Learn from the US: put patients before doctors29 August 2012
Hurricane Isaac has passed Tampa, where the Republican convention opened yesterday, but political storms are raging. Mitt Romney and his running mate Paul Ryan want to make healthcare a key theme in the presidential election. They are likely to hit out at “socialised medicine”, such as the Obama reforms and the NHS.
In return, our politicians fret about privatisation and free markets. But both sides of the special relationship ought to know there is much to learn from each other. There is a growing realisation in America that its old health system is unfair. At present about 50 million people are uninsured, which is partly why it spends more than any other country but does poorly in international rankings.
Every year thousands die because they can’t afford treatment and hundreds of thousands more file for bankruptcy over medical bills. “Obamacare” seeks to stitch together the crazy quilt of payment systems and fill the gaps. The prototype was developed in Massachussets — by Mitt Romney, actually, when he was Governor — based on the Dutch and Swiss universal insurance systems.
Yet for all its faults the US market has created more leading healthcare organisations than any other country, defining global standards of what is possible. Innovation is rare in the NHS and it is even rarer for innovations to become big enough to make a real difference. Britain should learn from America. Here are three things to study.
First, we must make patients more important than doctors. At the Cleveland Clinic in Ohio the consumer is everything. This is one of the best hospitals in the world for quality but its costs are half those of rival providers. Its dedicated website enables patients to browse for information, view lab results online on the same day as the test, book appointments any way they want — and doctors are held to account.
Since 2004 the clinic has published its outcomes for each major disease area allowing hospital leaders to set the bar higher for clinicians. Unlike in the NHS, where doctors rule the roost, doctors are on a one-year contract: if they’re not up to the job they leave.
Second, we should target those most in need. A classic criticism of the US system is that the rich get the best care while the poor get nothing; in fact the poor often get a huge amount of care — it’s just not very good. The same applies here. Anyone in the NHS is familiar with their “frequent flyers” — people admitted day in, day out. They usually have complex chronic conditions, mental health issues and will typically be smokers and heavy drinkers. They get remedial, not preventive treatment that doesn’t help them to become functioning members of society. Surely it would cost less to solve the causes than to ignore them?
In 2005 McKesson, a technology company, won the contract to run Medicaid, the publicly funded programme for poor people, in Illinois. It audited terabytes of data — about referrals, treatments and payments — looking for patterns. They worked out who was ill and at risk of getting ill, and contacted everyone to test their findings. At-risk patients were given diet and exercise regimes; “frequent flyers” were monitored intensively and visited by nurses and social workers who co-ordinated services and treatment in their homes and communities, reducing unplanned hospital admissions. In four years McKesson saved $569 million (£362 million) and improved care.
This shows us that compassion and technology can be mutually reinforcing. The Left may recoil from cold number-crunching, while the Right may not like special treatment for people who don’t seem to deserve it; but scattergun spending hasn’t worked. Illinois shows that smart use of data and social outreach can help us to spend money more effectively.
And third, we must make care more joined up. Kaiser Permanente, an insurance plan with nine million members, has spent years pioneering medicine for patients with chronic conditions. By getting hospital doctors, GPs, nurses and carers to work together it meets the needs of patients from well before admission until well after discharge. It ensures that if you have diabetes, for instance, you can have a test at any time of the day or night. A computer analyses the data and if there’s a problem your doctor will get an e-mail and call you. Kaiser is a world leader in preventing unnecessary visits to hospital, and beats the NHS on value for money.
Some claim that competition and integration are at odds, yet this fiercely commercial organisation is the template for seamless care: “Everyone at Kaiser will tell you they’re successful because of the threat of competition,” says Chris Ham of the King’s Fund think-tank. “They don’t simply integrate services because it is the right thing to do: they do it because higher quality care costs less.”
With national pride riding high after Danny Boyle’s Olympic celebration, the last thing most of us want is US politicians using the NHS as a political football. But let’s not be complacent. The Francis Report on Mid-Staffs, out this autumn, will remind the NHS that it must become safer and more caring, even as dozens of hospitals face bankruptcy. The truth is that we are running out of options in the NHS. The best US organisations have real answers to our most pressing problems.
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