Tag Archives: Healthcare reform

HTA in Italia: pessimismo dell’intelligenza, ottimismo della volontà

Il 24 ottobre scorso sono stato invitato da Giovanni Morana, dinamico direttore della radiologia dell’ospedale di Treviso, ad un convegno sul tema della TAC Dual Energy. Il programma prevedeva una parte dedicata a questa interessante tecnologia ancora in fase di sviluppo e ricerca e una dedicata all’HTA.


L’incontro si è tenuto all’Ateneo Veneto, una fondazione istituita da Napoleone dopo il disfacimento della Serenissima Repubblica di Venezia, in uno splendido palazzo a fianco del Gran Teatro La Fenice.

Per un accidente della storia, il 9 ottobre 1996, nella stessa sede avevo organizzato un workshop, alla presenza dei politici e direttori generali della aziende sanitarie del tempo, dal titolo: “Razionamento o razionalizzazione dell’assistenza sanitaria – il ruolo dell’HTA”, starring Renaldo N. Battista al quale il collega direttore generale di Venezia (il compianto Carlo Crepas) aveva tributato gli onori che la Serenissima Repubblica tributava ai Capi di Stato e agli Ambasciatori in visita a Venezia: il corteo in barca lungo il Canal Grande.


L’invito di Giovanni Morana ha suscitato in me due sentimenti: il piacere di discutere oggi con i clinici (italiani, stranieri e un brillante giovane collega italiano che lavora a Charleston, Carlo De Cecco) e i produttori di tecnologia i metodi e le opportunità offerte dall’HTA; l’amarezza di toccare con mano la lentezza con la quale in questi vent’anni l’HTA si è diffusa in Italia!

Quanta strada ancora da percorrere! Se smettessimo di buttarci a pesce sulle cose urgenti e ci occupassimo un po’ di più delle cose importanti (De Gaulle) …..!!!

Il XXI secolo non ci ha portato ancora superare lo storicismo gramsciano: “Tutti i più ridicoli fantasticatori che nei loro nascondigli di geni incompresi fanno scoperte strabilianti e definitive, si precipitano su ogni movimento nuovo persuasi di poter spacciare le loro fanfaluche. D’altronde ogni collasso porta con sé disordine intellettuale e morale. Pessimismo dell’intelligenza, ottimismo della volontà”. (Q28, III)




BETTER HEALTH CARE AND LOWER COSTS @leadmedit @medici_Manager @pash22 @WRicciardi


Executive Summary

In recent years there has been success in expanding access to the health-care system, with millions gaining coverage in the past year due to the Affordable Care Act. With greater access, emphasis now turns to guaranteeing that care is both affordable and high-quality. Rising health-care costs are an important determinant of the Nation’s fiscal future, and they also affect the budgets for States, businesses, and families across the country. Health-care costs now approach a fifth of the economy, and careful reviews suggest that a significant portion of those costs does not lead to better health or better care.

Other industries have used a range of systems-engineering approaches to reduce waste and increase reliability, and health care could benefit from adopting some of these approaches. As in those other industries, systems engineering has often produced dramatically positive results in the small number of health-care organizations that have implemented such concepts. These efforts have transformed health care at a small scale, such as improving the efficiency of a hospital pharmacy, and at much larger scales, such as coordinating operations across an entire hospital system or across a community. Systems tools and methods, moreover, can be used to ensure that care is reliably safe, to eliminate inefficient processes that do not improve care quality or people’s health, and to ensure that health care is centered on patients and their families. Notwithstanding the instances in which these methods and techniques have been applied successfully, they remain underutilized throughout the broader system.

The primary barrier to greater use of systems methods and tools is the predominant fee-for-service payment system, which is a major disincentive to more efficient care. That system rewards procedures, not personalized care. To support needed change, the Nation needs to move more quickly to payment models that pay for value rather than volume. These new payment models depend on metrics to identify high-value care, which means that strong quality measures are needed, especially about health outcomes. With payment incentives aligned and quality information available, health care can take advantage of an array of approaches using systems engineering to redesign processes of care around the patient and bring community resources, as well as medical resources, together in support of that goal.

