Eurohealth - World Health ...
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
Eurohealth
RESEARCH • DEBATE • POLICY • NEWS Volume 16 Number 3, 2010
Measuring and
managing
performance
Improving
performance in
the English NHS
The performance
paradigm: potential,
pitfalls and prospects
Health system performance
management: quality for
better or worse?
User fees in the Czech Republic • Evidence for policymaking: the ECHI initiative
England: Independent Sector Treatment Centres • Uzbekistan: barriers to physician workforce development
Eurohealth
C
Managing performance: what do we
know? LSE Health, London School of Economics and Political
Science, Houghton Street, London WC2A 2AE, UK
If there was ever a time for putting an emphasis on fax: +44 (0)20 7955 6090
improving performance management then surely this is http://www.lse.ac.uk/collections/LSEHealth
O
it. At a time when economic resources are tight but
Editorial Team
Europeans continue to demand an ever more personalised
EDITORS:
approach to health care, it is of critical importance that
David McDaid: +44 (0)20 7955 6381
systems operate as cost-effectively as possible. They also email: d.mcdaid@lse.ac.uk
need to maintain high quality standards and be flexible Sherry Merkur: +44 (0)20 7955 6194
enough to respond to changing population need. Even email: s.m.merkur@lse.ac.uk
FOUNDING EDITOR:
M
more fundamentally, health systems need to be held
Elias Mossialos: +44 (0)20 7955 7564
accountable for decisions that are made. email: e.a.mossialos@lse.ac.uk
DEPUTY EDITOR:
Better performance monitoring mechanisms can Philipa Mladovsky: +44 (0)20 7955 7298
potentially help with these issues, but what has happened ASSISTANT EDITORS:
in practice? What do we know about how well they work? Azusa Sato +44 (0)20 7955 6476
This issue of Eurohealth focuses on this issue. It features email: a.Sato@lse.ac.uk
M
Lucia Kossarova +44 (0)20 7107 5306
articles that originate from a seminar hosted by LSE email: l.Kossarova@lse.ac.uk
Health and the NHS Confederation and funded by the EDITORIAL BOARD:
Higher Education Innovation Fund in April 2010. Reinhard Busse, Josep Figueras, Walter Holland,
Julian Le Grand, Martin McKee, Elias Mossialos
The situation is complex. Gwyn Bevan in looking at SENIOR EDITORIAL ADVISER:
different motivations to respond to performance Paul Belcher: +44 (0)7970 098 940
E
assessment measures finds that systems that potentially email: pbelcher@euhealth.org
have an impact on the reputation of service providers, for DESIGN EDITOR:
Sarah Moncrieff: +44 (0)20 7834 3444
example by ranking them publicly, are more likely to email: sarah@westminstereuropean.co.uk
generate incentives for poorly performing providers to SUBSCRIPTIONS MANAGER
make improvements. A reliance on altruism or market Champa Heidbrink: +44 (0)20 7955 6840
mechanisms is less likely to be effective. Chris Ham email: eurohealth@lse.ac.uk
N
looking at experience in England argues that the
Advisory Board
introduction of targets and national standards has
Tit Albreht; Anders Anell; Rita Baeten; Johan Calltorp; Antonio
indeed contributed to performance improvement in Correia de Campos; Mia Defever; Isabelle Durand-Zaleski;
the English NHS. Nick Fahy; Giovanni Fattore; Armin Fidler; Unto Häkkinen;
Maria Höfmarcher; David Hunter; Egon Jonsson; Allan
Krasnik; John Lavis; Kevin McCarthy; Nata Menabde;
Both Mark Exworthy and Niek Klazinga focus on what Bernard Merkel; Willy Palm; Govin Permanand; Josef Probst;
T
is measured. Exworthy points out that with all the Richard Saltman; Jonas Schreyögg; Igor Sheiman;
competing pressures on providers, it is important for Aris Sissouras; Hans Stein; Ken Thorpe; Miriam Wiley
regulators, managers and other users of data to agree on Article Submission Guidelines
what will be measured and how data will be used. He see: www2.lse.ac.uk/LSEHealthAndSocialCare/LSEHealth/
further stresses the importance of knowing what does not documents/Guidelinestowritinganarticleforeurohealth.aspx
get measured and how this affects performance. Klazinga
Published by LSE Health and the European Observatory on
also argues that when utilised improperly data from
Health Systems and Policies, with the financial support of
performance management can result in sub-optimal Merck & Co and the European Observatory on Health Systems
service delivery. and Policies.
Eurohealth is a quarterly publication that provides a forum for
Clearly no system of performance assessment will ever researchers, experts and policymakers to express their views on
health policy issues and so contribute to a constructive debate
be perfect, but we need to learn more from systems that on health policy in Europe.
have been implemented. What may be lacking to date is The views expressed in Eurohealth are those of the authors
sufficient consistency in health policy over time to fully alone and not necessarily those of LSE Health, Merck & Co.
or the European Observatory on Health Systems and Policies.
evaluate the impact of different approaches.
The European Observatory on Health Systems and Policies is a
partnership between the World Health Organization Regional
David McDaid Editor Office for Europe, the Governments of Belgium, Finland,
Ireland, the Netherlands, Norway, Slovenia, Spain, Sweden and
Sherry Merkur Editor the Veneto Region of Italy, the European Commission, the
Philipa Mladovsky Deputy Editor European Investment Bank, the World Bank, UNCAM (French
National Union of Health Insurance Funds), the London
Lucia Kossarova Assistant Editor School of Economics and Political Science, and the London
Azusa Sato Assistant Editor School of Hygiene & Tropical Medicine.
© LSE Health 2010. No part of this publication may be copied,
reproduced, stored in a retrieval system or transmitted in any form
without prior permission from LSE Health.
Design and Production: Westminster European
Printing: Optichrome Ltd
ISSN 1356-1030
Contents Eurohealth
Volume 16 Number 3
Health policy Arpo Aromaa is Professor, Finnish National
Institute for Health and Welfare (THL), Finland.
1 User fees in the Czech Republic:
The continuing story of a divisive tool Gwyn Bevan is Professor of Management
Ewout van Ginneken, Alena Ottichova and Matthew Gaskins Science, Department of Management and LSE
Health, London School of Economics and
4 Providing a solid evidence base for policy makers: ECHI initiative Political Science, UK.
Marieke Verschuuren, Pieter Kramers, Gudrun Kr Gudfinnsdottir
and Arpo Aromaa Mark Exworthy is Reader in Public Manage-
ment and Policy, School of Management,
8 Private sector providers in England: Royal Holloway University of London, Egham,
The implications of Independent Sector Treatment Centres UK.
