Current lssues and Future Trends
i
n Health Care
Errol Pickering
Director General, International Hospital Federation
INTRODUCTION
It is a pleasure to bring greetings to our Indonesian colleagu-
es from the 21 members of the Council of Management of the
International Hospital Federation, which in turn represents 21
nations. The federation has members in all five continents and in
90 nations. I, therefore, have the great privilege of seeing and
hearing of health services developments around the world. Today,
I will review some of the important trends and ideas I see
emerging in health services delivery. I have identified 8 trends
which I wish to describe. While I will identify them as trends 1
to 8, I don t wish to imply that one is any more significant than
the other.
TREND 1 -- CONTROLLED COMPETITION
Throughout the history of health care organisation, there
has been a debate about the role of government versus private
initiative in health care provision. Until recently the United
States and the United Kingdom have been at opposite ends of this
spectrum. Britain has had a government dominated health service
whilst in the United Sates private initiative has been the driving
force. It may be of interest then to reflect on one of the outcomes
of these approaches. The United States spends presently 13% of
its Gross National Product on health care. In the United
Kingdom that figure is only half of that, 6.5%. If one considers
the difference in the per capita income of citizens of the United
States and the United Kingdom, you can see what a dramatic
difference there is. However, in both countries there is major
change under way. The United States has found that competition
which is promoted by a system based on private initiative has
resulted in, inter alia
a)
Service duplication
Presented at the Vlth Congress of the lndonesian Hospitals Association
Hospital Expo, Jakarta 21 25 November 1993
b) Over supply of high technology
c) Poor community health systems and status and
d) Denial of access based on ability to pay of 37 million
Americans.
In the last few weeks I have been in the United States
discussing the US President s proposed reforms with my
American colleagues. It is too early to say what will be the
ultimate outcome of the reform movement in health care in the
US but some elements of the President s package will clearly
remain intact. Firstly, for the first time 100% of the American
population will have access to health care irrespective of their
ability to pay. Secondly, employers both in large industries and
in small businesses will be forced to carry health insurance for
their staff and families and thirdly, that health care financing will
be organised on a state level through insurance alliances in each
state. The final essential of President Clinton s programme is
that there be community-wide managed care systems at the local
level. This will in turn lead to a system of controlled competition
of purchasing and providing care.
The United Kingdom has already moved to controlled
competition through its internal market approach. This involves
hospitals and other health care facilities competing for govern-
ment funds to provide local services. The system has now been
in operation for some two years and the impact of the reforms are
becoming evident.
Firstly, there has been improved productivity in hospital and
health services. This has had the impact of reducing usage of big
city teaching hospitals. This is likely to result in the near future
in the closure of some of London s great, world famous hospitals.
Another hoped for impact of the government was that there
would be a reduction in waiting lists for elective surgery. The
22
Cermin Dunia Kedokteran , Edisi Khusus No. 90, 1994
results in fact have been mixed. The overall analysis suggests
that there has been no real benefit in this context. The other un-
expected outcome has been that increase in productivity has
brought with it rapid patient throughput which has meant that
hospitals have often spent their elective surgery budgets within
the first half of the year and have no funds remaining to continue
their elective surgery for the remainder of the year.
It is of concern to me that many countries are beginning to
copy the UK model. New Zealand has completely moved to this
model and Sweden is in the midst of its implementation and
many countries are about to adopt the system. My concern is that
all the evidence on the system is not yet in. Governments should
be more cautious about adopting such radical reforms.
TREND 2 RE-DEFINING QUALITY
Quality has become a central focus for nations in organising
their health services. This is because poor quality health care is
a waste of resources. Our communities are also becoming better
educated and so demand a better quality of health care. It used to
be that health service providers thought of quality as a lesser
priority but now it is one of the major driving porces of health care
delivery.
We can see this move focusing on quality in the expansion
of accreditation systems throughout many countries. Existing
accreditation systems are also becoming more sophisticated. In
the United States the Joint Commission on Accreditation of
Hospitals and Health Facilities has spent many millions of dollars
on identifying patient care outcomes as a means of measuring
standards of health care.