Additional barriers limit the spread and dissemination of systems methods and tools, such as insufficient data infrastructure and limited technical capabilities. These barriers are especially acute for practices with only one or a few physicians (small practices) or for community-wide efforts. To address these barriers, PCAST proposes the following overarching approaches where the Administration could make a difference:

  1. Accelerate alignment of payment systems with desired outcomes,
  2. Increase access to relevant health data and analytics,
  3. Provide technical assistance in systems-engineering approaches,
  4. Involve communities in improving health-care delivery,
  5. Share lessons learned from successful improvement efforts, and
  6. Train health professionals in new skills and approaches.

Through implementation of these strategies, systems tools and methods can play a major role in improving the value of the health-care system and improving the health of all Americans.

Summary of Recommendations

Recommendation 1: Accelerate the alignment of payment incentives and reported information with better outcomes for individuals and populations.


1.1  HealthandHumanServices(HHS)shouldconvenepublicandprivatepayers(includingMedicare,Medicaid, State programs, and commercial insurers) and employers to discuss how to accelerate the transition to outcomes-based payment, promote transparency, and provide tools and supports for practice transformation. This work could build on current alignment and measurement-improvement efforts at the Center for Medicare and Medicaid Services (CMS) and HHS broadly.

1.2  CMS should collaborate with the Agency for Healthcare Research and Quality (AHRQ) to develop the best measures (including outcomes) for patients and populations that can be readily assessed using current and future digital data sources. Such measures would create more meaningful information for providers and patients.

Recommendation 2: Accelerate efforts to develop the Nation’s health-data infrastructure.
2.1 HHS should continue, and accelerate, the creation of a robust health-data infrastructure through widespread adoption of interoperable electronic health records and accessible health information. Specific actions in this vein were proposed in the 2010 PCAST report on health information technology and the related 2014 JASON report to the Office of the National Coordinator for Health Information Technology (ONC).

Recommendation 3: Provide national leadership in systems engineering by increasing the supply of data available to benchmark performance, understand a community’s health, and examine broader regional or national trends.

3.1 HHS should create a senior leadership position, at the Assistant Secretary level, focused on health-care transformation to advance information science and data analytics. The duties for this position should include:

  • Inventory existing data sources, identify opportunities for alignment and integration, and increase awareness of their potential;
  • Expand access to existing data through open data initiatives;
  • Promote collaboration with other Federal partners and private organizations; and
  • Create a more focused and deep data-science capability through advancing data analytics and
  • implementation of systems engineering.

3.2 HHS should work with the private sector to accelerate public- and private-payer release of provider-level data about quality, safety, and cost to increase transparency and enable patients to make more informed decisions.

Recommendation 4: Increase technical assistance (for a defined period—3-5 years) to health-care professionals and communities in applying systems approaches.

4.1 HHS should launch a large-scale initiative to provide hands-on support to small practices to develop the capabilities, skills, and tools to provide better, more coordinated care to their patients. This initiative should build on existing initiatives, such as the ONC Regional Extension Centers and the Department of Commerce’s Manufacturing Extension Partnership.

Recommendation 5: Support efforts to engage communities in systematic health-care improvement.


5.1  HHSshouldcontinuetosupportStateandlocaleffortstotransformhealthcaresystemstoprovidebetter

care quality and overall value.

5.2  Future CMS Innovation Center programs should, as appropriate, incorporate systems-engineering

principles at the community level; set, assess, and achieve population-level goals; and encourage grantees

to engage stakeholders outside of the traditional health-care system.

5.3  HHS should leverage existing community needs assessment and planning processes, such as the

community health-needs assessments for non-profit hospitals, Accountable Care Organization (ACO) standards, health-department accreditation, and community health-center needs assessments, to promote systems thinking at the community level.

Recommendation 6: Establish awards, challenges, and prizes to promote the use of systems methods and tools in health care.

6.1 HHS and the Department of Commerce should build on the Baldrige awards to recognize health-care providers successfully applying system engineering approaches.

Recommendation 7: Build competencies and workforce for redesigning health care.


7.1  HHS should use a wide range of funding, program, and partnership levers to educate clinicians about

systems-engineering competencies for scalable health-care improvement.

7.2  HHS should collect, inventory, and disseminate best practices in curricular and learning activities, as well as encourage knowledge sharing through regional learning communities. These functions could be accomplished through the new extension-center functions.

