Sir Muir heads up the Knowledge Service in the UK National Health Service. He gave the opening keynote on the final day of the Congress and here he runs over some of his most salient points, explaining what he means by the third healthcare revolution.
Dr Lewis explains some of the background and detail to his presentation on the use of a Combined Predictive Model by the UK National Health Service and in particular the “Virtual Wards” Project which he is now helping to replicate in New York.
Dr Kumar attended the Congress from Delhi, India. Here he gives his views on broadening the scope of the conference proceedings and associated conversations beyond European Healthcare Systems.
Niall Dickson, Kings Fund
A new dispensation - at the time of the creation of the NHS in 1948 the response from the public was gratitude and a huge welcome, but no real expectations of what it would provide and what universality of provision would really look like. One size fits all was accepted and at the same time doctors knew best. It seems that deference and placebo were key to medical practice.
But the world has now moved on with the creation of the notion of a consumer culture and customer influence, we all have expectations of being listened to but you won’t necessarily find it in care homes or in out-patient departments.
There has been a challenge to professional dominance in the UK especially after a number of scandals, Shipman, Bristol, Neal and there is a general loss of public trust in experts. Together with the arrival of the Information Age this all means that patients and service users question more and accept less. We have to accept that access to information will not be equal though and this is primarily seen as an age-related difference.
We are in the age of choice, we use it as voters and as consumers - and we’re losing the idea that vulnerable people can’t make choices for themselves. Yet we have a system that denies choice. People think they should have more choice than they currently do. Women more pro-choice than men and the assumption that choice is a middle-class privilege is challenged by the evidence.
Information and involvement are still poor. 33%-50% of patients wanted more information and involvement. Around a third received conflicting information from professionals. If you were a private company and you had that sort of customer feedback, you’d be worried.
The social care system in England is a system that fails to meet aspirations - it’s not well defined or resourced, massive budget constraints, help concentrated on those with severe needs, relationship with benefits system extremely complex. However there are lessons to learn for healthcare. CSCI have found that many older people ask questions about vfm and press for more choice and control. We are putting users now in charge with direct payments which have much higher satisfaction rating. Kent CC have given people getting direct payment a VISA card effectively outsourcing much monitoring to the banks. But change is slow - there has been a duty to offer direct payments since 2003 but still only 4.2% of service users get them. For elderly people who just need simple home care then it’s perhaps too complex and some are just one-off payments rather than regular arrangements.
Now adopted another approach of individual budgets as a direct payment or managed by the LA as required which is showing great promise. Focus now on empowering service users, living independently.
Example: Andrew was a mental health user, he was offered day care went in and out and then relapsed and went in and out of hospital, didn’t want day care any more. He was allocated an individual budget and given a chance to evaluate his life - asked what he’d like - he said a holiday and a photographic course. He’s now discharged and employed as a photographer.
What are the lessons for this? Why wasn’t he listened to first time round? As well as handing over financial control we need to look at the whole paradigm for supplying care. This has parallels in Expert Patient studies. So could we do individual budgets in healthcare? There is some evidence of success in US, health & social care users are often the same people, but in UK co-payment could undermine universal health care and we’re not sure how to reconcile with increasingly evidence-based care pathways. Nevertheless there are lessons for the new professionalism. We are moving from the reactive episodic directive model where doctor knows best, to proactive, ongoing, shared decisions where the doctor helps the patient to navigate.
All the photographs I’ve taken over the last few days are available here.
I’ve shot some video too, so you should see that here on the blog in the next few hours 
Patrice Blemont, Director, Regional Hospitalisation Agency of Franche-Comte, France
[taken from the translation feed so errors of understanding may have crept in]
We often wonder why in High Burgundy how we manage to launch a comprehensive healthcare information system while other regions lag behind. Before our system became a model we had to prepare the ground with the principle of “The minimum of force and maximium of conviction”.
1st objective - to optimise the flow between doctors to improve medical strategies
2nd objective - to make our patients responsible partners which means they need access to medical information
3rd objective - to set up a regional authority and partner to overcome the fragmentation between medical establishments to encourage collaboration and teamwork.
We were able to concentrate our funds and efforts, co-operating with associations of stakeholders and asked for public support, and promotional work, starting small and then raising the bar and giving ourselves higher targets, we also spoke about the funds available and making sure that we have sufficient to achieve what we want. We very transparently came together with our industrial partners and re-used things that had worked elsewhere to improve efficiency.
Seeing that things were running smoothly, we gave autonomy to the players and freedom to manoeuvre. I think we’ve done well.