Nidhi Vaid
Gary L. Filerman is a member of the Faculty,
11 Five barriers to physician workforce development in Uzbekistan Georgetown University, Washington DC, USA.
Zukhra Karimova and Gary L. Filerman
Matthew Gaskins is Research Fellow,
Department of Health Care Management at
the Berlin University of Technology, Germany.
Performance Gudrun Kr Gudfinnsdottir is Policy Officer,
European Commission, DG SANCO, Health
15 Managing performance: An introduction Information Unit.
Rachel Irwin
Chris Ham is Chief Executive of the King’s
16 The performance paradigm in the English NHS: Fund, London, UK.
Potential, pitfalls, and prospects
Rachel Irwin is Research Assistant, LSE Health,
Mark Exworthy
London School of Economics and
20 If neither altruism nor markets have improved NHS performance, Political Science, UK.
what might?
Zukhra Karimova is Faculty member, Tashkent
Gwyn Bevan
Paediatric Medical Institute, Uzbekistan.
23 Improving performance in the English National Health Service Niek Klazinga is Professor of Social Medicine,
Chris Ham Academic Medical Centre, University of
Amsterdam, the Netherlands and Coordinator
26 Health system performance management:
of the Organisation for Economic
Quality for better or for worse
Co-operation and Development’s (OECD)
Niek Klazinga
Health Care Quality Indicator project.
Pieter Kramers is Senior Advisor, Dutch
National Institute for Public Health and the
Environment (RIVM), the Netherlands.
Evidence-informed Decision Making
Alena Ottichova is PhD candidate, Salzburg
29 “Mythbuster” If a drug makes it to market, it’s safe for everyone
Centre of European Union Studies (SCEUS),
Salzburg University, Austria.
Nidhi Vaid is Specialist Registrar in Acute
Medicine, Chelsea and Westminster Hospital,
Monitor London, UK.
31 Publications Ewout van Ginneken is Senior Researcher,
Department of Health Care Management at
32 Web Watch the Berlin University of Technology, Germany.
33 News from around Europe Marieke Verschuuren is Senior Researcher,
Dutch National Institute for Public Health and
the Environment (RIVM), the Netherlands.HEALTH POLICY
User fees in the Czech Republic:
The continuing story of a divisive tool
Ewout van Ginneken, Alena Ottichova and Matthew Gaskins
Summary: The introduction of user fees and the ongoing discussions on their
continuation have caused a great deal of debate in the Czech Parliament, media
and general public. Although evidence from the first year after their introduction
suggests a decrease in resource utilisation, second-year data already show a slight
increase for some important indicators. Measuring the effectiveness of user fees is
notoriously difficult, but in the Czech Republic this challenge has been further
compounded by efforts in some regions to tap into regional budgets to reimburse
patients for user fees, undermining the mechanisms on which the system was based.
Key words: health reform, cost sharing, user fees, Czech Republic
User fees have become a very sensitive Slovakia (26.2%) for that year.1 In the The population enjoys virtually universal
political issue in the Czech Republic, present review, we describe the introduc- coverage and a broad range of benefits.
sparking debate in Parliament, the media tion of user fees, the political controversy Some important health indicators are
and the general public. Their introduction surrounding them, and their impact on better than the EU15 and EU27 averages
and the ongoing discussions on their con- health care utilisation in the Czech (such as mortality due to respiratory
tinuation have played a key role during Republic. disease and infant mortality rates). On the
the last three regional and national other hand, the standardised death rates for
Background
elections and were widely seen as a major diseases of the circulatory system and
Since 1993, the Czech Republic has had a
contributor to the collapse of Prime malignant neoplasms are well above the
system of social health insurance (SHI)
Minister Mirek Topolánek’s centre-right EU27 average. A range of health care util-
based on compulsory membership in one
coalition in spring 2009. isation rates, such as outpatient contacts
of a range of health insurance funds. Eli-
This seems quite remarkable given that and average length of stay in acute care
gible residents may freely choose among
private households’ out-of-pocket pay- hospitals, are also above this average.
these and among health care providers.
ment on health as a percentage of total Overall, there is substantial potential in the
SHI contributions are mandatory and cal-
health expenditure in the Czech Republic Czech Republic for efficiency gains and
culated as a percentage of wages.
has been relatively modest from an improved health outcomes.2 This was
Compared to Western Europe, the health
international perspective. In 2008, this recognised by the centre-right coalition led
system is characterised by relatively low
percentage stood at 13.7% (compared to by Prime Minister Mirek Topolánek’s
total health care expenditure as a share of
13.2% in 2007, the year before user fees Civic Democratic Party (ODS) from 2007
gross domestic product (GDP), low out-
were introduced), which is slightly lower to 2009, forming the rationale for the intro-
of-pocket payments and plentiful human
than the EU15 average of 14.5% and sub- duction of the user fees in 2008.
resources, albeit with some substantial
stantially lower than the percentages for regional disparities. Prior to 2008, inpatient and outpatient
Hungary (25.2%), Poland (24.2%) and health services were free of charge at the
point of use, with the exception of some
co-payments for prescription pharmaceu-
Ewout van Ginneken is a Senior Researcher in the Department of Health Care
ticals and medical aids. From the
Management at the Berlin University of Technology, Germany.
perspective of the centre-right coalition,
Alena Ottichova is a PhD candidate in the Salzburg Centre of European Union Studies this had in many cases led to high utili-
(SCEUS), Salzburg University, Austria. Alena.Ottichova2@sbg.ac.at sation rates and the inappropriate use of
scarce health resources. Indeed, the
Matthew Gaskins is a Research Fellow in the Department of Health Care number of outpatient contacts per person
Management at the Berlin University of Technology, Germany. in the Czech Republic (15.0 per year) was
1 Eurohealth Vol 16 No 3HEALTH POLICY
the highest in the WHO European Region sensitive political nature of the subject and implemented their own reimbursement
in 2006.1 Moreover, an estimated CZK4– negative media coverage may have led to systems, leading to a different system in
10 billion (€144–360 million) worth of general uncertainty about the new system almost every region. In several regions,
prescribed pharmaceuticals were being among insured individuals. This was patients were automatically reimbursed for
wasted or went unused each year.2 The reflected in a public opinion poll in which user fees, while in other regions patients
chief aim of user fees was to reduce over- a third of respondents stated at the time had to file a written request for reim-
consumption and inefficiencies in the that they did not know the purpose of the bursement.
