Return the money
1. Put the patient first
2. Among patients, put the poor and disadvantaged first
3. Start at scale
4. Return the money
5. Act locally
When I read this, number four stood out like a sore thumb. In Berwick’s words:
This is the hardest principle of them all. Success will not be in our hands unless and until the parties burdened by health care costs feel that burden to be lighter. It is crucial that the employers and wage-earners and unions and states and taxpayers – those who actually pay the health care bill – see that bill fall.
Just an American problem?
I wondered if this principle was unique to the high cost, poor outcome US healthcare system? The US spends 17.9% of GDP on healthcare (see graph). Healthcare costs for employees were said to be a major contributor to the bankruptcy of General Motors in 2009. Yet choose your population health performance marker and you’ll find the US does not do well (data from World Bank): life expectancy at birth (US 78.2, UK 80.4, EU 79.6), infant mortality per 1,000 live births (US 6.4, UK 4.4, EU 4.1), maternal mortality per 100,000 live births (US 21, UK 12, EU 8). So it seems the US could spend half as much, and still get better results for its population.
In 2000, Tony Blair pledged to increase UK healthcare expenditure (as a proportion of GDP) to the EU average by 2005. And expenditure did rise, until the global economic downturn in 2008. The gap with the EU was narrowed, though the pledge was never fulfilled, despite the accession of 12 poorer countries lowering the bar. This politically popular move set expectations of rising healthcare expenditure within the NHS. After all, healthcare inflation is higher than that in the general economy and there is increasing need for healthcare due to an ageing population.
At an interview for consultant posts recently, I asked the candidates what they thought of Berwick’s “return the money” principle. They all accepted the premise, but framed it as a response to the current economic downturn. They talked of increasing efficiency, and limiting new developments. Underneath was a belief that this will pass, and the good times of increasing health expenditure will return. After all, what better way to spend society’s money than on healthcare? The UK view still seems to be that we are not spending enough on healthcare.
Health or Education?
But there are other worthwhile things that we can, and should spend our money on. Education and employment may do more to improve the health of the population than increasing spending on healthcare.
For me this has been crystallised by the impending Scottish independence referendum. Soon we may be making the decisions about our own country – what balance of expenditures will give us the healthiest and happiest population?
I’m fairly confident that diverting money from nuclear missiles to healthcare would be a good thing. But how do we balance the competing demands of a universal high speed broadband network or higher teacher-pupil ratios?
For a lot of patients admitted to the Medical Assessment Unit, we are patching up problems, not providing cures. For some, a decent education and a job would have been better for them, better for the healthcare system and better for society as a whole.
Getting the Balance Right
So what is the right proportion of GDP to spend on healthcare? Self-evidently, it can’t just keep rising. From US experience, it seems that 17.9% is too high, creating a structural drag on the economy, which is in turn not good for the population’s health. Is our 9.6% too low? I don’t know the answer. However, I suspect it will be a much more painful experience for the US to cut back to 10%, than it is for us to remain below 10%.
As clinicians, we need to put the days of campaigning for more resources behind us. Ahead of us is the productivity challenge: maximising health gains within existing resources – not just during the recession, but in the long term. If we can accept that we have all we’re going to get, then the good news is that we can focus on improving the quality and efficiency of healthcare using our own ingenuity and initiative – thankfully, there is no limit to those.
@micmac650 is an Associate Medical Director and consultant nephrologist in NHS Ayrshire & Arran. He is also a Health Foundation fellow.
We hope regular reader of #ayrshirehealth have enjoyed this week of daily blogs with its diverse range of topics – thanks for reading/following.
#ayrshirehealth returns tomorrow to its usual weekly blog slot of Friday morning with @ceonhss – Director General Health & Social Care and Chief Executive NHSScotland who reflects on NHS Scotland’s journey of improvement.