56705 Redesigning Health Care in ECA: Some Lessons from the UK Patricio Marquez, Kalipso Chalkidou, Derek Cutler, and access to quality services and led to a significant increase in Nick Doyle out-of-pocket spending by patients for healthcare 2. The main challenge now is to redesign health systems to effectively Key Messages address the changing health needs of the population - chiefly Health systems in the Europe and Central Asia region the increase in non-communicable diseases such as (ECA) have been struggling to deliver good and cardiovascular diseases, cancer, and injuries, as the leading affordable health care to their populations. causes of ill-health, premature mortality and disability. The basic structure of the health care systems in the Fixing Health Care: A Worldwide Dilemma region must be redesigned from within, based on available scientific evidence, by revamping clinical processes, organizational structures, management The extraordinary progress in public health and medical systems, and the cultures that support them. knowledge over the last 50 years, coupled with the introduction of new technologies, drugs and procedures, has The UK Government's National Institute for Health contributed to the improvement in health conditions and and Clinical Excellence (NICE), set up in 1999 to quality of life across the world. But these developments have provide national guidance on the promotion of good also disrupted health care organization, as is evident from the health and prevention and treatment of ill health, experience in different countries where medical care has offers some lessons in this respect. In addition to become fragmented and uncoordinated, with multiple setting national quality standards, NICE clinical providers serving the same patients3. Several studies show guidelines are used to determine how payments are that fragmentation of health service delivery adversely made to general practitioners and funds allocated for impacts quality, cost, and outcomes of health care4. The hospital care in the National Health Service (NHS). unrestrained acquisition and use of new medical technologies and procedures (for example, open heart surgery to replace Knowledge partnerships between countries that help clogged arteries, ultrasound technology scanners to aid in the them learn from each other's experiences and best detection of heart disease, and life-saving antiretroviral drugs practices are becoming increasingly important in the for HIV/AIDS) also lead to increased health care costs. new era of global health. The World Bank can play a major role in fostering these partnerships. There are no easy solutions to manage these tensions. Countries around the world, not just in ECA, are searching for new approaches to cure their ailing health systems. The Why Redesign Health Systems in ECA? shared goal is to improve the quality of services and reduce or curb escalating costs. But, as argued in a recent Harvard The countries in ECA have been struggling to deliver good, Business Review article5, regardless of what happens to many affordable health care to their populations.1 Indeed, life reform efforts, the old, basic structure of the health care expectancy gains in the region have been significantly lower than in other middle- or high-income countries, and in some 2 ECA countries the relative low level of public sector funding World Health Organization. 2009. The European Health Report. 2009. Geneva. to cover the cost of free medical care that is already promised 3 Lee, T.H. and J.J.Mongan. 2009. "Chaos and Organization in Health by the governments to their citizens has consistently hindered Care." Cambridge, MA: Massachusetts Institute of Technology. 4 Enthoven, A.C.. 2009. "Integrated Delivery Systems: The Cure for Fragmentation." The American Journal of Managed Care 15: S284-S290. 1 5 Rechel, B. and M. McKee. 2009. "Health Reform in Central and Eastern Bohmer, R. 2010. "Fixing Health Care on the Front Lines." Harvard Europe and the Former Soviet Union." The Lancet 374: 1186-1195. Business Review 88: 63-69. ECA Knowledge Brief system will remain in place for the foreseeable future. Health both length and quality of life as a measure of health systems must be redesigned from within by revamping public benefits.10 While important, the cost per additional QALY is health and clinical processes, organizational structures, meant to inform, but not determine, NICE's decisions. Social management systems, and the cultures that support them, by values are also essential components in the decision-making taking into account scientifically established best practices for process and strengthen the legitimacy and social acceptability preventing, diagnosing and treating diseases and injuries. of NICE's guidance. The United Kingdom (UK) Experience: Using Table 1: NICE's Core Objectives and Operational Evidence to Improve Health Care Principles Objectives Principles Faced with the above challenges, the UK government set up the National Institute for Health and Clinical Excellence (NICE) in 1999 to develop national guidance on the Set evidence-informed quality Independence from government, promotion of good health, and the prevention and treatment standards industry and individual of diseases on the basis of available scientific evidence6 7. In professional and patient groups addition to setting national quality standards (Table 1), NICE Reduce unwarranted variation in Transparency: guidance clinical guidelines are used to help determine how payments medical practice and improve products and methods are a are made to general practitioners and funds allocated for equity public good hospital care across the UK National Health Service (NHS). Develop best practice guidance Consultation with all those Over 100 guidelines covering major diseases have been for professionals affected by the decisions published and a further 40 are