health sector by encouraging people to use user fees nor feel that they were necessary.5
Since January 2009, great uncertainty has
health services responsibly. The Public
prevailed. For example, some public hos-
Budgets Stabilisation Act, passed in The unrest begins
pital pharmacies have tapped into regional
August 2007, introduced small user fees for It thus came as no surprise that the results
budgets to reimburse patients for the user
a variety of health services and changed the of the regional and Senate elections in
fees, whereas privately owned pharmacies
system for setting prices and reim- October 2008 were a disaster for the gov- have not. In some cases, actions likes these
bursement rates for pharmaceuticals. erning centre-right coalition. Thirteen of have been prohibited by the courts on the
the fourteen regions were lost to the oppo- grounds of unfair competition after com-
Introducing the user fees sition. The aftermath of the autumn plaints made by the private pharmacies.6
A range of user fees were introduced on elections was chaotic. In December 2008, Furthermore, the Czech Ministry of
1 January 2008, amounting to flat rates of members of the C ̌ SSD voted in the Health began an administrative proceeding
CZK30 (€1.20) per doctor visit, CZK60 Chamber of Deputies in favour of abol- against four regions in January 2010, and
(€2.40) per hospital day, CZK90 (€3.60) ishing user fees for health services nine sickness funds protested openly
per use of ambulatory services outside of altogether. This was rejected by the Senate against regional hospitals and their phar-
standard office hours, and CZK30 (€1.20) in January 2009, which instead preferred to macies that had not been collecting user
for prescription pharmaceuticals. reduce the burden on the young and the fees.7
Some vulnerable groups were exempted elderly.
As a countermeasure, the C ̌ SSD launched
from the fees, including people living The political landscape remained volatile. a ‘struggle against fees’ campaign and filed
below the poverty line, neonates, chroni- In March 2009, in the middle of the Czech two complaints with the Constitutional
cally ill children, pregnant women, patients Presidency of the European Union, the Court in February 2010.8 The European
with infectious diseases, organ and tissue centre-right coalition led by Mirek Commission voiced the informal view that
donors, and individuals receiving pre- Topolánek lost a vote of confidence. An the current system, in which regional
ventive services. Moreover, an annual independent, Jan Fischer, was selected to authorities pay the fees, is discriminatory
ceiling of CZK5,000 (€200) per insured become the Prime Minister of a caretaker and, if formally investigated, might be
individual was established for selected user government in April. His government, deemed as conflicting with European state-
fees (excluding user fees for hospital stays nominated by both major parties (the ODS aid rules.9 Another problem is the costs:
and the use of ambulatory services outside ̌ SSD), was inaugurated on 8 May
and the C reimbursing patients for the fees places a
of standard office hours), as well as for co- 2009, and new elections were scheduled for great burden on regional budgets. After
payments on prescription pharmaceuticals May 2010. Again, the C ̌ SSD pledged to one year, approximately two thirds of
with a price exceeding the reference price repeal user fees if they regained power in patients in regions governed by the C ̌ SSD
in a particular pharmaceutical group. the Chamber of Deputies in the 2010 took advantage of user-fee reimbursement,
As early as March 2008, user fees began to elections. leading to a total cost of CZK478 million
play a major role in the campaigns for the Under enormous political pressure, the (€19 million).10
regional and Senate elections planned for new caretaker government adjusted the
October that year. On 28 March 2008, the user fee system in April 2009. Although Have the user fees worked?
Chamber of Deputies for the first time the annual ceiling had been reached by Data from the Czech Institute of Health
rejected the Social Democrats’ (C ̌ SSD) only approximately 0.2% of insured indi- Information and Statistics show that the
proposal to repeal user fees. The C ̌ SSD viduals in 2008,2 the ceiling was lowered. number of visits to ambulatory specialists
then pledged to eliminate user fees in As of 1 April 2009, a new annual ceiling of fell by 17% in 2008.11 The decrease in the
regional hospitals and pharmacies if they CZK2,500 (€100) was set for persons use of ambulatory care services outside of
regained power. Furthermore, on 28 May standard office hours was even more pro-
under 18 years or over 65 years of age;
2008 the Czech constitutional court nounced at 41%; importantly, this was not
moreover, those under 18 years were also
̌ SSD’s claim that the user fees
rejected the C accompanied by an increase in the use of
exempted from user fees for doctor visits.
were unconstitutional.3 emergency services.
In June 2009, the Czech Senate rejected
A large portion of the population opposed new efforts by the Chamber of Deputies to Looking at hospitalisations in 2008, the
the user charges, and the C ̌ SSD could be abolish user fees. number of hospital days decreased by
assured of their backing. Indeed, many 4.4% in acute care hospitals and by 3.2%
people in the Czech Republic were not The regions revolt in non-acute care hospitals11 even though
bothered by the amount they had to pay In the meantime, the regions, which by the number of hospitalised patients
(that is, €1.20–3.60), but by the principle February 2009 were all governed by the increased by 3% and 5%, respectively,
of having to pay user fees, which went ̌ SSD with the exception of Prague, had
C during the same period.2 This suggests a
against the idea of free health care delivery decided on the 1st of that month to pay the reduction in the average length of stay,
– one of the main tenets of the Czech fees from their own budgets on behalf of which is confirmed by Health for All
health care system.4 Furthermore, the patients. To achieve this end, the regions (HFA) data, which show a reduction of 0.6
Eurohealth Vol 16 No 3 2HEALTH POLICY
days (to an average of 7.4 days) between established Public Affairs party (VV) with
2006 and 2008 for all hospitals observed.1 10.9% of the vote. The success of TOP 09 REFERENCES
It should be noted, however, that a and VV was unparalleled in the political 1. WHO Regional Office for Europe.
decrease in the average length of stay was history of the Czech Republic. The elec- European Health for All Database.
already visible in 2007, the year prior to the tions were a political earthquake in which Copenhagen: WHO Regional Office for
introduction of user fees. the established parties suffered heavy Europe, 2010. Available at:
losses. As a result, another centre-right http://www.euro.who.int/hfadb
Finally, the number of prescribed pharma-
coalition was formed, this time with the 2. Bryndová L, Pavloková K, Roubal T,
ceuticals and the number of unit packs of
ODS, TOP 09 and VV. Rokosová M, Gaskins M, van Ginneken E.
prescribed pharmaceuticals fell by 26.7%
Czech Republic: Health system review.
and 7.4%, respectively. At the same time, Opinions about user fees remain divided.