Around the world we see hospitals adopting continuous
quality improvement and Total Quality Management Systems as
apart of the central core of their management. That is, their total
organisational structure and their information systems are being
re-designed to focus on quality.
One of the interesting developments in this regard is the
increasing use by American hospitals of what have been called
Standard Treatment Protocols. These protocols set out what is
necessary to be done for each diagnosis at each phase of care and
identifying what diagnostic and treatment services are required
and how the patient s treatment should be scheduled.
The British approach has been different; they have focused
their standards on attempting to determine the patient s perspec-
tive on quality and service. We can see from the listing which
follows that the British definition of quality is quite different to
that of the United States (see attachment 1). This concept of the
patient s charter of rights is a personal initiative of the British
prime minister, Mr. Major. This charter of rights has been
distributed widely through hospitals and thecommunity and each
patient has access to the patient s charter booklet which sets out
what they may expect of the health service provider. The listings
which follow provide more detail of the patient s charter in
Britain (see attachments 2 3) .
Another approach that governments are using to define
quality in health services is to look at the health status of the
community. In particular they are setting targets for preventable
diseases and health promotional activities. So for example,
governments or regions are setting targets for reductions in
infectious diseases of various kinds and in coronary disease etc.
In some way it can be seen that there is a re-definition of
quality which expands the focus from the clinical level to the
patient level and to the community level.
TREND 3 MANAGING WITH DATA
Some years ago I visited Cuba to examine their health
system. They have a very advanced system of community health
mapping. That is, that they are able to identify morbidity not only
in every community but in every house in their cities. They then
use this information to get a basis for the organisation of their
health services and for developing priorities.
In the United States there are sophisticated community-
oriented information systems being developed with the use of
Attachment 1
British Patient s Charter Rights
National Standards
1. Respect for privacy, dignity and religious and cultural beliefs.
2. Arrangements to ensure everyone, including people with special needs, can
use services.
3. lnformation to relatives and friends.
4. Waiting time for an ambulance service.
5. Waiting time for initial assessment in accident and emergency departments.
6. Waiting time in outpatient clinics.
7. Cancellation of operations.
8. A named qualified nurse, midwife or health visitor responsible for each
patient.
9. Discharge of patients from hospital.
Attachment 2
British Patient s Charter Rights
Existing
1. To receive health care on the basis of clinical needs regardless of ability to
pay.
2. To be registered with a GP.
3. To receive emergency medical care at any time, through your GP or the
emergency ambulance service and hospital accident and emergency depart-
ments.
4. To be referred to a consultant, acceptable to you, when your GP thinks it
necessary, and to be referred for a second opinion if you and your GP agree
this is desirable.
5. To be given a clear explanation of any treatment proposed, including any
risks and any alternatives, before you decide whether you will agree to the
treatment.
6. To have access to your health records, and to know that those working for the
NHS are under a legal duty to deep their contents confidential.
7. To choose whether or not you wish to take part in medical research or medical
studcnt training.
Attachment 3
British Patient s Charter Rights
N
ew
1. To be given detailed information on local health services, including quality
standards and maximum waiting times.
2. To be guarantecd admission for treatment by a specific date no later than two
years from the day when your consultant places you on a waiting list.
3. To have any complaint about NHS services -- whoever provides them --
investigated and to receive a full and prompt written reply from the chief
executive or general manager.
C
ermin Dunia Kedokteran,Edisi KhususNo. 90, 1994 23
Attachment 4
Appendix A. Sample Surgical Clinical Path-DRG 104: Valve Procedure with Catheterization
Critical
Occurances
Preadmit:
Tele Unit
Tele Unitl
Cath
OR
Day
POD 1
POD 2
POD 3
POD 4
POD 5
POD 6
POD 7
LOS Day 0 LOS Day 1 LOS Day 2 LOS Day 3
LOS Day 4 LOS Day 5 LOS Day 6 LOS Day 7 LOS Day 8 LOS Day 9
Consults
Tests
Treatments
(includes
needs)
Activity
Diet
Discharge
Teaching
SS
Home
nursing
Dietician
ECG. CXR.