[Presentation taken over by a technician - didn’t get his name]
Since 2002 we’ve had a guideline plan which has been implemented locally. So the technical side of it was to install electronic elements while the doctors, hospitals etc were negotiated with as stakeholders. We wanted to network better the health services in the region. The advantage was that the communication between the individual hospital specialists could be improved. So we demonstrated that our project was feasible and we had better networking between hospitals on the one hand and I’d like to stress in particular the information needed to admit someone to hospital the issue now is we have specialists like gerontologist they have linked up with specialists in alzheimers so we want to attain an integrated medical care and the regional administration has been very active providing co-financing.
Let me now come to the doctors who work in their own surgery, we have 5,000 doctors linked to our system so far. As Patrice has mentioned, we have not gone to extremes, but we proceeded step by step. Our approach was centralised, we have our israeli partners with whom we could sort out issues including the centralisation of the French health system. Another task was to network data coming from the health authorities available to private doctors and to network all this data and build a platform to co-ordinate all of this. Now 100% of blood samples taken are now recorded in IT - all results are computer readable and can be communicated wherever needed. The patient has the right to quick access to all the information. In France we don’t have a uniform ID code, though we’re introducing a patient code system which means we need a key for doctors and patients that we can link them as quickly as possible so that the disease can be identified quickly. Then we have to collect the information and the users at the various levels may need to be networked too. So when I have my id number it is sufficient to get some medical information. We also have to take into account that we border Germany and Switzerland and their systems are quite different. Medical images are now available online so a certain physician in the region can get access to certain images for this particular patient. Quite interesting is also the fact that we have other complementary information systems like in the emergency hospital units. We have a monitoring system installed which lets us report the situation in emergency wards - 15 months ago this was all on paper cards. The electronic information system plays a special role here because they have to act very quickly, so it is not only about identifying a patient but also what needs they have.
Nino Mangiapane, Federal Ministry of Health
We are in the situation in Germany with regard to the objective of our project that i will be able to speak not only about technology, but also a survey of the German health system, because inclusion of stakeholders is important for us.
The objectives are to boost quality, enhance efficacy of national insurance, avoid follow-up costs, avoid adverse effects, avoid submission of false claims, reduce admin expenses by structured use of IT in medical care.
The current situtation is that we have lots of IT but traditionally these technologies have been used to document services and calculate fees for providers and payers and the systems are largely unable to communicate with each other, there are about 200 different systems in use already.
The health sector is of course extremely complex with very large numbers of players - linking and networking all of these players is the task we’ve set ourselves. We’ve tried to change things before, but no-one was interested so we passed legislation in 2003 to unify the Health Telematics Framework - we’re introducing electronic health cards with mandatory parts (admin data, finance status, prescriptions) and discretionary data. There was a political insistence on the participation of insured persons and data security. This is not a state-run project but the framework is set by the state and run by healthcare stakeholders - statutory and private insurers (50%) and Health Care providers (50%) So decisions need to be taken by them to define the necessary specifications. The health card is the physical manifestation and key to the dedicated technical infrastructure. We have focused strongly on security features. We are now releasing a range of features - the electronic health card, health professional card, card terminals, connectors to the telematic platform network infrastructure etc.
And all of these go through rigorous testing and consultation before release and implementation which is phased and implemented offline before online. Field testing is starting already across different regions and movement towards roll-out is progressing well. It’s been a long journey and many obstacles had to be overcome but these are essential technological platforms that will enable the communication we’ve heard so much about already today.
Sir Muir Gray, Chief Knowledge Officer, DH & NHS, UK
The future is something we make, not something we discover. And the future is easy to make because as William Gibson has said, the future is here, it’s just not evenly distributed.
We’re in the middle of the third Healthcare revolution. The first was based on common sense, an empirical revolution, the health of nations was transformed by making observations and deductions from data and improving conditions based on those deductions. So now, for example, we take clean clear water for granted.
The second revolution took place in the latter part of the 20th Century. It was driven by science, making plastics, aeroplanes, televisions and innovation in chemical and mechanical technology in health care. We have made amazing progress, but we have though not solved the following “magnificent 8″ problems:
errors and mistakes,
poor quality healthcare,
waste,
unknowing variations in policy & practice,
poor patient experience,
overenthusiastic adoption of interventions of low value,
failure to get new evidence into practice,
failure to manage uncertainty.
More science and more money is not going to help these. I have reservations about putting more money into health services, because my experience is that this just makes people more obsessed with money.