7.3  HHS should create grant programs for developing innovative health professional curricula that include systems engineering and implementation science, and HHS should disseminate the grant products broadly.

7.4  HHS should fund systems-engineering centers of excellence to build a robust specialty in Health-

Improvement Science for physicians, nurses, health professionals, and administrators.

Full Report: http://www.whitehouse.gov/sites/default/files/microsites/ostp/PCAST/pcast_systems_engineering_in_healthcare_-_may_2014.pdf

How and why do countries vary so much in their use of health services? @WRicciardi @leadmedit @Medici_Manager @pash22

BY ADAM WAGSTAFF , http://bit.ly/1e48HAI

I’ve been struck recently by how little we (or at least I) seem to know about variations in use of health services across the world, and what drives them. Do people in, say, India or Mali use doctors “a lot” or “a little”. Even harder: do they “overuse” or “underuse” doctors? At least we could say whether doctor utilization rates in these countries are low or high compared to the rate for the developing world as a whole. But typically we don’t actually make such comparisons – we don’t have the numbers at our fingertips. Or at least I don’t.

I’m also struck by how strongly people feel about the factors that shape people’s use of services and what the consequences are. There are some who argue that the health problems in the developing world stem from people not getting care, and that people don’t get care because of shortages of doctors and infrastructure. There are others who argue that doctors are in fact quite plentiful – in principle; the problem is that in practice doctors are often absent from their clinic and people don’t get care at the right moment. There are others who argue that doctors are plentiful even in practice and people do get care; the problem is that the quality of the care is shockingly bad. Who’s right?

WHS to the rescue – again

As in a recent post of mine on Let’s Talk Development, I thought the World Health Survey might shed some light on these issues. The WHS was fielded in the early 2000’s in 70 countries – spanning the World Bank’s lower-, middle- and high-income categories. The WHS enumerators asked a randomly-selected adult in each household about his or her use of inpatient care and outpatient care; in the numbers that follow I’ve focused on use in the last 12 months. As I said in the earlier blog post, the WHS does have some drawbacks: it covers some regions fairly fully, other much less fully; it’s 10 years old; and all we can tell is whether inpatient or outpatient care was received, not the number of contacts. But despite these problems, the WHS gets us quite a long way.

A lot of variation – but not necessarily what you’d expect

The maps below show the inpatient admission and outpatient visit rate – actually the fraction of people who had at least one admission or visit in the last 12 months. Green countries are above the developing-country average; red countries are below it.
For IP admissions, most of the OECD countries are above the developing-country average (6.98%). Brazil, Namibia and the European and central Asian countries are also above it. African and Asian countries are mostly below or close to the developing-country average.

The picture is different for outpatient visits. Several OECD countries are actually below the developing-country average (27.52%). And for the most part, the countries below the developing-country average are in Africa: many are considerably below it (Mali stands out dramatically); only a few are above it (Kenya and Zambia stand out). By contrast, several countries in Asia are above the developing-country average: India and Pakistan are dramatically above it, but China and Vietnam are also above it; a few Asian countries are below it – Laos and Myanmar are considerably below it, Malaysia and the Philippines less so.

Do variations in doctor numbers and infrastructure explain variations in utilization?

The maps below show data on doctors and hospital beds per 1,000 persons. I got the data from the World Development Indicators, and took the country averages for the first half of the 2000s. As before, green countries are above the developing-country average; red countries are below it. The countries above the developing-country averages are mostly those in the OECD and Europe and central Asia, though in the case of doctors per 1,000 some of them are also in Latin America and the Caribbean. Except for China, most of Asian countries fall below the developing country average.

Correlating the WHS utilization data with the WDI doctor and beds data shows that doctors and beds per 1,000 persons are positively associated with outpatient visit and inpatient admission rates. A lack of doctors and beds looks like it could indeed be part of the explanation for low utilization rates, though of course we haven’t established causality.

But a lack of doctors and hospital beds is only part of the story. Together they “explain” only 60% of the cross-country variation in inpatient admission rates, while doctors “explain” an even smaller 20% of the cross-country variation in outpatient visit rates.