Labs.
Client lists
home needs
Old records
to unit
UP
NPO 6 hrs
before
procedure
Assess
home
support
health habits
coping
ability
Cath
Booklet
Pre-op Labs
I V
Sheath
removal
BR --> UP
NPO p MN
Pre-op
Tcaching
and tour
Post-op
ECG, CXR,
labs, VS,
Neuro
checks
Monitor
Ventilator
Artline/CVP
NG
T. pacer
Chest tubes
, IV
Foley
Skin Care/
incision
I
O/wt
Analgesics
Turn q 4 hr.
ROM
NPO
Respiratory
Therapy
D/C 2-4L 02 NC
D/C
D/C
D/C
Dangie X 2
Liquid diet
Begin post-op
tcaching
Cardiac
rehab
CNS
Diabetic
Cardiac
DC ECG
02 pm
1.5./C D8
D/C box
D/C
HL (Change
site)
DC Central
Lines
Anti-
conguiartis
Ambulate
tid
Cardiac Diet
or diet as at
home-fluid
restriction
(DC when at
pre-op wt)
DC CXR
D/C 02
D/C wires
DCI + O if at
pre-op wt.
D/C labs
except PT
continue
D/C
tid and
ad lib
D/C
Physician
order on
chart for DC
mg nereds
Transfer
record
Discuss D/C
plans
I
GXT
scheduled
Predischarge
orders,
scripts, med
sheet on
chart
Complete
Done
prior 9a
D/C before
12 Noon
Review
meds,
activity
level , S S
to report,
diet, labs,
appts.
2 4
Cermin Dunia Kedokteran
, Edisi Khusus No . 90, 1994
computers these link hospitals to community health services, to
local GPs; One example is in San Diego where half the population
is covered through this network of information.
The most obvious example, of course, of managing health
services through the use of data is that of "DRGS" (Diagnosis
Related Groups). This system means that hospitals are reim-
bursed on the basis of the average cost of dealing with a particular
diagnosis. This system which began in the United States about a
decade ago has now reached Australia, Spain, Sweden and I
understand parts of Asia. However, DRGS have now been
extended, as indicated early, to standard protocols but further to
the concept of developing patient critical paths for dealing with
aparticular diagnosis. The attached appendix (i.e. attachments
4 5) gives an indication of what is involved. You can see not
only what will occur in each phase of care but when each phase
ofcare will take place. You can see, from the chart setting out the
"cardiac path" for the treatment of three types of surgery, the
potential cost saving implications of using these systems. I think
we will hear much more of this new concept.
TREND 4 COMMUNITY ORIENTATION
Australia has been a leader for many years in orienting its
health services to the community. Many of its hospitals have
been carrying out community outreach programmes for more
than a decade. Many European countries also have a regional
basis for their health service delivery which puts an emphasis on
care at the community level. Sometimes this extends beyond
health care workers, for example in Sweden that postmen have
been given a responsibility to ensure that the house-bound elderly
in the community are "okay".
Concepts of health promotion have also been with us for at
least two decades. It must be reported, however, that the results
of these programmes have been, in large part, disappointing.
Hospitals are still filled with the problems associated with
lifestyle. Research I think is beginning to show us that what we
mustdo in regard to influencing of lifestyles is to start withhealth
promotion programmes for our children. In this context I have
been delighted to find outMickeyMouse is coming to our aid in
that the Disney Corporation is beginning to produce health
promotion materials for children around the world.
Another aspects of community orientation of health services
is our growing research base on health care screening economics.
It has now been cleariy shown that cervical cancer, colon cancer,
breast cancer, hypertension and hypercholesterolemia are all
targets for cost beneficial national screening programmes.
The World Health Organisation has long recognised that the
health of a country is not primarily related to the nation s health
services. The health of the citizens of a country of course relates
to the standard, or the environment, transport, education, welfare
and housing. This can all be distilled into one word "poverty".