Health Systems in Transition
SHI expenditure on prescribed pharma- It seems unlikely that the new centre-right 2009;11(1):1–122.
ceuticals rose by 8.3%, indicating a shift in coalition will abolish or significantly
SHI reimbursement from less expensive, reform the user fee system. On the con- 3. C̆abanová A, Šenký M. Soud: U lékar̆e
everyday pharmaceuticals to more costly trary, the new coalition inherited a health se bude platit dál [Court judgment: Keep
on paying at the doctors]. Lidové noviny
pharmaceutical treatments and bigger unit system affected by the financial crisis and
29 May 2008. Available at: http://www.
packs.11 with a large deficit (CZK 10 billion in 2009,
lidovky.cz/ soud-u-lekare-se-bude-platit-
€400 million) and is currently looking at
For 2009, utilisation data for health dal-dmy/ln_noviny.asp?c=A080529_
ways to increase out-of-pocket payments 000003_ln_noviny_sko
services show a moderate reversal of the
and the responsibility of patients to share
trend seen in 2008. For example, the
in costs.17 The opposition C ̌ SSD and 4. Antonova P, Jacobs DI, Bojar M et al.
number of prescribed pharmaceuticals Czech health two decades on from the
Communist Party continue to call for the
increased by 6%.12 Although the number Velvet Revolution. The Lancet
repeal of the user fees. Since June 2010,
of unit packs of prescribed pharmaceuticals 2010;375:179–81.
health facilities in some regions have abol-
fell by 1.8%, expenditure on prescribed 5. STEM/MARK agency public opinion
ished the reimbursement of user fees to
pharmaceuticals rose by 9.6%.13 The research, 5–9 August. In: C̄tvrtina lidí neví,
retain more resources and to lessen their
average number of hospital bed days k c̆emu slouží zdravotnické poplatky [A
administrative burden.18
increased slightly, by 1.3 days to 255.5 third of people do not know the purpose of
days, while the average length of stay user fees]. Ceske noviny 12 August 2010.
Conclusion
remained at 7.4 days.14 Also, the number Available at: http://www.ceskenoviny.cz/
User fees remain a divisive issue in Czech
of visits to ambulatory specialists and the zpravy/ctvrtina-lidi-nevi-k-cemu-slouzi-
politics. Although out-of-pocket spending
use of ambulatory care services outside of zdravotnicke-poplatky/514955?rss
is still low from an international per-
standard office hours in 2009 increased by °
6. Purová Z. Vrchní soud podpor̆il zákaz
spective, the concept of having to pay for
9.2% and 10.1%, respectively.13 Rathových klic̆ek s poplatky [High Court
something that had been historically pro-
The 2009 statistics may reflect the effect of vided for free has led to a great deal of supports ban on Rath’s fee loopholes].
the reimbursement of user fees by the Mladá Fronta Dnes 17 September 2009.
public debate and played a large role in
Available at: http://zpravy.idnes.cz/
regions, which likely undermines the effec- several elections since 2008. The intro-
vrchni-soud-podporil-zakaz-rathovych-
tiveness of the system. It should also be duction of user fees is widely thought to
klicek-s-poplatky-pj2-/domaci.asp?c=
noted, however, that measuring both the have contributed to a change in political
A090917_ 143415_domaci_taj
short- and long-term effects of user fees is leadership, which if true shows the ability
notoriously difficult. Even decreasing util- of this relatively small measure to pack a 7. Pojišt’ovny zac̆nou rozdávat pokuty za
isation rates may give an incomplete big punch. Other countries contemplating neplacení poplatku° [Sickness funds will
picture of the cost-saving potential of user impose fines for non-payment of fees].
the introduction or expansion of user
Mladá Fronta Dnes 9 February 2009. Avail-
fees, with costs arising elsewhere in the fees might want to consider the Czech
able at: http://zpravy.idnes.cz/pojistovny-
system. For example, patients may forgo experience.
zacnou-rozdavat-pokuty-za-neplaceni-
necessary treatment or fail to adhere to
Good evidence is essential when deliber- poplatku-p32-/domaci.asp?c=A090209_
treatment, which could lead to the need for 174636_domaci_ban
ating whether to introduce user fees.
costlier treatments at a later time. Interna-
Although evidence from the first year after 8. Kopecký J. Pr̆ed volbami sílí boj o
tional evidence on the effectiveness of user
the fees were introduced suggests a poplatky, k soudu mír̆í hned dvĕ ústavní
fees, especially over the long term, is
decrease in resource utilisation, the second stížnosti [Fight against fees grows before
inconclusive.15,16 More data will be needed
year data already show a slight increase for elections, two constitutional complaint
in the coming years to make useful inter-
some important indicators. When inter- before court]. Mladá Fronta Dnes 5 Febru-
pretations about the effectiveness of the
preting these data, however, it is important ary 2010. Available at: http://zpravy.idnes.
measures taken in the Czech Republic. cz/pred-volbami-sili-boj-o-poplatky-k-
to keep in mind that the mechanisms on
which the system was based were under- soudu-miri-hned-dve-ustavni-stiznosti-
Latest developments: the unrest continues 14c-/domaci. asp?c=A100205_140636_
mined by the regions that chose to
̌ SSD won
Against all expectations, the C domaci_kop
reimburse patients for the user fees from
the May 2010 elections of the Chamber
the regional budgets. Several more years of 9. EC denounces payment of health fees by
of Deputies with only 22% of the vote,
data are needed before any definitive Czech regions. Prague Daily Monitor
followed closely by the ODS with 20%,
conclusions can be drawn on the impact of 2 June 2010. Available at: http://prague
the newly founded TOP 09 party with an monitor.com/2010/06/02/ec-denounces-
user fees in the Czech Republic.
unexpected share of 16.7%, the Commu- payment-health-fees-czech-regions
nists (KSČ M) with 11.3% and the newly
3 Eurohealth Vol 16 No 3HEALTH POLICY
10. Syslová J, Tvarohová J. Proplácení
poplatku° už stálo kraje pul
° miliardy. Jako
nĕkolik kalamit [Reimbursement of fees
Providing a solid evidence
have already cost regions half a billion
Czech Crowns]. Mladá Fronta Dnes 21
January 2010. Available at: http://zpravy.
base for policy makers:
idnes.cz/proplaceni-poplatku-uz-stalo-
kraje-pul-miliardy-jako-nekolik-kalamit-
12e-/domaci.asp?c=A100121_101015_
ECHI initiative
domaci_ban
11. ÚZIS. Institute of Health Information
and Statistics of the Czech Republic.
Consumption of Health Services in the
Years 2005–2008. Prague: ÚZIS, 2009;63. Marieke Verschuuren, Pieter Kramers and
Available at: http://www.uzis.cz
Gudrun Kr Gudfinnsdottir and Arpo Aromaa
12. ÚZIS. Institute of Health Information
and Statistics of the Czech Republic. Phar-
maceutical Services in 2009. Prague: ÚZIS,
2010;21. Available at: http://www.uzis.cz
Summary: With the aim of providing a solid evidence base for policy making, the
13. ÚZIS. Institute of Health Information European Commission initiated a European public health monitoring policy a
and Statistics of the Czech Republic.
decade ago. The European Community Health Indicators (ECHI) projects have
Consumption of Health Services in the
Years 2006–2009. Prague: ÚZIS, 2010;46.
played a central role in the development of this policy. ECHI currently is in its
Available at: http://www.uzis.cz fourth phase (Joint Action for ECHIM). Twenty-four EU Member States are
engaged in an effort to implement the ECHI shortlist (88 indicators). One of
14. ÚZIS. Institute of Health Information
and Statistics of the Czech Republic. the major challenges will be to find sustainable solutions for public health
Hospitals in the Czech Republic in 2009. monitoring, both at Member State and at European level.