being developed as of 2010. Promote the efficient use of Scientific rigour in methods for NICE is also responsible for appraising new medical healthcare resources guidance production technologies - including pharmaceuticals, medical devices and diagnostic (imaging and laboratory) tests - for use in the Encourage good value innovation Timeliness to meet the needs of NHS.8 NICE's guidance informs NHS drug coverage and a changing healthcare system reimbursement decisions for new pharmaceuticals and its decisions have an international impact, with 25% of the Source: Elaboration by authors. global market referencing UK prices. Scientific evidence is not enough: social value and Methodology of evaluation feasibility considerations NICE uses an extensive network of UK universities and NICE engages with the users of the NHS and the broader professional organizations to synthesize and evaluate public public in a number of ways: health, clinical and economic data which are then assessed for All decision making committees have lay 9 their quality and applicability to the local UK setting. NICE membership. is, by law, required to make economic evaluations to judge All guidance, as well as the methods and processes the comparative value of technologies that provide additional for their production, are subject to public benefit but at an increased cost. Where available, NICE uses the quality adjusted life year (QALY), which takes account of consultation. Patient testimonies are a core component of decision- 6 S.D. and M. Rawlins, 2005. "Quality, Innovation, and Value for Money: making committee meetings. NICE and the British National Health Service." Journal of the American Patients are invited to submit written evidence. Medical Association 294:2618-2622. 7 WHO. 2006. The Clinical Guideline Program of the National Institute for Patient organizations can appeal against NICE Health and Clinical Excellence (NICE). Geneva (EUR/05/5063284). decisions. 8 Technology Appraisal Program of NICE: A Report by WHO, 2003; http://www.nice.org.uk/newsroom/pressreleases/pressreleasearchive/pressr NICE sponsors a dedicated Patient and Public eleases2003/2003_020_independent_international_experts_from_world_he Involvement Program, responsible for engaging with alth_organisation_review_nice_technology_appraisals.jsp 9 Information on NICE's methods for Clinical Guidelines production can be and drawing on the expertise of individual patients found at: and patient groups. http://www.nice.org.uk/aboutnice/howwework/developingniceclinicalguide lines/clinicalguidelinedevelopmentmethods/clinical_guideline_developmen 10 t_methods.jsp and information on NICE's Technology Appraisal methods More information can be found at: can be found at: http://www.nice.org.uk/aboutnice/howwework/devnicetech/technologyappr http://www.nice.org.uk/aboutnice/howwework/devnicetech/developing_nic aisalprocessguides/guidetothemethodsoftechnologyappraisal.jsp?domedia= e_technology_appraisals.jsp 1&mid=B52851A3-19B9-E0B5-D48284D172BD8459 ECA Knowledge Brief All NICE products are also issued in a simple format and Examples of Impact of NICE Guidance: distributed to patients directly and through the internet. In Improving screening for cancer addition, NICE runs the Citizens Council to periodically discuss critical issues, such as: Should age be a factor when In 2003, a new technology for cervical screening, Liquid making healthcare resource allocation decisions and should Based Cytology (LBC), was positively evaluated for its efficiency be sacrificed up to a point to favor disadvantaged clinical effectiveness and cost-effectiveness and adopted by social groups? The reports form the basis of NICE's guideline the NHS. By 2007, almost 90% of laboratories in England on "Social Value Judgments" for the decision-making were using LBC. The improved technical characteristics of committees.11 LBC compared to smear test mean that about 200,000 women across England do not have to go through repeat smear tests Practical issues are considered before guidance is produced. because the percentage of tests with wrong results has For example, training requirements for clinicians, in case of a decreased, saving inconvenience, extra cost and concern for new recommended intervention or need for capital investment the patients. in imaging equipment, are all factored into the guidance. All public health guidance is field-tested among public sector Ensuring the rational use of drugs bodies (for example, education boards) before being issued. Based on extensive evidence, NICE recommended statins as part of the strategy for primary prevention of cardiovascular Budget impact evaluations are also undertaken but NICE disease (CVD) for adults who have a 20% or greater 10-year guidance is driven not by budgetary impact in the short term risk of developing CVD. It also recommended that therapy but by longer-term value for money. Affordability concerns, should usually be initiated with generic drugs. Similarly, though legitimate, can often have perverse implications and NICE guidance on the use of proton pump inhibitors, bias against, for example, prevention interventions, which antihypertensive medication and clopidogrel for secondary may, on aggregate, be expensive in the short-term but are prevention of CVD recommended the use of generic drugs potentially life- and cost-saving in the longer run. and set limits on the initiation and duration of treatment. According to a 2007 report by the UK National Audit Office, Who makes the decisions? the four drug classes above accounted for approximately 20% The clinical, public health and economic evidence, and the of the UK's drug bill in primary care. Adherence to NICE broader societal values, are considered by independent guidance was estimated to reduce variation across the country advisory committees made up from frontline practitioners, and generate savings