Secretary of State for Health Andrew Lansley laid out the new Coalition Government's plan for health care reform in the white paper, "Equity and Excellence: Liberating the NHS," published July 12, 2010. The plan detailed in the paper envisions broad decentralization of the English National Health Service (NHS) in what some commentators have described as the greatest overhaul of the NHS since its inception in 1948.
The government will phase out England's 150 primary care trusts and 10 strategic health authorities. They will be replaced by approximately 500 general practitioner (GP) consortia. These consortia will be GP-led and responsible for purchasing care on behalf of their patients and, in total, be responsible for more than 80 percent (£80 billion, or US$126 billion) of the NHS spending. Commissioning and payment would be guided by quality standards to be developed by the National Institute for Health and Clinical Excellence (NICE) and overseen by a new NHS Commissioning Board.
Patients, guided in the NHS by the new principle, "no decision about me without me," will be given greater choice—including choice of provider, GP practice, and treatment—as well as increased control over their personal care records. A new consumer advocacy body, HealthWatch England, situated in the Care Quality Commission, would further support patients' rights.
The proposal would also increase openness to the private sector by increasing social enterprise in the NHS, allowing private companies to compete with the NHS, and by transforming Monitor, the NHS body currently overseeing the foundation trusts, into an economic regulator overseeing and promoting a competitive health care market.
Finally, the proposal announces the Government's aim to achieve £20 billion (US$31 billion) in efficiency savings by 2014 and to reduce NHS management costs by more than 45 percent; savings would be reinvested to support quality and outcome improvements.
The proposal set out in the white paper remains subject to Parliamentary approval.
The National Institute for Health and Clinical Excellence (NICE) ruled that Avastin (trade name for bevacizumab) is not a cost-efficient treatment for colorectal cancer, and therefore should not be prescribed by the English and Welsh NHS. Despite clinical evidence from drug-maker Genentech/Hoffmann-La Roche that Avastin, when coupled with other chemotherapies, can extend patients' lives by an average of six weeks, NICE decided that at a cost of £21,000 (US$33,362) per person per year, Avastin is too expensive for the NHS. While NICE maintains that other, less-costly therapies are available, oncologists, patient advocates, and cancer charities have criticized the ruling, highlighting its availability elsewhere in Europe, in addition to its proven efficacy. They have further argued that, in addition to prolonging life for six weeks, Avastin, in combination with other drugs, can reduce the size of liver tumors in 78 percent of patients, who would then be able to receive surgery to remove the tumor.
Critics hope that the new Cancer Drug Fund, to be established in April 2011 with £200 million (US$318 million) achieved through efficiency savings, may enable patients to access Avastin. The Fund will cover oncology treatments that NICE has not approved or not yet considered, as well as "off label" prescribing. £50 million (US$79 million) in interim funding, spent at the discretion of doctors, will be available from October 2010 through next April. At its current cost, £136.5 million (US$216.9 million) would be needed to cover the 6,500 patients eligible for Avastin treatment per year, and alone would bankrupt the Fund, further highlighting the drug's enormous cost.
Prof. Sir Mike Richards, National Clinical Director for Cancer Care, submitted the Second Annual Report on the NHS End of Life Strategy (launched in 2008) to Care Services Minister Paul Burstow. According to the report, significant steps forward in the care of patients at the end of life include the piloting of locality registers (electronic records recording details about patients approaching end of life) to improve care coordination, and the launch of: e-learning on end-of-life care for health and social care staff; the Dying Matters Coalition, which aims to increase public awareness of issues around death and dying; and the National End of Life Care Intelligence Network. Minister Burstow acknowledged the improvements, but noted variation in progress and the need to improve end-of-life care across the entire NHS. Plans for the next year include: continued work to identify when end-of-life care should begin for people with progressive disease; enhancing locality registers; completion of foundation projects on support staff training and development; and implementation of a communications strategy.