Prague: ÚZIS 2010;5:4.
Available at: http://www.uzis.cz Key words: evidence-based policy making, public health monitoring, indicators,
15. Lagarde M, Palmer N. The impact of European Union.
user fees on health service utilization in
low- and middle-income countries: how
strong is the evidence? Bulletin of the The need for international public health information presented in the report raises
World Health Organization questions; why do so many Dutch people
comparisons
2008;86:839–48. smoke? Are the anti-smoke policies in
The gap between the Netherlands and the
16. Thomson S, Foubister T, Mossialos E. European Union (EU) average is widening countries with a lower smoking rate dif-
Can user charges make health care more for rates of female cancer mortality. The ferent than the policies applied in the
efficient? British Medical Journal Netherlands has higher than average rates Netherlands? Are there other factors, such
2010;341:c5225. of smoking while relatively few mothers as cultural differences, which may explain
17. Petrášová L, Syslová L. Ve zdravot- breastfeed their babies. The 30-day in-hos- the different smoking rates in the EU
nictví chybí už deset miliard, strany ale o pital fatality rate for stroke in the countries? The same kind of questions may
reformĕ nemluví [Ten billion missing in Netherlands is high compared to other be asked of the indicators for which the
health care system, but parties don’t talk European countries. On the other hand, Netherlands is doing relatively well.
about reform]. Mladá Fronta Dnes 11 May injury-related mortality is very low in the
2010. Available at: http://zpravy.idnes.cz/ These examples illustrate the usefulness
Netherlands, and it is among the best
ve-zdravotnictvi-chybi-uz-deset-miliard- and necessity of international public health
scoring countries when looking at health
strany-ale-o-reforme-nemluvi-1ju-/ monitoring by means of indicators for
determinants such as levels of physical
domaci.asp?c=A100510_205611_domaci_ policy making. Through international
activity and overweight.
vel benchmarks, authorities may be made
These are some of the main conclusions of aware of good practice examples in other
18. Králová S, R̆íhová B. Pardubický kraj
the report Dare to Compare! Bench- countries. Moreover, this international ori-
ruší jako první proplácení poplatku° v
nemocnicích [Pardubice region is the first marking Dutch health with the European entation may draw attention to some of the
to abolish the reimbursement of fees in Community Health Indicators (ECHI), causes of avoidable health inequalities
hospitals]. Mladá Fronta Dnes 1 June 2010. written by the Dutch Public Health between European citizens, achievable
Available at: http://zpravy.idnes.cz/ Institute (RIVM) in 2008.1 The indicator health gains and the efficient use of
pardubicky-kraj-rusi-jako-prvni-
proplaceni-poplatku-v-nemocnicich-10h-
/domaci.asp?c= A100601 _155131_
domaci_bar Marieke Verschuuren is Senior Researcher and Pieter Kramers Senior Advisor, Dutch
National Institute for Public Health and the Environment (RIVM). Gudrun Kr
Gudfinnsdottir is Policy Officer, European Commission, DG SANCO, Health
Information Unit and Arpo Aromaa, Professor, Finnish National Institute for Health
and Welfare (THL). Email: marieke.verschuuren@rivm.nl
Eurohealth Vol 16 No 3 4HEALTH POLICY
resources. That such an approach is suc-
cessful is shown by figures from Finland Box: Joint Action for ECHIM: participating countries, Core Group members and project partners
that reflect a remarkable decline in the rates
of many cancers, as well as a large Member States
reduction in traffic accidents and cardio-
vascular deaths, which were among the 1 Belgium (Core group member)
highest in Europe in the 1970s. 2 Bulgaria
3 Czech Republic (Core group member)
The ECHI initiative
4 Cyprus
Aiming to meet policy makers’ need for
comparable international public health 5 Denmark
information, more than a decade ago the 6 Estonia (Core group member)
European Commission initiated a 7 Finland (Core group member and project partner)
European public health monitoring policy, 8 France
starting with the EU Health Monitoring 9 Germany (Core group member and project partner)
Programme, which ran from 1997 until
10 Greece (Core group member)
2002. Within this Programme, many
projects were involved in indicator devel- 11 Hungary
opment. The ECHI-I project acquired a 12 Ireland (Core group member)
key role, collecting proposals for indicator 13 Italy (Core group member and project partner)
definitions from all of these projects. These 14 Latvia
proposals were arranged systematically in 15 Lithuania (Core group member and project partner)
the so-called ECHI long list, comprising at
16 Luxembourg
that time more than 200 indicators.2
17 Malta
It was clearly not feasible to implement all 18 Netherlands (Core group member and project partner)
indicators on the ECHI long list at once.
19 Poland
Therefore, DG SANCO and the ECHI
experts decided to create a shortlist for pri- 20 Portugal
ority implementation. Further refinement 21 Slovenia (Core group member)
of the indicator selection was coordinated 22 Spain (Core group member)
by the ECHI-II project, and carried out in 23 Sweden (Core group member)
close cooperation with DG SANCO and 24 United Kingdom (Core group member)
its working parties and committees under
the Health Information Strand. The next
Other countries
phase, under the Public Health Programme
2003–2008, was coordinated by the 25 Iceland
ECHIM project (M stands for Moni- 26 Norway
toring). ECHIM identified national health 27 Moldova
information experts, and started mapping
the availability of data in the EU Member Other Core Group Members
States for calculating the shortlist indi-
DG SANCO
cators. Indicator metadata (definitions,
calculation methods, preferred data DG EUROSTAT
sources etc) was documented in a struc- WHO-Europe
tured way in ECHI Documentation
Sheets.3
In 2007 the EU Health Strategy White duration.5 (See Box for an overview of the – The indicators should serve user needs,
Paper Together for Health was adopted, Joint Action for ECHIM partners and par- meaning that they should support
stating as one of its actions the implemen- ticipating countries). potential policy action, both at EU and
tation of a European ECHI system.4 In Member State level.