of about US$ 360 million annually. The academics, industry representatives, hospital administrators use of statins for primary prevention of CVD alone is and budget holders, patients, and members of the public. The estimated to prevent about 15,000 heart attacks each year. committee members are not paid by NICE but volunteer their time. NICE facilitates the decision-making process but does Tackling high blood pressure not make the decisions itself. This ensures the independence NICE guidance called for an additional investment of about of the final advice and increases its buy-in by stakeholders US$ 108 million in drug treatments for lowering blood across the country. pressure. The guidance was estimated to result in savings of Political backing matters about US$ 396 million from preventing unnecessary hospitalizations due to cardiovascular events; the guidance Given the often difficult and conflicting policy environment was estimated to prevent up to 10,000 strokes and 12,000 that is influenced by public pressure to adopt new health heart attacks every year. technologies and procedures, support at the highest levels of government is critical for ensuring that priorities are defined Controlling alcohol abuse on the basis of best available scientific evidence and consideration is given to social values and available Guidance is being developed for dealing with alcohol use budgets12. disorders, from prevention and early diagnosis, clinical management of acute alcohol withdrawal, alcohol-related liver disease and pancreatitis, to psychological interventions to help overcome alcohol dependency. NICE analysis considered three interventions for controlling 11 The Social Value Judgments guideline is available from this link: alcohol abuse: banning discounting and buy-one-get-one-free http://www.nice.org.uk/aboutnice/howwework/socialvaluejudgements/soci promotions; price increases through increases in tax and duty; alvaluejudgements.jsp and introduction of a minimum price per unit. Figure 1 12 UK House of Commons, 2007. Health Select Committee, National depicts the potential savings, over a 10-year period, from the Institute for Health and Clinical Excellence, Session 2007-08, Ordered by alternative interventions. the House of Commons to be printed: December 2007. ECA Knowledge Brief Figure 1: Cumulative Discounted 10-year Savings Conclusion from Selected Alcohol Pricing Polices (£m) While the NICE model cannot be simply transplanted to other countries' healthcare settings, policy-makers would benefit from looking at elements of its methodology, process, evidence base, and actual products. Many of them can be adapted to other countries' local realities to improve health care organization, public health and clinical practices, and develop new financial mechanisms that link budget allocation with improvements in service delivery and better health outcomes. NICE is currently advising and working with Ministries of Health from around the world to help them build capacity, Source: NICE documentation. gather locally relevant evidence, and strengthen processes and structures for turning this evidence into actionable Making alcohol less affordable appears to be the most policies for better public health practices and delivery of effective way of reducing alcohol-related harm. The medical care13. A good example in ECA is the recent evidence, extremely relevant for countries such as the agreement signed on March 3, 2010 between the Georgia Russian Federation where there is a high prevalence of Ministry of Labor, Health and Social Affairs and NICE. alcohol abuse, suggests that young people who drink and people who drink harmful amounts of alcohol tend to choose The development of partnerships between countries to share cheaper drinks. Therefore, establishing a minimum price per knowledge, experience and good practices is becoming unit has the greatest potential of limiting the ability of these critical and increasingly important in the new era of global groups to 'trade down' to cheaper products, whereas it has a health. Institutions like the World Bank have a major role to negligible impact on people drinking small amounts of play in fostering these partnerships. Indeed, as Julio Frenk, alcohol. the former Minister of Health of Mexico and current Dean of the Harvard School of Public Health, says: "In our turbulent Dissuading at-risk groups from smoking world, still scarred all too often by intolerance and exclusion, NICE analysis showed that interventions to improve the science remains as the most powerful force for enlightened reach, use and retention of smoking cessation programs in social transformation. Every country should have access to disadvantaged groups are good value for money. The cost per global knowledge repositories, along with the capacity not so QALY gained for these interventions ranges from about US$ much to adopt evidence as to adapt it to local 234 to US$ 1,080 (Figure 2). Workplace smoking cessation circumstances."14 programs, for example, are 230 times better value for money than alternative interventions. Figure 2: Cost Per QALY Gained for Selected Stop About the Authors Smoking Interventions (£) Patricio Marquez is a Lead Health Specialist in the Human Development Unit of the Europe and Central Asia Region of the World Bank. Kalipso Chalkidou, Derek Cutler and Nick Doyle work for NICE in the UK. _________________________________________ 13 Hawkes, N. 2009. "NICE Goes Global." British Medical Journal 338:b103 14 Frenk. J. 2009. "Changing Health Goals in Globalized World." 2009 David E. Barmes Global Health Lecture at the US National Institute of Health (NIH), December 15, 2009. "ECA Knowledge Brief" is a regular series of notes highlighting recent analyses, good practices and lessons learned from the development work program of the World Bank's Europe and Central Asia Region http://www.worldbank.org/eca