The third revolution is different - everyone’s involved and it’s everywhere, it’s adaptable, it’s pervasive, it’s inclusive and convergent. I’m very much inspired by Manuel Castell’s work: The Rise of the Network Society. The third industrial (and therefore, healthcare) revolution is driven by citizens, IT and knowledge. Professionals are by and large two decades off the zeitgeist and this is not restricted to healthcare, it’s seen across all professions.
Knowledge is the enemy of disease, the application of what we know will have a bigger impact than any drug or technology likely to be introduced in the next decade. I’m talking about three types of knowledge here Statistics, Evidence and Mistakes - we need to be able to deliver these as simply and abundantly as we deliver clean water.
We need to take pure research and systematically review it to produce guidance that goes into the “water supply” and then comes out of the tap. What we’re introducing in NHS bodies is a Chief Knowledge Officer - because you need energy to make knowledge appear everywhere.
So how might this come together? In the past we’ve given knowledge to clinicians who’ve then passed it on to patients, now our principles are that we give knowledge to patients and give them the opportunity to discuss it with clinicians. What is the best structure for financing and organising healthcare in 21C? - it doesn’t matter - you just have to decide how much to spend, how to allocate it and maximise use of resources. We should be thinking systems rather than structures, recognising the network that runs alongside every bureacracy is responsible for innovation.
And this will help us move from thinking about hospitals, trusts etc to thinking about our core business - the treatment of disease.
Adapting healthcare strategies to changing demographics.
Ministers from Netherlands (NL), Poland (PL), Russia (RU) and Estonia (EE)
Dr Schneider: Ministers, what are the most urgent issues on your desk?
NL - Biggest question will be demographic change and what we do about it. We’ve tried to make fundamental reform to the structure of insurance to help with this by increasing competition between insurers and providers. We want to see higher volume at lower prices and innovation in the system. We need to deal with the issues of labour shortage by investing in our people.
PL - I’ve had only 4 months in my job but it’s been 4 months of hard work. 2 big issues - 14% of our population are over 65 and that our medical specialists 70% are over 45. Newly educated polish doctors emigrate abroad not because they can’t find well-equipped hospitals but because they earn too little. the existing insurance and healthcare system allows them to earn less than the national average salary so we’ve spent time negotiating wages with doctors and nurses. i made it my personal task to build and arrange the healthcare system around patients and their rights and finance based on real cost and real health needs. Today when we have one public payer and the service provider that is the doctor in hospitals we often people grappling with the way these institutions work. Hence one of the purposes of my reform is to decentralise the payers. We will now make hospitals the reference point because it is there where polish doctors should earn much better. another major problem is the policy on medicines which has been focused on prices. A system in which the providers and payers will be competitive I want this system to reduce the waiting times so as you can imagine there is huge work to be done but owing to education that I get from this conference i will go back home convinced that you can improve systems and I promise you that i will do it in a strongly determined way.
RU - Samara
We have similar problems to those that face all Russia - for patients - accessibility to treatment, waiting lists, low quality care, high co-payment rates for physicians - low salaries, access to medical information and lack of equipment as well as no professional insurance. for government - poor health status of the population, poor efficiency in healthcare, low rates of satisfaction and high disparities between the regions. The National Project in Healthcare by 2010 changes such as 4x budget and double salairies in primary care renewing up to 80% of equipment, special programs for children and maternity. 
Big problems since 1990 have been low financing, lack of medication supply on outpatient level, nursing staff deficiency, poor resource management. So the president has set aims to raise life expectancy from 66.7 to 75 and decrease mortality to 10% from 15%. We’re introducing better information support - we think this is one of the best ways .
EE - One of our key objectives is to improve digital services and interoperability between information systems. We expect much from EHR - efficiency increases and better quality. Also patient services will be better, faster and more developed by more competent clinical staff. Patients will have a comprehensive overview of their medical records and so be better informed. We also expect to be better able to gather medical statistics to improve planning. Less paperwork also reduces the workload of doctors giving them more time to focus on each patient.
Q: Do you have a solution for larger countries like India where insurance model cannot work.
A: NL - to increase economic growth and aim for universal coverage P - there is no perfect healthcare system in europe - it’s probably good to use european experience and to use the ideas which are born here and translate them. healthcare cannot be separated from the cash resource you have which is why it’s so difficult but there is nothing more important than health RU - you have strong traditional medicine, I would recommend taking step by step and not throwing out tradition wholesale. It’s important to invest in healthcare sufficiently.