2008 the European Commission therefore The ECHI shortlist
– Existing indicator systems, such as the
called for a Joint Action for ECHIM. This The following set of criteria was applied
WHO-Health for All (WHO-HFA)
new financing mechanism implies a direct for selecting indicators in the ECHI long
and Organisation for Economic Co-
invitation from the Commission to the and subsequent shortlists:
operation and Development (OECD)
Member States to present a proposal. – The list should cover the entire public indicators, should be made use of as
Public health institutes from five countries health field, following the commonly much as possible, but there is also room
took the lead in preparing the proposal, applied structure of the well known for innovation.
and twenty-four Member States in total Lalonde model; health status, determi-
gave a declaration of intent to participate – Adopt viewpoint of the general public
nants of health, health interventions/
in the Joint Action for ECHIM. It started health official (‘cockpit’) as a frame of
health services, and socioeconomic and
on 1 January 2009 and has a three year reference.
demographic factors.6
5 Eurohealth Vol 16 No 3HEALTH POLICY
– Focus on large public health problems, policy makers. This distinguishes the Communities, Eurostat is the main data
including health inequalities. ECHI shortlist from many other existing provider for ECHI.7 From the onset of the
data collection initiatives, which may either ECHI initiative, Eurostat has been
– Focus on the greatest potential for
apply a broader or more limited orien- involved in the developmental work. The
effective policy action.
tation. main result of this ECHI-Eurostat coop-
Applying these criteria resulted in a eration is the embedding of the ECHI
The ECHI shortlist represents a carefully
selection of about 80 indicators. This so- shortlist in the new Regulation on Com-
considered selection of available public
called ECHI shortlist was approved in munity statistics on public health and
health data, which was supplemented by a
2005 by the European Commission and health and safety at work, which states that
number of indicators covering important
the Network of Competent Authorities of its aim is to obtain “…data for structural
public health issues currently not (ade-
the Health Information Strand under the indicators, sustainable development indi-
quately) described by existing data
then Public Health Programme. Under the cators and European Community Health
collections. This explicit attention on
ECHIM project an update of the shortlist Indicators (ECHI), as well as for the other
health information gaps also distinguishes
was carried out. The most important sets of indicators which it is necessary to
ECHI from other health data initiatives.
change was the addition of seven new indi- develop for the purpose of monitoring
cators which represented emerging policy The ECHI shortlist was developed Community actions in the fields of public
information needs, such as heat wave through intense cooperation with a large health and health and safety at work”.9
related mortality and selected communi- number of European health information
The above-mentioned Regulation provides
cable diseases. The current version of the projects and Member State experts, which
a general framework for the development
shortlist contains 88 indicators.7 has resulted in the incorporation of inno-
of several detailed implementing acts. One
vative results. This holds especially true in
The shortlist is divided into an implemen- of the first implementing acts to be realised
those areas for which currently no compa-
tation section and a development section. will be on the European Health Interview
rable data are readily and regularly
The first section holds the indicators for Survey (EHIS), which contains many
available. Examples are the attack rates of
which detailed definitions and calculation topics from the ECHI shortlist. Currently,
acute myocardial infarction and stroke,
methods have been developed, and for comparable Health Interview Survey
perinatal health and health promotion.
which data are either available in existing (HIS) data at European level are scarce due
international databases or in a reasonable ECHI also focuses on obtaining data from to variations in methodology. Some
number of EU Members States at national the Member States for the shortlist indi- European surveys, such as the Labour
level. The development section holds the cators for relevant subgroups, most Force Survey (LFS) and the Survey on
indicators covering those areas of public importantly subgroups defined by socio- Income and Living Conditions (SILC) do
health for which there is a need for data, economic status. It is widely contain several questions on health or on
but for which no common indicator acknowledged that there is an urgent need health related topics. A harmonised
methodologies and data collections exist in for public health data stratified by socio- European Health Interview Survey
most EU Member States. The ECHIM economic status. Yet, adequate data to a therefore will be an important step forward
experts and the European Commission are large extent are still lacking. Several initia for ECHI and thus for European public
dedicated to facilitating further work on tives have started in recent years to health monitoring.
the development section being placed on overcome this lack of information, one of
Another important development initiated
the political agenda. the most important being the social pro-
by the Commission is the European
tection and social inclusion indicators
Health Examination Survey (EHES),
Added value and specific features ECHI which are being developed through the
starting with the FEHES project in 2003,
compared with existing indicator systems Open Method of Coordination (OMC).8
which examined the feasibility of carrying
What is the added value of the ECHI ini- ECHI will build on the work already
out an EHES in the EU Member States.10
tiative? After all, there are several carried out in this field, in particular the
In 2009 the Commission called for a Joint
international indicator databases con- OMC work.
Action for the implementation of a pilot
taining public health data, such as
A final characteristic of the ECHI initiative European Health Examination Survey, and
WHO-HFA, OECD and Eurostat. Fur-
is the strong focus on communication 14 countries responded to this call. In
thermore, there are several European
aimed at the dissemination of health infor- future, when EHES will be fully imple-
Agencies collecting data for their specific
mation to policy makers - as a first target mented, this survey will be an important
areas of practice, for example, the
audience - and other user groups. One data source for ECHI.
European Monitoring Centre for Drugs
aspect of this communication within the
and Drugs Addiction (EMCDDA), the
current Joint Action will be the dissemi- Towards implementation of the ECHI
European Centre for Disease Prevention
nation of meta-data, explaining in a shortlist
and Control (ECDC) and the European
structured and clarifying way to what During the ECHI-I and ECHI-II projects,
Environmental Agency (EEA).
extent the data are valid and comparable. the focus was on the development and
The ECHI shortlist is a practical public For indicator information to be used as an selection of indicators. The ECHIM
health policy tool for general use. A theo- evidence base for decision making, this project prepared for the process of imple-
retical framework was applied for the kind of information is essential. mentation of the ECHI shortlist, by
selection of indicators, leading to the assessing the availability of data for the
ECHI shortlist representing in a very Synergy with Eurostat and other ECHI shortlist indicators in the Member
focused yet comprehensive way the public Commission activities States and by establishing a network of
health topics which are most relevant for As the Statistical Office of the European national health information experts.3 With
Eurohealth Vol 16 No 3 6HEALTH POLICY
the Joint Action for ECHIM the work tation pilot, which was developed by the term commitment to valid and comparable
now moves into a new phase; the phase of ECHIM experts.7 The results of this pilot health monitoring is a challenge for
actual implementation at Member State serve as an example for other Member States, particularly in these days
level. (inter)national ECHI data presentation ini- of financial restrictions.
tiatives.
Implementation of the ECHI shortlist
indicators entails putting the indicators
Challenges ahead REFERENCES
into practical use in the Member States by:
Successful implementation of the ECHI 1. Harbers MM, Wilk EA van der, Kramers
– introducing the indicators to national indicators requires close cooperation PGN et al. Dare to Compare! Bench-
(and possibly regional/local) adminis- between the European Commission, the marking Dutch health with the European
trators and decision makers ECHIM experts and Member States. It is Community Health Indicators (ECHI).
also clear that future development of the Bilthoven: RIVM, 2008. Available at:
– modifying existing data sources,
ECHI system is dependent on policy http://www.rivm.nl/bibliotheek/
applying new calculation methods and
support and sustainable financing. rapporten/270051011.html
creating new data sources in order to
improve national data availability and Regarding the cooperation between the 2. ECHI-I final report: design for a set of
quality different stakeholders, the Directorate European Community Health Indicators.
