14 October 1993 - 16 October 1993

The Shaping of Health-Care Systems

Chair: Sir Donald Maitland GCMG OBE

(In association with the Health Education Authority and the University of Bath)

This conference differed from Ditchley’s normal pattern in a number of ways. It was the first, as we plan, of a linked pair, run in collaboration with the United Kingdom Health Education Authority and the University of Bath; we hope that the two will result in a book; and we had the particular satisfaction, with the help of generous support from Glaxo pic, of having with us much the largest contingent Ditchley has ever had of participants from ex-Communist countries in Central and Eastern Europe (CEE). The Secretary of State for Health, the Rt Hon Virginia Bottomley MP, joined us and spoke at dinner on the Saturday.

The background to our discussion - intensified even since Ditchley had last addressed health-care, as recently as March 1992 - was a wave of system questioning and reform sweeping across a wide range of countries. High-profile debate in the United States reflected a deliberately-chosen priority of the new Administration, fuelled in its turn by the perceived mismatch between a high GDP-share expenditure on health and a notably imperfect population coverage; by the methodology used in a striking recent World Bank Development Report, we heard, the US rated very low in world value-for-money ratings. The United Kingdom too was working its way through uncomfortable and controversial reforms. In the CEE countries a near-automatic revulsion from the patterns of the Communist era was heightened by realisation that though the old ways had some creditable features, like high levels of child immunisation, the achievement overall - no significant life-expectancy change in four decades which had seen general improvement elsewhere in the world - was inadequate. But reform was complicated by falling GDPs and unstable socio-political settings.

Given a widely-shared recognition, however diverse the reasons, that things must be done better, how were lessons best to be distilled and options appraised? It was not the conference’s aim (though temptation flickered from time to time) to identify a best-buy system, but rather to illuminate and to help improve the mechanisms and processes - especially cross-national learning - by which policy and system choices were made.

We picked out a list of characteristics or criteria in terms of which the suitability and success of systems might be gauged. Inevitably, the list grew as we talked. We began with effectiveness, customer-acceptance, efficiency (including the ability to price and evaluate marginal improvement realistically), readiness of access, equity and relevance to health need. We added accountability; affordability overall; sustainability amid political and economic change; the availability of customer choice; and ideological “fit”. By this last we meant whether system design conformed with underlying national expectations, which might differ crucially from country to country, according to whether health promotion and health-care were seen as the basic responsibility of the individual or of the state. Ingrained social-culture attitudes in such respects bore heavily on which aspects of system performance and therefore which options for system design in matters like financing, delivery and incentive structure counted most.

We suspected that there might be some ideological convergence in progress between apparently-opposed outlooks. CEE countries and the UK (as arguably the most state-oriented of the main Western models) were inclining towards at least a greater degree of individual choice and of accompanying responsibility; the U.S. - where the theory of personal responsibility had been widely sheltered by the reality, now thinning out, of tax break-assisted employer provision - was by clear implication entertaining a deeper sense that proper coverage must entail governmental involvement. There was perhaps a recognition there that national accountability for total system achievement in healthcare must rest somewhere definite and did not so rest at present.

We acknowledged the continuous importance of public acceptance, understanding and consensus, and the role accordingly of the media. Not for the first time at Ditchley, we were worried about the media; it was difficult for them to command the professionalism needed for grasp of complex health-care issues, and more difficult still for them to put across, amid the black-and-white temptations of adversarial headlines and vivid human-interest anecdotes, the fact of resource-constrained hard choices and, often, the related imperative for change. This problem might sometimes sit awkwardly with another key element in system operation - the need to command the confidence of major system participants like the medical profession. Direct material interest aside, such participants - who were among the most powerful influences on the media - usually tended towards conservatism, partly through the nature and strength of their initial formation.

Amid all this welter of considerations, how were reformers to learn, and to pick their path wisely? There were risks already emerging in the CEE area of over-hasty movement towards over-sold Western models without full comprehension of whether they had proven validity and whether their repercussive implications made them suitable for transplantation. We observed different - not mutually exclusive - routes towards learning: for example, the search for dependable generalisations; reciprocal consultancy and criticism in bilateral pairings; study of differences between systems broadly similar enough to offer controlled- experiment approximation. We asked ourselves whether successful decision-making might be helped by the establishment of some new non-governmental idea-exchanging mechanism, more flexible and less baggage-laden than the formal bureaucratic structures of Government-based organisations like WHO. We agreed to revert to this among other questions at our next meeting, having first conducted some more systematic reconnaissance.

We plan collectively to define and carry out more work of this kind in preparation for the May 1994 conference. Only after that conference will we be able to assess the value of our enterprise in the round. But we have now established, and will do our best to maintain in May, a strong team of participants habituated to the Ditchley method and with much common ground captured, both conceptually and practically. With an important EC/WHO intergovernmental conference on health-care systems scheduled for December 1994 in Copenhagen, we look to make a timely and relevant contribution.

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 Donald Maitland GCMG OBE


Professor Richard Feachem
Dr Spencer Hagard
Mr Graham Hart CB
Mr Alasdair Liddell
Professor Rudolf Klein
Dr Robert Maxwell JP
Ms Annabelle May
Professor Alan Maynard
Mr John O'Sullivan

Mr Michael B Decter
M Claude Forget
Mr Scott Serson

Dr Martin Bobak
Professor Martin Bojar

Dr Rolf Levedag
Dr Manfred Zipperer

Dr Tamás Angelus
Dr Peter Makara
Dr Eva Orosz

Mr Iwaki Tabayashi

Mrs Kieke Okma
Dr Jan Stiphout

Professor Antonina Ostrowska

Professor Dr Dan Enachêscu
Dr Stelian Pop
Dr Milovoi Stamoran

Dr Marian Benčat MD

Mr Harry P Cain II
Mr John Glaudemans
Mr Michael Hirsch
Dr Roz Lasker
Professor Theodore R Marmor
Professor Jerry L Mashaw LLB