This August, three Australian general practitioner networks were chosen as test sites for the Australian National E-Health Transition Authority's pilot project on implementing a national electronic health records system. Each site's contract will last two years and the project is estimated to cost $12.5 million (US$12.1 million) in total, which was accounted for in last year's federal budget. Health Minister Nicola Roxon announced that the sites will test the government's newly implemented patient Healthcare Identifier numbers and will be the first to send hospital discharge summaries and referrals using national requirements. Although Minister Roxon advised that it would take at least two years for personal health information to be readily available to patients, these technological advances are intended to provide better access to patients' records, increase achievement of clinical outcome measures, and break down information barriers.
In an effort to provide better health care in rural and remote Australia, the newly reelected Labor Party and Australian Prime Minster Julia Gillard have pledged their dedication to the establishment of better broadband infrastructure and Internet access. Highlights from the $43 billion (US$42 billion) National Broadband Network plan include Medicare rebates for about 495,000 online consultations over four years, financial incentives to general practitioners and specialists to deliver online services, video-conferencing to support and expand existing after-hours care general practitioner help lines, and training support for health professionals' use of online technologies. Prime Minister Gillard has stated that harnessing the benefits of modern technology will enable patients to be connected to health services that they would otherwise have to travel long distances to receive. The government plans to roll out the network starting in July 2011.
Written by Sharon Willcox, 1999–2000 Australian Harkness Fellow
In August 2010, the Australian Commission on Safety and Quality in Health Care released a discussion paper on patient safety in primary care. The paper seeks to map potential safety issues arising in primary care, as well as describing some of the solutions being developed and implemented in Australia, the United Kingdom, the United States, and by the World Health Organization's World Alliance for Patient Safety. The Commission is seeking responses to the discussion paper from various stakeholders in order to identify priority areas for discussion and development. It also provides information on the newly developed Australian National Safety and Quality Framework, the national model for safety and quality accreditation and a range of other programs targeting safety improvements in primary care.
Canadian premiers recently attended the annual Council of the Federation conference in Winnipeg to discuss a purchasing alliance between provinces and territories. In an effort to drive down rising health care costs, the group agreed to work together in establishing a national agency responsible for purchasing $10 billion in prescription drugs, medical supplies, and equipment—resulting in reduced drug spending. This marks the first time that provinces have come together to leverage their negotiating power with the federal government for health care dollars. The federal government currently contributes approximately 20 cents per dollar (US$0.19) on health expenditures in each province, which is set to increase 6 percent a year until March 2014. The premiers pledged to begin discussions with the government to ensure continued health care payments to provinces and territories.
Chiropractors, dentists, optometrists, midwives, nurses, and other health professionals recently gained access to patient health information found in Alberta's electronic health record system. Although many health care professionals have already had access to patient data via Netcare (an e-health record portal), it was limited to health services provided by and paid for under government-funded insurance. Amendments to the Health Information Act now grant access to patient X-rays, MRIs, and blood test results to include privately funded services. According to the Information and Privacy Commissioner Frank Work, these changes aim to make the health care system more efficient and seamless by allowing medical professionals to quickly retrieve patient information. However, the Commissioner also cautioned that electronic medical information should be treated ethically, and that regulations will include authorization securities and periodic audits to monitor appropriate use.
After months of debate, German Health Minister Phillip Roesler's plans for health care system reform have been approved to start in 2011. The new agreement will raise premium rates, which are shared between employers and workers, from 14.9 percent to 15.5 percent of an individual's gross income. Health insurers will also be able to charge unlimited "additional contributions" (payments to insurer by members) to cover extra costs, although competition between insurers will limit the amount of additional payments. In contrast to the existing income-level based contributions, the government will now provide subsidies when payments exceed 2 percent of total income. Opponents have voiced that the plan falls short, as it does not address high incomes of doctors and hospitals, doctor shortages, or disease prevention. However, Minister Roesler believes these system changes will help lower the expected €11 billion (US$19 billion) deficit faced by the statutory health funds, while getting the "health system on course for sustainable, solid financing."