General Health and Consumers (DG 2001. Available at: http://ec.europa.eu/
– setting up a sustainable data flow from health/ph_projects/1998/monitoring/fp_
SANCO) of the European Commission
Member States to a central ECHI monitoring_1998_frep_08_en.pdf
organised an ‘extended ECHIM core
database
group’ meeting in February 2010, in which 3. Kilpeläinen K, Aromaa A and the
– setting up a presentation system, inte- representatives from all Member States ECHIM Core Group (Eds). European
grating the ECHI shortlist with existing have had the opportunity to participate. Health Indicators: Development and Initial
national health reporting systems (if This has been an essential step forward for Implementation. Final Report of the
existing) the implementation process. Furthermore, ECHIM Project. Helsinki: KTL, 2008.
Available at www.healthindicators.eu
DG SANCO’s Expert Group on Health
– analysing and interpreting the results
Information (former Health Information 4. Commission of the European Commu-
for health policy and planning
Committee, HIC) can play a key role as nities. Together for Health: A Strategic
General guidelines for implementation the principle advisory committee for the Approach for the EU 2008–13. Brussels:
have been developed by the ECHIM European Commission on health infor- Commission of the European Commu-
experts to support the national contacts in mation. nities, 2007. vailable at:
formulating feasible short- and long-term http://ec.europa.eu/health-eu/doc/
DG SANCO mainly funds activities whitepaper_en.pdf
national implementation plans. A central
through projects or tenders. A Joint Action
element in the national implementation 5. ECHIM project website:
is slightly different as a financing mech- www.echim.org
plans is the formation of national imple-
anism as it involves a more explicit
mentation teams, which should consist of 6. Kramers PGN. ECHI-II final report:
commitment from Member State author-
representatives of the major stakeholders Public Health Indicators for Europe:
ities. However, it too is a temporary
in health information. At the time of Context, Selection, Definition. Bilthoven:
construction. Health information systems
writing of this paper (September 2010), RIVM, 2005. Available at:
are not static; they need to be constantly
most of the countries represented in the http://www.rivm.nl/bibliotheek/
developed in order to reflect current policy
ECHIM Core Group, as well as some rapporten/271558006.html
needs and advancing scientific insights. It
non-Core Group countries, have started 7. ECHIM products website:
is therefore important that consideration
forming their national implementation www.healthindicators.eu
already be given to possible venues for the
teams and drafting their national imple-
continuation of work on the ECHI indi- 8. Social protection and inclusion indi-
mentation plans. The remaining countries
cators to ensure sustainability of cators. See: http://ec.europa.eu/
participating in the Joint Action for
developmental work as well as in imple- employment_social/spsi/joint_reports_en.
ECHIM will do so in the coming months.
mentation. htm
Within the Joint Action a system to facil- 9. Regulation (EC) No 1338/2008 of the
National health information systems form
itate data flow from the Member States to European Parliament and of the Council
the basis of the European ECHI moni-
a central ECHI database will be tested. of 16 December 2008 on Community
toring system. The involvement of
This central database will be hosted by the statistics on public health and health and
Member States therefore is a prerequisite
European Commission and is linked to a safety at work. Available at: http://eur-lex.
to success. As illustrated at the beginning europa.eu/LexUriServ/LexUriServ.do?uri=
European level web-based data presen-
of this paper, national health information
tation system.11 The ECHIM Core Group OJ:L:2008:354:0070:0081:EN:PDF
systems producing relevant and compa-
members, who are experts in the field of 10. Feasibility of a European Health
rable indicators are of direct use to
public health statistics and monitoring, are Examination Survey (FEHES) project.
Member States. The financial burden of the
working together with the Commission See: http://www.ktl.fi/fehes/
ECHI monitoring system should therefore
to ensure that the data presentations will
not be carried by the European Com- 11. European Health Indicators data pres-
meet basic quality standards for presenting entation tool at website DG SANCO:
mission alone. National authorities need to
international public health comparisons http://ec.europa.eu/health/indicators/
recognise the importance of basic health
to a policy maker audience. These basic indicators/index_en.htm
data collection for a well functioning
requirements are reflected in a data presen-
health system. Working towards a long-
7 Eurohealth Vol 16 No 3HEALTH POLICY
Private sector providers in England:
The implications of Independent Sector Treatment
Centres
Nidhi Vaid
Summary: Over the last few years, private sector providers have begun to have an
increasing role in the NHS. This article outlines the advantages and disadvantages of
private sector involvement following the introduction of one such initiative, the inde-
pendent sector treatment centre. It further discusses how we should learn from the
mistakes made and apply what we have learnt to the proposed government reforms
that have been outlined in the recent White Paper “Equity and Excellence: Liberat-
ing the NHS”. There are certainly potential benefits to be gained from private sector
involvement; however, we must take care not to develop a segregated, two-tier NHS
that disregards the principles on which it was originally founded.
Key words: NHS, private, commissioning, reforms, ISTCs
The National Health Service (NHS) is the Scotland, with the first ISTC opening in Association (BMA) and the Royal College
publicly-funded health care system in the 2003. This was followed by further pro- of Physicians, with suggestions that the
United Kingdom. In 2002, there were curement with the first of the second wave procedures ensuring adequate competence
already sixteen NHS-run treatment opened in 2007. The locations for the new were not rigorous enough.1,3 It has also
centres. They vary in the scope of care pro- ISTCs were identified by local service been suggested that this policy hindered
vided but centre mainly on the provision commissioners. The criteria for an ISTC integration between ISTCs and NHS
of elective surgery, together with diag- was either a lack of capacity or long trusts; in fact staff mobility was key to
nostic and outpatient services. As part of waiting times. In the first wave 25 fixed site cooperation between the two providers.
reforms in the first years of the previous and two mobile site ISTCs were opened. The rules were subsequently relaxed
Labour government, bids for such services The second wave was originally intended during the second wave and NHS staff can
were invited from the private sector. These to develop 24 schemes but this was subse- now, albeit with some restrictions, work in
new Independent Sector Treatment quently reduced to just ten with the DH ISTCs.
