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The US-based Commonwealth Fund has released a new 11-country comparative ranking of health systems. See the diagram. commonwealth fund table

Before the UK pops the champagne corks, let’s decode this ranking a little bit. Oh yes, before we also get too excited, rankings like this are useful only as a discusion tool. What does it say say operationally, if you had to choose a system to be ill in?

In effect the UK is tops and the US bottom, overall. But there are some disturbing issues with the data that necessitate a reflective pause.

If the UK is 1 for Quality of Care, and 1 or 3 for Access, and 1 for Efficiency, why doesn’t that translate into Healthy Lives? If the US is middling for these, which it appears to be, are we surprised that they have poor efficiency, equity and healthy lives?

What strikes me is that the UK despite having scored 1, that all this effective care, etc. is really ineffective as it doesn’t translate into better results. Efficiency, too, seems a technical measure, and one which also seems to fail to translate. So two quite different systems on the ground, and which are poles apart on the ranking, are competing with each other for impact on people’s healthy lives.

If we look at the other countries through that same lens, we’re struck by how much better they are at driving improved results (in the jargon of the Fund: mortality amenable to medical care, infant mortality, and healthy life expectancy at age 60. It seems to me on this basis, that while France has poor access (really!), it produces the highest ranking for Healthy Lives. Now isn’t that the point of having a healthcare system in the first place? Something else is going on that this ranking is illustrating but which isn’t being drawn out from any commentary,

So, my summary:

  1. The reason the US is last on Healthy Lives is mainly ideological and not for a lack of trying to things better, but regretfully, only for those who have insurance cover, with eye-watering variances from state to state. I do find this surprising to some extent as the US is very well served by a research community that analyses costs and treatment flows and the ability of payers to drive incentives into the system. Perhaps the distributional inequity of access will pass the reform, while the relative inefficiency may be a measure of the tolerance of a wealthy country has for ensuring people who can afford the care do in fact get it. Hmmmm.
  2. The failure of the UK to translate all those 1’s into Healthy Lives is evidence of the dysfunctional nature of the design of the health care system to actually deliver care itself and a fetish with structural reform, rather than organisational reforms which would enable other models of care to emerge. This focus on driving out variance actually drives out innovation rather than enables it: the UK’s public health system eats its young and fails to bury its dead, so the system goes round and round, in some massive holding pattern and people wonder why things don’t change. The system is efficient once you get the care and access, at least defined in terms of general practice is great, but waiting times for tests and access to the hospital based specialists doesn’t really translate well into timeliness. I question the 3 for the UK as countries with direct access to specialists enjoy much quicker access to care and this indeed does translate into the higher Healthy Lives rankings we see.
  3. I’m not sure how you can have a healthcare system that scores 10 for effective care and 2 for Healthy Lives. If you’re getting ineffective care, wouldn’t that translate into poorer results like in Sweden? Hmmmm, again.
  4. It is interesting to see how poorly performing very wealthy Norway is, but then it has a state-run monoply health system. But again, how can you square all those 11’s?  Are the poor results evidence that a state-run bureaucracy is not working? Probably.
  5. Canada’s system is a fragmented mess at the best of times, and affected by a powerful mythology about its performance, premissed mainly on it not being like the US. Restrictions on patient access to care are systemic, and designed in by the slavish belief in the Canada Health Act prohibiting alternatives. A real policy straitjacket, I think.
  6. Finally, the one’s that in the middle, so to speak, Australia, Netherlands, Switzerland may be more worthy of further consideration.

 

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A recent report from the Royal Bank of Canada on baby boomers (2013 report) got me thinking about whether generational factors will drive health system reform; this report notes that baby boomers are more likely to worry about their health than their finances. What might that mean if we generalise our thinking to embrace generational profiles of the world that baby boomers have grown up in and the expectations of Gen X, Y and Z?

And what a brain it is!

Think (Photo credits: http://www.mysafetysign.com)

Let’s start with the boomers. Apart from the critical view that baby boomers have had it really good, they did invent much of the world we see today, and which the next generations are driving forward.

Baby boomers have become accustomed to things like one-stop shops, not waiting, being kept informed, and prepared to pay for both  quality and service. They are unlikely to sit around waiting for home care to decide when it is convenient to show up, they are impatient when their appointment with the doctor is delayed. They are not used to be told what to do and are problem solvers because that is what baby boomers had to do with some of the stuff left behind from the 1950’s and 1960’s.

Gen X, Y and Z are inheritors and translators of that tradition. What came before the boomers is the problem.

Why hasn’t this translated to healthcare?

Regardless of institutional and political inertia, Integrated care is a response to disruptive patient expectations that healthcare meet their needs.

Our healthcare systems were designed with notions of structure and function that date back to at least the 1920s (hospital management) and use policy instruments popular in the 1950s and 1960s. Countries that are modernising today, have different notions of healthcare and have not adopted the European-type social models, despite hyperactive people pushing this logic at them. We don’t live in that kind of world any more. Baby boomers who have seen substantial economic and social change certainly understand that, while the Gens are growing up without that sort of historical millstone.

Tired nostrums and the moaning of healthcare managers are hardly useful, when we see entrepreneurialism all around us. There is a Silicon Valley of healthcare but where is the Silicon Roundabout of healthcare?

A note on the Gens

Gen X, born between 1966 and 1976 experienced the trials and tribulations of divorcing baby boomer dual income parents. They are sceptical but very well educated. They are more pragmatic and cautious, given what they have been through, but will have little trouble with unstable systems as long as they understand how they work. Not afraid of chaos perhaps? And healthcare is a complex adaptive system, a.k.a, a system characterised by chaotic behaviours.  Policy is uncomfortable with disruptive chaos, yet it is that which creates the seeds for health system reform.

Gen Y, born betwen 1977 and 1994 are the largest population cohort beside the baby boomers. Very technologically sophisticated, they’ll certainly wonder why they can book a doctor’s appointment off an app! Apparently, they are not very brand loyal according to advertisers, so perhaps they not going to worry so much about sacred cows of social institutions, but look beyond that to the fundamental purpose of these institutions. I like people in this group a lot for their unconventional thinking and lack of faith in tried and test solutions and willingness to think new thoughts.

Gen Z, born between 1995 and 2012/now are growing up a world that is digital, connected, always on (McLuhan would understand). They expect things to be customisable, not one size fits all. That sounds like they’ll not be happy with being regimented through a care pathway that doesn’t work for them. Twenty odd years from now when they start to take the reigns of power, I would be very surprised if they didn’t engineer radical rethinking of healthcare. I, for one, would like to get inside that room today to see why we can’t think those thoughts today.