Something NICE needs to do

NEWS FLASH: Setting a minimum price for a unit of alcohol would help tackle Britain’s drink problem, health advisers are expected to recommend. The National Institute for Health and Clinical Excellence (Nice) will include the advice in its guidance on how to crack down on problem drinking. (1 June 2010)

This commentary is not on whether to set a minimum price for alcohol. This is a comment about expansion of the scope of NICE’s mandate.

What is NICE for and why are they now becoming involved in more fundamental health policy matters? Under the rubric of health excellence, one assumes they are pushing this as far as they can possibly go.

NICE is really a disguised authoritarian advisory body because of their lack of proper public accountability coupled with their privileged access to ministers in government.

NICE are not ‘health advisors’; they are a fourth hurdle advisory body with a focus on what works in healthcare service delivery, such as medicines and device technologies. By moving outside this, they are creating the impression that any area of health interest can be subjected to their methodologies. Indeed, that all matters of policy can be reduced to a QALY analysis and some economic modelling. No doubt at some point, they will pass judgement on the health impact of the national speed limit,  the salt content of food, the pub opening hours, as long as there is some way to tie the analysis to a health outcome. Invoking their brand of technocratic thinking to replace the fine art of public consultation is hardly the way ahead — that there is some evidence for the benefits or costs, does not lead inexorably to the conclusion that health policy should change.  Running health policy by the numbers in this way guts the democratic process for deciding social priorities.

This all-purpose extension of the mandate of NICE is not a good thing, for democracy or for health policy in the UK.

For all the reform and protestations that the public deserves a health system for the 21st century, the ongoing saga of health reform in Britain continues to amaze.  The Secretary of State for Health for England, Andy Burnham, has decided that NHS providers get to try twice to prove they are worthy of continuing public confidence.  As he has put it, the NHS is the “preferred provider”, apparently for itself.

Those not familiar with the reform of the NHS, and indeed those who are, must be wondering why mediocrity should be rewarded, and in these difficult times, why the taxpayer or the government should countenance circumstances that public public money at risk.

The NHS commissioners (purchasers in real world speak) are the surrogates for consumer choice, as while NHS patients do have some choice, commissioners in the end are deciding in which directions that choice can be exercised.  A bit like Henry Ford’s model T car: you can have it in any colour as long as it is black.

Why should this matter? The Minister has said that the NHS should not be agnostic about who provides healthcare service delivery but instead favour NHS providers.  But as a monopoly supplier of services, the NHS and the English Department of Health must be mindful of abuse of a dominant position and in particular favouring institutions that are in effect emanations of the state, on the one hand, and forcing the public to experience second-rate service on the other.

Favouring a failing provider strikes me as looking a lot like state aid.  It also does not appear to be a service contract either, as the reason for awarding the contract seems to depend on the ownership of the provider (and protecting their status) and not whether they can deliver the service to a quality standard (which is the purpose of the contract).  The clue that this is a policy fudge is that a failing provider gets another chance to be a preferred provider over a potentially more competent and higher quality provider.  Can you legally enter into a contract for a service to a quality standard, knowing in advance that the provider is unlikely to be able to deliver to the terms of the contract?

Hmm. So much for value for money and healthcare fit for the 21st century.  Do I hear the auditors stirring?

The leaked McKinsey report on the NHS, which endeavoured to provide a review of areas where efficiencies can be achieved in the face of declining public finances does not really offer anything we don’t or at least shouldn’t already know.

NOTE: This post does endorse the McKinsey’s report findings — only to express some surprise that it was not more insightful.  Of course, I have only read the leaked documents, and cannot comment more fully, but then if the Department of Health did want a proper (adult) debate, they would put it in the public domain for all to see.  Perhaps McKinsey would, as supposedly insightful strategy consultants, suggest to the Department the value of a wider social debate on the NHS priorities — but this isn’t their style.  The wisdom of crowds, or the madness of experts?