Centres (ISTCs), while privately owned, stating that the extra capacity was no
have contracts to treat NHS patients. longer required.1,2 This article aims to Although all doctors employed by an
discuss the implication of contracting out ISTC are required to be registered with the
The ISTCs were designed with several General Medical Council, there is no
clinical services to the private sector, using
objectives in mind. Their main focus was equivalent to the NHS Advisory Appoint-
the introduction of ISTCs in the English
to reduce waiting lists, thus moving ments Committees to act as a quality
health care system as an example.
towards the ‘patient centred’ model pro- control mechanism. Consequently, ISTCs
posed in the 2000 NHS Plan. Additional What are the implications for health care take on responsibility not only for
proposed benefits included encouragement professionals?
recruitment, but also professional devel-
of reform within the NHS by providing During the first wave, ISTCs were unable
opment and appraisal, an area where the
competition, facilitating innovation and to employ staff who had worked in the
Healthcare Commission in 2007 identified
reducing spot purchasing prices*, thus NHS in the preceding six months. This
some shortfalls.4
improving value for money. resulted in ISTCs being staffed largely by
overseas doctors. This led to questions With regards to training, concerns have
There have been two phases or ‘waves’ of
regarding not only the quality of their been voiced by senior surgeons that the
ISTCs procured by the Department of
training, but also their suitability to be transfer of ‘straightforward’ elective pro-
Health (DH) throughout England and
working with potentially unfamiliar NHS cedures, suitable for training junior
techniques and processes. The policy was doctors, from NHS hospitals to ISTCs has
Nidhi Vaid is Specialist Registrar in Acute heavily criticised by the British Medical impacted negatively on training.5 The
Medicine, Chelsea and Westminster
Hospital, London, UK. * Treatment in the private sector which is purchased by the NHS on an ad hoc basis in order
Email: nvaid07@gmail.com to cut waiting lists.
Eurohealth Vol 16 No 3 8HEALTH POLICY
apparent efficiency of ISTCs may also in Commission warned that it is difficult to to choose less complex cases, leaving the
part be accounted for by a lack of respon- form such conclusions since the data is not NHS with complex cases together with
sibility for training which, although time directly comparable.1 longer, more expensive inpatient stays.
consuming, is extremely important. A There have been calls by the BMA for the
ISTCs were intended to reduce waiting
solution is to place junior doctors in ISTCs payment structure of selective ISTCs to be
times by both adding capacity and intro-
where they can be trained in a ‘high altered to reflect this.
ducing competition, consequently
volume, low risk’ arena; subsequently
stimulating productivity within NHS facil-
ISTCs in the second wave were obliged to Is the data comparable?
ities. Although in certain specialties ISTCs
include a training component if requested ISTCs are required to provide data
account for a substantial proportion of
by postgraduate deans. regarding quality outcome and monitoring
activity, nationally, ISTCs account for only
to the DH in the form of performance
Innovative workforce management, such 2% of NHS elective activity, indicating that
indicators; however, the DH retains the
as in the case of Blakelands NHS treatment they have not been a significant contrib-
publication rights of these data. Some
centre, includes regular staff consultations utory factor to the reduction in waiting
times.9 Additionally, an analysis by the authors have concluded that the data pro-
and multi-tasking, and has led to a four day
King’s Fund found no difference in the rate vided by the ISTCs are of poor quality, and
working week by maximally utilising the-
at which waiting times were reduced when as discussed below, not directly compa-
atres and clinic rooms, leaving Fridays for
comparing areas with and without ISTCs.10 rable with NHS data. This clearly needs
administration.6 Based on case studies of
improvement, and following recommenda-
individual ISTCs, it certainly seems that
How are they financed? tions by the Healthcare Commission in
novel workforce management is increasing
Funding for ISTCs is negotiated by the 2007,4 changes have been made to
efficiency and there are lessons to be
DH in the form of five year contracts and reporting methods in ISTCs; despite
learned for the NHS where clinical and
payment is made based on the NHS improvements in the last two years, the
administrative agendas are not always well
national tariff, together with a further quality of data is still not equivalent to that
integrated.
premium to cover capital costs. During the collected by NHS providers making com-
first wave, ISTCs received a ‘take or pay’ parisons difficult.11
What are the implications for health care
users? guarantee meaning that they received the Regulation of the ISTCs, as for the NHS,
One of the main stated objectives of the full contracted value from PCTs irre- is carried out by the Care Quality Com-
introduction of ISTCs was to provide a spective of whether or not they reached mission. However, whilst NHS providers
more patient centred system. The sepa- activity targets, a payment strategy which are required to meet ‘core standards’
ration of emergency from elective has been heavily criticised. The DH together with ‘developmental standards’,
procedures ensures that patient appoint- informed the House of Commons that ISTCs are only required to meet the
ments and procedures do not have to be Wave 1 ISTC providers received, on ‘National Minimum Standards’. A new
cancelled if an emergency case is admitted. average, payments that were 11.2% greater registration system has been introduced in
Since ISTCs concentrate on specific proce- than the NHS equivalent cost which incor- an attempt to standardise regulation but
dures, streamlined patient care pathways porates other NHS costs such as pensions there are now new ‘improvement stan-
with efficient pre-operative processes have ¹. The payment structure was modified in dards’ which will still only be applicable to
led to high ratings in patient satisfaction the second wave and although the full con- the public sector. Whilst these discrep-
surveys. However, one may also argue that tract value is no longer guaranteed, ISTCs ancies in required standards and data
patient satisfaction outcomes have no still receive guaranteed fixed value pay- publication remain, quantitative compar-
demonstrable correlation with health out- ments from the DH. isons are impossible. The variation in
comes and although clearly important, There have been further criticisms with case-mix between ISTCs and NHS facil-
they should be given less importance than regards to both under and over-commis- ities is also marked, making even
other indicators. sioning of services. Poor initial needs qualitative comparisons challenging.12
Under new initiatives, patients are able to analysis and projected demands have
resulted in flawed commissioning and Further implications for the health system
choose where they have their procedure
under-utilisation of ISTCs. The Raven- Encouraging innovation is certainly the
performed, however, they are not given
scourt Park treatment centre in London case in some ISTCs, for example, Boston
any information regarding the quality of
was forced to close just four years after and Gainsborough Treatment Centre
care provided, thus their choices are not
opening. It was operating at just 50% implemented a new technique for general
informed, questioning whether it is really
capacity and failing to be cost-effective. anaesthesia which decreased post-operative
patient choice or government waiting list
Improvements in integrating referrals, side effects and enhanced recovery time
targets that have driven ISTCs. ISTCs have
both vertically and horizontally, from the with subsequent improvements in patient
been criticised by clinicians for providing
NHS are certainly required in order to care as well as improved productivity
inferior care with a low level of monitoring
prevent other centres facing a similar measures for the ISTC.6 Many prominent
and governance, for example, the British
demise. Over-commissioning has also been surgeons have argued that these, and anal-
Orthopaedic Association has stated that
a problem, with more procedures being ogous techniques, have previously been
more revisions of operations are required
commissioned than individuals on current evaluated in the NHS, and they are neither
when patients are treated at ISTCs.7 This
NHS waiting lists, with resultant negative original nor innovative and have no
statement however has not been supported
financial consequences. discernible impact on service delivery ¹.
by the National Centre for Health Out-
comes Development (NCHOD),8 and in Criticisms even extend to include selection There are suggestions that some NHS
fact the chief executive of the Healthcare policies, with some ISTCs being allowed providers have responded to a new ISTC
9 Eurohealth Vol 16 No 3You can also read
