted but not addressed.
There was some discussion of the impact of “private” medicine operating in parallel with state systems (in Germany, Canada, Belgium, the US, and no doubt elsewhere, the distinction is irrelevant). In general it was felt that such private medicine provided useful competition in standards of comfort and care, but that in quality of treatment there was nothing to choose between them - and rightly so. There was a need for more dialogue between the two sides.
Finally the question of priorities within the system was discussed. Although insurance companies were beginning to intervene between doctor and patient in an effort to contain costs, this was not to be encouraged and was not a feature of systems funded by the state. However the funder had legitimate interests in shifting resources to meet perceived needs, and probably also in overseeing the supply of personnel, in both the medical and para-medical fields, to meet anticipated demand - and perhaps also in encouraging mid-career re-training to redress imbalances. In many systems such oversight was not practised and might be impracticable. The point was made that the professions involved in health care had little loyalty to the system as such and could not be motivated by calls for efficiency: it was necessary to enlist their cooperation by appealing to their professional wish to provide better care. If governments saw a need for a particular sector to grow, they must lift the cap on expenditure in that sector.
To sum up, health care was seen as part of a social contract. There was no ideal system, but in each country, the system must reflect the culture and values of society, in the recognition that tensions between equity, personal responsibility, freedom of choice and cost restraint were inevitable. The evaluation in terms of cost efficiency of new treatments and the dissemination of the results were essential; and if the consumer was to be given choice, he must be given information. There was no case for the funder intervening in clinical decisions, but priorities could and should be set and resources shifted to correct imbalances. Such shifts must be based on quality, not cost, if the cooperation of the professions was to be secured.
This Note reflects the Director's personal impressions of the conference. No participant is in any way committed to its content or expression.
Chairman: Sir Roger Bannister CBE DM FRCP
Master, Pembroke College, Oxford; Honorary Consultant Physician, National Hospital for Nervous Diseases, London; Honorary Consultant Neurologist: Oxford Regional and District Health Authorities; St Mary’s Hospital, London
LIST OF PARTICIPANTS
Mr Robert Van den Heuvel dr Jur
President, World Association of Health Care Friendly Societies
Professor Brenda Almond
Director, Social Values Research Centre, and Professor in Philosophy and Education, Hull University
Dr Alex Gatherer
District Medical Officer and Director of Public Health, Oxford
Sir Roy Griffiths
Deputy Chairman, National Health Services Board; Adviser to the Government on National Health Service (NHS)
Dr Spencer Hagard
Chief Executive, Health Education Authority, London
The Baroness Hooper
Life Peer, (Conservative)
Professor Ian Kennedy
Executive Director, Centre of Medical Law and Ethics, King’s College, London
Professor Rudolf E Klein
Professor of Social Policy, and Director, Centre for the Analysis of Social Policy, School of Social Sciences, University of Bath
Dr Robert J Maxwell JP
Secretary and Chief Executive, The King’s Fund for London Hospitals
Professor Alan Maynard
Director, Centre for Health Economics, University of York
Dr Harry McNeilly MD FFPHM
Director of Health Services, Private Patients Plan, and Chairman and Chief Executive, PPP Medical Centre, London
The Rt Hon Sir Patrick Nairne GCB MC PC
Retired as Master, St Catherine’s College, Oxford (1981-88); Chancellor, Essex University
Rabbi Julia Neuberger
Member: Ethics Advisory Group, Royal College of Nursing; Council, St George’s Hospital Medical School; Human Fertilisation and Embryology Authority;
Dr Helen van Oss
Principal in General Practice
Sir Leonard Peach
Director of Personnel and Corporate Affairs, IBM, Portsmouth
Mr Stephen D Withers
Assistant Director, Group Strategy, British United Provident Association (BUPA)
Mr Michael B Decter
Deputy Minister of Health, Province of Ontario
Professor Robert Evans
Professor of Economics, University of British Columbia, Vancouver
Mr Claude E Forget
Vice-President, Laurentian Group
Dr Jean de Kervasdoué
President and Director-General, SANESCO, Paris (organisation specialising in the management of health care institutions)
Professor Dr Klaus-Dirk Henke
Professor of Economics, University of Hanover (specialising in public finance and health economics)
Dr Francis Pinto
Director of Strategic Planning, Glaxo Holdings
Professor Naoki Ikegami
Professor of Health and Public Service Management, Faculty of Policy Management, and Professor of Hospital and Medical Administration, School of Medicine, Keio University, Tokyo
Ms Kieke G H Okma
Executive Secretary, Steering Committee for Health Care Reforms in Netherlands, Ministry of Welfare, Health and Cultural Affairs, The Hague
M Jean-Pierre Poullier
Administrator, Health Unit, OECD, Paris
Mr Göran Rådö
Under-Secretary of State, Ministry of Health and Social Affairs, Stockholm
Mr Theodore Bernstein
Director, Benefit Funds Department, International Ladies’ Garment Workers’ Union
Mr John C Erb
Principal and spokesman on health care issues, A Foster Higgins & Co Inc
Mr Jacob Getson
Senior Vice President, Medical Delivery, US Healthcare
Professor Theodore R Marmor
Professor of Public Policy and Management, School of Organization and Management, New Haven
Dr Hamilton Moses III
Vice President, Medical Affairs, The Johns Hopkins Hospital and Health System, Baltimore
Mr Leonard D Schaeffer
Chairman and Chief Executive Officer, Blue Cross of California
Mr W Vickery Stoughton
CEO, Duke University Hospital and Vice Chancellor for Health Affairs, Duke University
Dr Henry Wendt
Chairman, SmithKline Beecham pic, Brentford
Professor John W Wennberg MD
Director, Center for Evaluative Clinical Sciences, and Professor of Epidemiology, Dartmouth Medical School, Hanover, New Hampshire (specialising in doctor-patient relationship and health care)