Medical doctor and professor Jurgen Windeler was recently appointed as the new director of Germany's Institute for Quality and Efficiency in Health Care (IQWiG). Professor Windeler has an extensive background in evidence-based medicine, serving as the medical director of the Medical Advisory Service of the German Statutory Health Insurance Funds for the past 10 years. A challenging road lies before Professor Windeler as he hopes to eliminate unnecessary drugs and to cut the budget by €2 billion (US$2.7 billion) annually. Furthermore he plans to extend the evaluation for effectiveness and cost-effectiveness to devices, diagnostic procedures and operations. He will also guide the institute in following regulations under a new law that mandates IQWiG to evaluate the effectiveness of all new drugs within a year of being put on the market. Pharmaceutical companies have also agreed to submit extensive data on efficiency and costs of new drugs. Previously, IQWiG had focused on drugs and procedures already on the market.
Edith Schippers was appointed new Dutch Minister of Health, Welfare, and Sport, replacing former Minister Ab Klink. Queen Beatrix swore her in on October 14, 2010, along with new Prime Minister Mark Rutte and his coalition cabinet. The Netherlands had been without a government since the June 2010 general elections, which followed the February collapse of the Dutch government. Following intense negotiations, the Prime Minister Rutte's free-market Liberal party (VVD) and the Christian Democrat Party (CDA) joined into a conservative coalition, and with an agreement guaranteeing parliamentary support from the Freedom Party, the new government will hold a narrow majority of one in the 150-seat Dutch parliament. Prime Minister Rutte's cabinet comprises major players from the VVD and CDA. Minister Schippers has been Prime Minister Rutte's number two in the VVD, and was a close advisor during coalition negotiations. She served as a policy advisor for health, welfare, and sport for the VVD in the Dutch House of Representatives from 1994 to 1997, and secretary of the VVD Health Committee from 1998 to 2000. Minister Schippers is co-author of "Close to Better Care" ("Dichtbij betere zorg"), the VVD's memoradum on the future of Dutch health care.
A September court ruling put an end to budget restrictions that were used to limit hospital expenditures in the Netherlands. The ruling applies to 35 percent of hospital care, which was previously subject to government guidelines and potential government intervention, but which will now be subject to the sole discretion of hospitals and third-party payers. This share is set to grow rapidly to 70 percent in the near future. While the price component of hospital care can still be regulated to some extent, quantity and therefore total costs are now out of the control of the government. As a consequence, hospital care cost control is transferred to the market.
New Zealand Health Minister Tony Ryall declined "Bridging the Gap," the Southern District Health Board's (DHB) proposal to allow patients in Otago and Southland to receive self-funded chemotherapy treatment for drugs not currently funded by PHARMAC, the New Zealand government body responsible for managing pharmaceuticals in the public health system. The DHB argued that the proposal would improve access to self-paying patients in the region, who are currently traveling to Christchurch and farther in order to receive care. Moreover, doctors behind the proposal view allowing patients to self-pay for unfunded therapies and services as enabling extension of services available in the public hospital system, while at the same time improving the professional work environment. In its decision, the Health Ministry responded that patients can currently receive publicly funded cancer treatment in Dunedin, and will soon be able to receive self-funded chemotherapy at Dunedin's private Mercy Hospital. The Government has also expressed concerns that allowing self-funded drugs to be prescribed in public hospitals will create a two-tier system, whereby patients receive care they can afford, but not necessarily the care they need. In response to the decision, the Southern DHB reiterated that its proposal would have kept patients in the public sector and avoided duplication of services.
International Health Policy and Innovation Program Highlights
Special thanks to the following advisors:
Anders Anell (SWE), Berit Bringedal (NOR), Zack Cooper (UK), Cathy Fooks (CAN), Robin Gauld (NZ), Xander Koolman (NETH), Stephanie Stock (GER), and Sharon Willcox (AUS).