Schneider - looking at China, they are made up of cosmopolitan world citizens - let them have their disneyland and fund it themselves - then there are more middle class people for whom integrated european model - then the urban migrants need walk-in clinics where they have a medical home - then the rural population where a little bit of money comes from local people but a lot has to come from government. So you need a 4-tier system. Plus educating people and persuading policy makers that healthcare is investment in economic productivity not a cost. in the US we do have similar disparities ironically enough - so you’re not totally alone.
Q: What drivers are there for innovation?
A: NL - we’re trying to get more competition between providers to stimulate innovation. I think the state can do someting to create a climate for providers to be interested in innovation. Technical innovations such as health records are important but we’re also trying to build networks of professionals around patients needs. We lead with incentive and example.
Q: In Israel, we have 4 HMO’s competing on quality, not on fees. I’d like to understand better what you mean about increasing competition.
A: NL - prices are fixed and we’re trying to liberate them (and lower them) but we have central levels of quality that we can’t go under
Q: I would like to hear about dealing with professionals in places where salaries are low are there problems of people focusing on their own salary rather than the patient
A: RU - we want to introduce payment for performance.
PL - what I want is that the Polish doctor is paid for what he actually does rather than just turning up! We put a value on the work of the doctor and the nurse in every procedure so that we can measure this. We want to prevent overwork and we have a program for newly-qualified doctors and we want to help them specialise and to make the career path shorter and make sure that 100% of graduates can specialise and we encourage them to move into those areas for which we have shortages.
Dr Schroeder is the German Secretary of State for Health.
I’m blogging this live from the translation feed so I apologise for some of the disjointed sentences.
From our point of view Health is a value in itself - the WHCC discussing the various challenges.
In the EU of 27 states, we are all facing exactly the same challenges - smaller, aging populations. On the one had this is a challenge, but at the same time we are also developing new techniques and technologies.
We want to look particularly for the opportunities. We have €240bn of which €115bn is statutory insurance. health is also the largest sector in the economy employing 11% of the workforce. Against this background we have to consider money spent as an investment. So we have to answer the question - how can we use limited funds the best. I’d like to outline our reforms from a German perspective. You may know that we have two different financing systems - roughly 70m people are insured by statutory insurance paying a percentage of your wage, a solidarity system. The smaller part pay for private insurance. We have developed a strategy of improving efficiency and quality in providing health services to such a large population.
We are making gradual introduction of competition into this sytem. The system of statutory insurance has been simplified from complexities that had grown up historically based on profession or work group. We have the principle that if you want to join a particular provider, you have the right to do so, so we have a method for balancing out risks between different social groups. We have also introduced competition in provision. At the macro level we have the regulations from Parliament, a legal framework - medical services are rendered based on what is medically necessary. It just says who does what, not how it is done. Then at the middle level there is a joint committee between insurance, doctors, dentists and hospitals. This is helping to make healthcare more patient-focused. At the micro level, we want more competition to be introduced but also more integration and co-operation. There are three parameters to facilitate this - adequate remuneration systems, the changing role of patients - increases in choice and willingness to exercise this choice and thirdly the collation of patient data in the electronic health record and the central IT infrastructure to support it (which must also be compatible with other european systems).
I’d like to finish on prevention. We offer relatively good healthcare provision, but our preventive efforts are not yet as efficient as we’d like. The aging population must be kept healthy as long as possible to minimise any burden. So we need to do more in this direction to enable people to take on their part, playing an active role for longer.
Q: Do you think there’s an appetite for compatibility?
A: What I meant was that in telematics we need to make them compatible because there’s a great readiness and interest in travel. It is clear that we have a responsibility for funding our own systems, but commonality offers great benefits - the size of the european market is an incentive for the pharma market to develop better treatments.
Q: We are all waiting for the services directive to be published by the EC - what does the german government plan to do?
A: we think we are justified in saying that we have been active in bringing forward this directive. We have not spoken to the new commissioner yet, but we are ready to do so. It seems that it will be difficult to get it into the parliamentary timetable. We see the necessity to have a framework across member states and we will support the new commissioner as much as possible.
Q: Which other countries do you look to for examples of healthcare reform?
A: Health systems are difficult to compare, but there are elements that we have in common. In the Netherlands there have been reforms to insurance, we look to the UK’s NHS and NICE for good work on raising quality and using evidence-based practice and we have looked to a range of other systems to find best-practice in creating the EHR.
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Matthew Holt interviews Jonathan Cohn, a senior editor with The New Republic whose book - "Sick: The Untold Story of America’s Health Care Crisis — and the People Who Pay the Price” - was recently published.
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