I think we in health services often forget the need to coordinate
with our colleagues in other sectors to help to improve the health
status of our peoples.
TREND 5 RATIONING
The Paris-based organisation OECD, the Organisation for
Economic Cooperation and Development, estimates that hos-
pital cost inflation is primarily caused by medical technology
developments. The study which demonstrated this is now a few
years old but it can be said that it is known that investment in bio-
medical research has increased to 4 billion dollars a year. It is
estimated that through new bio-genetic techniques that some four
thousand previously unmanageable diseases will become treat-
able. Health care economists around the world are recognising
the likely impact of these great leaps of medical science and
putting them into the context of an already cash-starved health
systems. Are we then heading into a period of rationing of health
care?
Let s examine the situation a little more deeply. We can see
that while bio-genetics has as potential for increasing costs it is
likely that new vaccines will become available through this
technology and therefore reduce infectious disease. Presently
pharmaceutical products account for some 40% of a reduction of
mobility in our communities and therefore there is the increased
potential for further reduction as medical research proceeds also
in terms of techniques, we already know that day surgery and
diagnostic approaches have reduced costs.
Further we can see that most nations are now setting up
national programmes of technology assessments to ensure the
appropriate introduction of high technology on a rational basis.
Attachment 5
Figure 4. CardiacPath " --Paticnt and Financial Outcomes Comparison
Pre-CardiacPath
Post-CardiacPath
Procedure
Avcragc Total Avcragc
%
Averagc Total Avcragc
%
Charges
LOS
Mortality
Charges
LOS
Mortality
Valve Surgcry
( DRG
104-105)
$54,017
13.4
10.2
$4O,122
10,6
4.3
CABG
Surgcry
( DRG
106-107)
$37
,
6
48
11.1
2.7
$33,913
9.9
2.7
PTCA
(DRG
112)
$17,566
3.8
0.9
$15,738
2.4
0.7
Includes anethesia
fees
.Source : Borgess Medical Center , Kalamazoo , Michigan
Cermin Dunia Kedokteran , Edisi Khusus No. 90, 1994
25
Another interesting dimension of this question is that of
appropriate utilization of resources; we can see from the attached
data (attachment 6), emanating from the Rand Corporation in
Los Angeles, that we have far to go in eliminating waste. Rand
have also identified the impact of the health financing system on
the utilization of services. You can see from their data on
caesarian sections what this impact is. The following chart
demonstrates the phenomenon (attachment 7).
In summary I think we can say that much can be done to
reduce costs and pressures on services in health care but it is my
personal view that rationing will have to come. The British
research on "qualies" has clearly demonstrated that health
services can be delivered on a more rational basis by allocating
resources relating to the quality of life expected following
particular medical procedures. That is, for example, any rational
health system would lower the priority of fund allocation to by-
pass surgery because of its rather doubtful long-term benefits yet
it would increase resources allocated to say, hip replacement
because of the profound improvement of the quality of life of the
reciopient of this particular procedure. You will be aware, I m
sure that the State of Oregon in the United States has developed
this "quality" system into an operational programme which has
just cleared the courts and is to be put in place in that state for
Medicare patients. It would seem to me that it is a model which
we must all examine in a future where health care rationing seems
imminent.
Attachment 6
Hospital Wastage (Rand Corporation Studies)
1 in 4 hospital days unnecessary.
1 in 4 clinical procedures unnecessary.
2 out of 5 medications unnecessary.
Attachment 7
Financial Disincentives
Caesarian Sections US Data
Rate
In government hospitals
21%
In voluntary not-for-profit hospitals
23%
In for-profit hospitals
31%
TREND 6 FOCUSING ON PATIENTS
We in hospitals and health care have always put emphasis on
patient care but experiments are going on in health service
delivery facing a renewed examination of a health service from
a patient s point of view. For example in the United States there
are several hospitals which have been restructured to become
what are called "patient-focused hospitals". This involves the
decentralisation of many of the allied health professional
services so that they actually operate at ward level. That is in
each ward there will be a physiotherapist, a laboratory techno-
logist, a pharmacist, a social worker etc. This means that a true
patient care team is developed at ward level.