So on with the commentary.

As if at least 20 years of NHS reform meant nothing, OECD countries together are grappling with rising healthcare expenditure coupled with demand that seems insatiable.  The recession and its consequences has for many offered a useful policy window through which to drive changes that under more benign economic circumstances would be untenable.  Health, as always, is the last to face the music.

What actually is the NHS?  In the UK, it is 4 devolved publicly (tax) funded universal health systems (England, Scotland, Wales, Northern Ireland run their own show); McKinsey is writing about the English NHS.  The “NHS” is often described as one of the largest employers in the world, but then healthcare systems are generally large employers, usually about 5% of a country’s workforce, consuming around 9% of GDP.  The whole health industry is usually about 15% of GDP, employing perhaps 7-8% of the workforce.  So they are all big.  What characterises the UK’s fascination with the NHS is the tendency to speak of the NHS as though it were ‘one thing’, whereas it is more likened, perhaps more accurately, to a confederation.  Regretfully, policy makers have failed to really make sense of the role of private and non-profit providers so there is really only weak integration of services across all providers.  This constrains policy and service delivery somewhat in England as there is always the fears of privatisation and so on.  It is worth keeping in mind though that general practitioners are private sub-contractors, while the acute sector is increasingly run by autonomous arm’s length hospital ‘foundations’ (a weak attempt at copying a hospital arrangement from Spain).

So the NHS is an acute service provider, a contractor for primary care from service providers, and a buyer of services from acute providers.  That it is characterised by a purchaser/provider split is helpful in understanding the constraints under which the system works, as the purchasers (primary care trusts) are in the main general practitioners commissioning (English jargon for buying) care from acute providers.  This engenders some confusion in the public domain between who is responsible for the planning and problems that get thrown up.  The McKinsey report can be seen either as a message to acute providers to reduce their overheads, or a message to purchasing organisations to set contracts with tighter cost controls for the value received (i.e. for the care provided at what level of quality to their patients).

The politicians are indeed running around in a bit of a frenzy because the NHS is seen as a sacrosanct public sector organisation, and that cutting the budget would be equivalent to committing treason.  Of course, this adds to the problem and increases the denial.  This strengthens the hands of those who oppose reforming healthcare, and makes the case for increasing efficiency and productivity, and in general ensuring that the public receives good value for the tax money spent on healthcare more difficult.

Yes, healthcare is a hands-on activity, and yes we need hospitals (at least for now).  But it is hubris to suggest that the acute hospitals are as productive and efficient as they could be, or that the distribution of clinical work across the health professions is a well done as it might be.  Hospitals by and large still draw on industrial age models of organisation — they are little different from commercial conglomerates.  Efficiencies in McKinsey’s report comes from things such as:

• vertical integration (hospitals into community care, for instance)
• integrated care pathways (something healthcare has been up to for at least 20 years)
• reduction of waste and duplication (no surprise there)
• role clarification of clinical work (yes, professional cartels called Royal Colleges)
• elimination of clinically ineffective or doubtful work (the tough call but is a natural consequence of evidence-based medicine).

Criticisms of the report are right to the extent that McKinsey has done what they are generally good at: stating the obvious.  Any of these items should be on any hospital CEO’s to-do list, and subject of Board level discussions.  Unfortunately, where McKinsey is less good is in looking at the NHS and assessing the underlying logic and meaning of its organisational structure, its clinical care paradigm, and how it can evolve, as a dynamic entity, into a better care system (they would surely argue that that wasn’t their brief, but good consultants work with, not just for, their clients).

But salaries and infrastructure (buildings) are the costs to look at: perhaps 80% of a hospital’s budget.  Choices here require a different logic, and include:

• using e-health, telehealth technologies to replace both staff and infrastructure (home telecare monitoring, for instance)
• use of supportive clinical decision-support technologies (from robotic vision systems to work with radiologists to scan mammograms, thus doubling the number of radiologists, to artificial intelligence systems to data-mine health records to identify patients are risk of A/E readmission to a COPD exacerbation)
• using medicines to replace hospital stays, surgical interventions
• using best-imaging-technology first to diagnose (the best technology to diagnose a problem is not generally used in initial diagnosis, an x-ray might be used, then CT, then MRI.  Just use the best first.)
• and so on.

