I’ve been lucky enough recently to learn more about health trends in the US. It isn’t a system most of us would wish to emulate, given that it consumes twice as much of the national resource as the NHS while leaving over 20% of the population with access to emergency care only.
Nevertheless, many of the challenges faced by their hospitals and health systems are comparable with those faced by the NHS. And there has been a steady shift in the nature of services.
Mergers and acquisitions are more numerous than ever, creating large groups and chains of hospitals. These are facilitating both greater market share and cost reductions from greater scale. Interestingly, back office savings are small (around 1-2.5%) while service rationalisation gains are much greater (some 10-16%).
While health spending has grown at five times the rate of the US economy since 1980, the spend on hospital care has fallen from 43% to 33%. Physician services have remained constant though, at 21%. And cost and quality are not well aligned, so that greater cost does not equate to better outcomes.
The larger health systems seem to be getting stronger, as margins have climbed in recent years following a steady fall in the nineties. Revenue from out-patient services has been rising, from just over 20% in 1990 to around 40% now, with in-patient income showing a corresponding drop.
The aging population is a factor, but the greatest cost pressure is the growing burden of chronic disease.
Rising health costs for employers are now driving increasing investment in ‘wellness’. As a consequence, accountable care systems, which are integrated and able to focus on overall population health, are gaining ground over the previous ‘production models’ of provision. Co-production of services with patients is increasing too (some systems offer access to health records through a phone ‘app’, with reminders and prompts also coming via mobile technology).
What of the future? Perhaps fewer, larger healthcare systems, concentrating as much on maintaining good health and provision of out of hospital care, as well as on the still necessary in-patient services? Specialist services consolidated to create excellence, procedures carried out in high volume ‘hubs’, and greater use of non-doctor professionals and increasing standardisation of care protocols?
Here in the UK, as we contemplate similar trends and cost pressures, and fret over the future of our hospital sector, it is easy to spot similarities. We talk a lot about integration, but seem unable to bring it about. I think the following need changing, for urgent care at least:
1. Tariff and Payment by Results for hospitals
2. The ‘purchaser provider split’
3. Separate targets and regulation for hospitals
4. Fragmented primary care provision
5. Reactive and unfocused community care
6. Too many small hospitals and unsustainable specialist services
They are all blocking progress.
It is surely time to trial a different approach? A budget built up on a ‘year of care’ tariff; standards and targets measuring whole system performance in terms of maintaining well-being; leaders willing to collaborate and being allowed, and incentivised, to do so; and greater patient involvement in designing a new system that facilitates self-care, access to records, and 24/7 access to advice and support.
Sure, it would require people to work differently, including doctors. But hospital specialists would be using their skills, and those of their teams, to better manage chronic illness and improve the quality of life of sufferers by actively working to improve wellness. That has to be rewarding and worthwhile, and a fitting utilisation of hard won skills and expertise?
This blog was originally posted on the HospitalDr website here on 22 October 2012