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Q & A with George Halvorsen , Jean Petit and David Nicholson

by Lloyd Davis

Interview Key: GH= George Halvorsen; DN=David Nicholson, JP=Jean

George Halvorsen , Jean Petit and David Nicholson

Question: Where should data registries reside?

GH - Maybe with the payer, within care systems at the hospital level. The key is to put them in a setting where they are part of the care management approach.

Question: Earlier we had the minister for Catalonia discussing their system, costs, and and some of the reforms they’ve been able to implement to cut costs.

DN - My first reaction was to not believe it. The issue for us is that we’ve had a whole series of excuses why we can’t be responsive. One was the amount of money spent. Although you can increase the amount, you don’t get a corresponding breakthrough in quality. So reform is really important especially in this area of chronic care. On any one day our hospitals are full of people with more than one chronic condition when they really would be better off at home or in the community.

GH - If it is true that if you get good food and exercise then you shouldn’t need to be spending more money, throwing money at the problem. Attacking the problem up up front would help enormously.

JP - I agree, we have a similar approach to address rising costs. We decided to have reforms advocating home care and giving responsibility to GPs. Then we switched finance to activities, then to concentrate on quality indicators - it’s difficult but we’re getting there.

Question: Why is prevention not taken more seriously?
GH - There’s no natural market constituency for prevention - no one gets paid for preventing disease. But Medicare going broke means we now have to do something about that. So employers are now talking about what can we do. Also, the science of prevention wasn’t always so good, so arguments have been less persuasive.

Question: How do you cooperate with education services?
GH - I think we need to make some political conversions and get economic interests and Congress to address the issue. Physical activity programs have disappeared in schools… It’s not going to spring up from the bottom - that just gives us more couch potato behaviour. What people want is best health not best care - and that’s what we have to show people how to get.

Question: We require a new type of health care. The effects of obesity are enormous. How do we start at the patient, giving people instruments to help themselves?
GH - I referred earlier to a culture of health, changing the belief system of the community be it opposition to smoking, tranfats, etc. That makes a real difference. The single most persuasive thing in healthcare is when a doctor looks you in the eye and says this is the problem and this is what I want you to do.

Q: Is the lack of general insurance system in the U.S. a barrier to dealing with chronic illness because they can’t afford regular healthcare?
GH - That’s exactly right. Far too many people are uninsured, so they only interact at the point of emergency. We desperately need universal care in America.
JP - In France we have social security covering most of the population but we still have obese children and children with poor medical problems so it’s important but not the only point. I think that government determination is very important.

Q: The need to improve the efficiency of chronic illness treatment - how do we fund this if it just leads to longer life?
GH - The payback is so quick with some conditions that they pay for it, e.g. reduction in care needed for asthma and congestive heart conditions.

Q: What role do clinicians have to play in tranformation?
DN: The NHS is very bossy - if you give doctors responsibility for dealing with obesity you end up with stapling stomachs. It should be led by the community rather than medicalising everything. In terms of transforrming the service, there is of course no way except to engage with clinicians and get them on our side. I can create an environment for them to operate in, but I can’t do it. Our big failing so far has been engaging clinicians and getting them to lead the way on the changes we need.
JP: Clinicians should adopt guidelines and this will reduce the cost. When we introduce the clinical pathways method, we can save 1/3 of the total cost by putting all the players around the table and defining the best choices for the patient.
DN: We’re only just learning that it’s possible to increase quality and reduce costs.


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