These all address the possibility of labour (clinical work) substitution, (which might improve the quality of the jobs clinical and support staff actually do), greater patient empowerment (as they take greater control of their healthcare, direct resources to achieve their own healthcare goals), and a real use, slowly being addressed by the Connecting for Health initiative, for information for clinical and patient decision-making.  This emerging information value-chain will produce improved measurement of clinical outcomes, and thus inform better in-hospital decision-making and resource allocation.

Of course this ignores the actual physical unbundling of hospitals themselves.  The organisational logic that requires the aggregation of clinical skills in the modern hospital is dated under many service scenarios.

So where are we?  We are at the point of knowing that much can be done to improve the patient’s experience of healthcare, by driving out dated clinical and organisational practices, adopting new practices and technologies, procedures and methods.  It should not be inconceivable for any healthcare system to achieve 20% savings.  Fear of alienating clinicians is less the issue than engaging them in service improvement, to which they should be committed.  This will in the end ensure the high-touch requirements of healthcare where it is needed, without protecting sacred cows and vested interest groups.  In the end, it will come down to political will, managerial commitment, and clinical professionalism to ensure, in a publicly funded healthcare system, that the public gets what it thinks it is already paying for.  Otherwise, resistance looks a lot like protectionism.

From across the Atlantic comes news of apparent financial maladministration at E-Health Ontario, the body charged with implementing the province’s e-health strategy.  It seems to be the usual nonsense of untendered contracts, friends in high places, and chums helping chums.  It is also an example where no one seems to have asked the simple question, “why would you do that?”  — the strategy is a nonsense, and I am surprised that no-one challenged this before the policy had gone this far in implementation.

I would, naturally be more inclined to be concerned if the province’s e-health strategy were actually about e-health, or likely to deliver results worth having, but the $700 million or so per year will be spent on things like a diabetes registry, wait times, electronic prescribing/electronic health records.  Only the last have anything really to do with e-health.  The last can also be procured, so there really isn’t a need to make a supplier meal out of putting something in place.  I will concede though that an EHR is a critical component of e-health, but it isn’t quite the same as e-health — it is a bit like confusing the foundation of a house with the home it will become.  But having worked on eRx,  the province’s failure to prioritise some sort of a patient-held smart card is a mistake as without this it is difficult to deal effectively with identity.

Without system redesign in the province, the e-health strategy is really just throwing good money away and given the current economic (and political) climate, this is no longer an option, if it ever really was.

Two things are of critical importance.  First the province needs to have a thorough-going governance review of e-health Ontario, mainly to determine how to make sure it is fit for purpose in actually providing the leadership for development of an e-health infrastructure service delivery platform.  Secondly, and this is the challenge, it is necessary to make sure that the e-health services are ones that the public will use and value.  The province has failed on both counts.  The next challenge though will be to find people to review e-health Ontario who haven’t been tainted by this scandal and benefited from the feeding frenzy e-health Ontario created. It may require looking further afield, to interested, but uncontaminated parties.  They may even not live in Ontario — golly gosh, so much for made-in-Ontario mediocrity.