The result of this restructuring has been shown to, not only
improve the patient s perspective of care, in that they truly obtain
the sense of being cared for by a small team of professionals, but
also cost savings have been demonstrated, ranging to as much as
5% of operating costs.
There are also developments concerning staff training. That
is there is a belief that a multi-skilled staff a more effective way
of dealing with patients. That is, there is a new level of professio-
nal which can carry out many of the basic professional functions.
This multi-skilling has also occurred at the low level of em-
ployee, whereby for example the ward cleaner takes on a broader
function of food delivery to the patients and messages around the
hospital as well as providing a patient comforting role.
There is also a world wide trend to educate the patient
concerning their condition and their health in general; there is
also a trend to sharing information with the patient particularly
the patient s records. In many countries it is now the law that
the record belongs to the patient and they have access to it at all
times.
The other dimension of patient focusing is in regard to
medical ethics where it is now recognised that questions concern-
ing the patient s fate or that of their family must be discussed with
them and that the patient and his family take a major role in the
decision-making concerning further medical procedures. The
most obvious example of this is Euthanasia in the Netherlands.
Another new patient-directed development is that of the
non-smoking hospital. Many us hospitals are now totally non-
smoking, that is neither patients nor staff may smoke in the
buildings or in the immediate surroundings of the hospital. This
idea is also spreading internationally and is evident now in parts
of Australia and in Britain and is gaining hold as a concept
everywhere.
TREND 7 DEPRIVATION AND DISASTER
Among all of the exciting developments in health care there
is also a dark side and that of course is so evident in Africa and
in the former Yugoslavia. In Africa of course the problem is
deprivation. I was.staggered to read recently that the health
budget for some African countries is as little as 50 American
cents per person per annum. This means that they have no
possibility of importing drugs or equipment and as a result their
pharmacies remain empty and their professionals helpless.
In Yugoslavia we have seen the grotesque sight of hospitals
being targeted as military objectives. Many hospitals have been
destroyed and health service professionals have been killed and
tortured. The Geneva Convention whereby hospitals are
sanctuaries of peace, has not held up in this horrible civil war.
TREND 8 HEALTH SERVICE RESEARCH BASE
POLICY
One of the truly hopeful signs of health services develop-
ment around the world in the establishment of National Health
Service Research Institutes. These research institutes can
provide information on the health of the country and the impact
of its health service systems through their research activities.
That is for the first time countries are obtaining facts to base
their health policy on rather than what has been in the past purely
ideology or supposition.
26
Cermin Dunia Kedokteran , Edisi Khusus No. 90, 1994
This development is long overdue particularly when we
make comparisons with industry where they spend very substan-
tial proportions of their budget on research and development; in
some industries this is as high as 30% of their input whereas in
health care we tend to spend nothing or very little. The establish-
ment of these Health Service Research Institutes and the use of
data can result in rational health policy development. This means
that health policy can be developed based on the following flow
chart (attachment 8).
CONTEMPLATIONS
Indonesia has been one of the success stories of health status
improvement over recent years. Indeed it is true to say that you
have much to show the world in regard to how to rapidly improve
the health status of a nation. Can I then say that whilst all of the
trends I ve outlined today are of great interest, all countries need
to carefully assess new trends before they take action to imple-
ment them. My advice would be to keep in touch with the world
through reading and attendance at conferences but to digest the
information carefully. Ask yourself whether what you ve just
read or heard relates to a problem in your country and whether the
Attachment 8
Rational Health Policy Development
Community health status data
Health morbidity geographic and social data
Present resource allocation information
Planned policy initiative
Community and professional feedback
Pilot initiative
Evaluation of impact
Policy amendment, abandonment or implementation
problem is one which requires a priority solution. In short to
develop Indonesian solutions to Indonesian problems.
Thank you for the honour of being invited to speak at your
conference and may I wish the rest of your deliberations well.
C
ermin Dunia Kedokteran, Edisi Khusus No. 90, 1994 27