So, having vented on that last point,what would an outline e-health strategy look like for Ontario, assuming that some governance arrangements are put in place,.  These are really just illustrations as certainly I would want to get a good understanding of priorities from interested patient groups:

• There are about 90 rural and small hospitals in the province.  A good plank in an e-health strategy would be to enable them to become a single, integrated, but distributed healthcare provider, perhaps with some sort of local and shared corporate governance.  A distributed healthcare provider, using e-health infrastructure technology would deliver specific outcomes to rural people, such as access to networked diagnostic imaging technologies, electronic prescribing and remote access to health records.  I would certainly save people in Thunder Bay a lot of trouble getting down to Toronto for a scan.  With a little bit of imagination and thought, this could work.
• About 60% of diagnostic facilities are located in Toronto, but which has only about 25% of the population; these are licensed clinics which often only offer a single procedure.  Using networked imaging technologies, remote diagnostic telecare booths (you can buy one from Cisco) many of these suboptimal centres could be relocated either to the rural network, in the previous plank, or provide a more accessible urban service across the provinces main urban centres.
• Smart card technologies (whether a smart card or an electronic secure passport) would give a better reason for constructing electronic health records than ones focused on improving data access for health professionals alone.  Patients, when given access to their health information, will have a vested interest in ensuring that the information is correct (my Ontario health record when I lived there had an error showing I had a condition affecting women, but I am a man — I still don’t know if the error was corrected; in an electronic system, that error would have been a problem, but I would have made certain that it was corrected, too).  As an ‘auditor of one’ patients can make sure information is correct, and drive substantial service quality improvements.  This is not to say that health professionals can’t do that, just that the evidence shows it comes slowly and is complicated by cartel-like professional practice barriers.  Start by putting the e-health card in the hands of the heavier users of the health system, to better manage their healthcare, access to information, and gradually as people see their family doctor, or get born, migrate the whole population over.  Of course, this will mean that family doctors, clinics, pharmacies will have to adopt some sort of information system.
• Don’t do what the English NHS is doing with Connecting for Health, by creating a large-scale government-led initiative.  E-health Ontario’s predecessor took a look at Denmark, but failed to learn the lessons despite what they wrote in their sham of a consultation document — they missed the point partly because they appeared to have another agenda heading toward a particular solution.  Denmark has shown how disparate stakeholder groups can work together to create an information system that works, and does things people value.   Better that than spend vast amounts of money on a grand plan to nowhere.

The general plan is to build an infrastructure that starts with the patient/family as user.  My experience in developing an interactive health television channel showed me the importance of starting there, and defining the benefits from that perspective.  Change will drive from that end too.  Finally, engage all the stakeholders (like the Danes did), find commercial partners with interesting technologies that do things that people value (rather than whizzy technologies), look for alternative systems to pay for healthcare services, as failure to develop a suitable and workable reimbursement system for e-health services is a barrier ( just ask Norway).  Oh yes, don’t forget political will.

The supply management system inflates the cost of diary products to Canadian consumers. Canada also applies substantial duties on imported dairy products. Both of these practices are of dubious benefit to consumers, and cost them substantial sums of money each year. It also has public health consequences that have been ignored.

In other countries, and particularly within the European Union, prices for milk, cheese, probiotics, yoghurt, etc. are about 30-40% of Canadian prices. By comparison, in a typical Canadian grocery store, a litre of low fat milk ranges between C$2.14 and C$2.40, three times the price in Europe.

There is some evidence that high prices may discourage parents from buying milk for their children. This may correlate with family income relative to poverty thresholds. Research has quantified how children substitute sugary carbonated drinks for milk. Reduced dairy consumption may be contributing to rising obesity in children and perhaps rising incidence of Type II diabetes, something we thought only showed up much later in life.

Milk consumption is also lower for girls, which may predispose them to osteoporosis later in life. Recent Canadian research has shown that reduced milk consumption during pregnancy leads to low birth-weight babies. We are also seeing the return of rickets.

At present, the parties to the supply management system itself are the main sources of information for consumers on dairy products. This makes it virtually impossible for consumers to access independent information. This is a tight circle that may not be acting in the public interest when looked at in terms of implications to human health.

The logic of the dairy supply management system is weak when tested against public health outcomes.  It is time to abandon this policy, which favours the few, has public health consequences for the many, and adds costs to provincial healthcare systems already under significant stress.