Some countries – India and Pakistan are examples – are below the developing-country average on doctors per 1,000 persons, but above the developing-country average on the outpatient visit rate. Doctors and hospitals in these countries treat far more patients than one would expect given the number of doctors and hospital beds in these countries. In these countries, it doesn’t look like accessibility is the pressing issue; as research by my colleague Jishnu Das confirms, at least in India, poor quality is the bigger problem.

By contrast, much – but not all – of Africa is in the opposite camp: these countries have inpatient admission and outpatient visit rates that are below what would be expected on the basis of their doctor and beds per 1,000 figures. So it’s not just that these countries lack doctors and beds; it’s also that people are not getting the level of contacts you’d expect from the existing staff and infrastructure. Here it looks like absenteeism could well be part of the story; recent research from my colleague Markus Goldstein confirms it – pregnant women whose first clinic visit coincided with a nurse’s attendance were found to be 46 percent more likely to deliver their baby in a hospital.

Two take away messages

Message #1 is that countries differ considerably in their utilization rates. Much of Asia visits doctors more regularly than both the developing world and the entire world; India’s consultation rate is a third higher than the global average. Africa stands out as the continent where outpatient visits and inpatient admissions lag behind the rest of the world.

Message #2 is that these variations are partly explained by differences in doctors and hospital beds per capita, but only partly. The problem goes deeper than hiring more doctors and building more hospitals. Africa has lower outpatient visit rates than its doctors per 1,000 figures would suggest, while the opposite is true of India and Pakistan. In Africa, it looks like the binding constraint may well be absenteeism, while in S Asia it looks like the first-order problem is the poor quality of care that’s actually delivered.

5 Reasons Employee Engagement Programs Fail @Medici_Manager @helenbevan @CEOdotcom

The latest State of the American Workplace report from Gallup tells us once again that only about 30% of Americans are engaged at work. The number of disengaged workers costs the U.S. $450 billion to $550 billion per year.

This engagement crisis is the same story we’ve been hearing for over a decade, yet most organizations still fail in their efforts to increase the commitment of their workers. Why?

Based on my own journey from bad boss to Best Place to Work award winner, and on my reviews of hundreds of case studies, these are the most common reasons executives’ employee engagement efforts fail:

1. They confuse engagement with happy.

Often engagement initiatives crater in the C-suite because senior executives don’t know what employee engagement is. They may confuse it with nice but “soft” efforts to make employees “happy.”

Engagement is the emotional commitment one feels to their organization, and to the organization’s goals. When engaged, employees give discretionary effort—the secret sauce to gains in productivity, sales and ultimately profits.

2. They don’t think engagement can be measured.

Even some notable business gurus were quoted recently as saying, “Don’t try to measure engagement or you’ll kill it.” Or you can’t measure engagement, but you know it when you see it.

To the contrary, HR consultancies from Gallup to Kenexa have found ways to measures proxies of engagement. Measurement is the first step in managing better outcomes.

3. They measure it but don’t share results.

Typically, when an engagement survey is completed, the results are scrutinized by the C-level executives and the HR professionals. Rarely are all the results shared throughout the company. Only when individual managers get their own team scores can transformation occur.

4. All the ideas for improvement come from the top.

Related to No. 3 above, senior execs often work as a council of wise men and women, brainstorming better benefits or new award programs for the whole company. The secret to engagement is that it comes from the relationships front line managers have with their direct reports. Only action planning at the individual team level will generate the ideas that will move the needle.

5. They think it’s about picnics and parties.

Unfortunately, top-down ideas typically include things like summer picnics, dress down Fridays and Employee of the Month awards. The true drivers of engagement are growthrecognitiontrust andcommunication. While people might feel “happier” during the time of a party, only a true change in their daily and weekly work experience will make them feel emotionally connected to their organization.

The employee engagement crisis has gone on long enough. All organizations that strive for excellence should implement an annual measurement survey, share the results down to the front-line managers, and insist on team-level action planning to move the scores in the right direction.

Kevin Kruse is a NY Times bestselling author, speaker and serial entrepreneur. His latest book is Employee Engagement for Everyone.


Reinventing care: a new era of networked health science @pash22 @Medici_Manager @helenbevan

by Leonard Kish http://bit.ly/149MDms

Technology, payment reform, and advancements in social and behavioral sciences are creating a perfect storm, leading to rapid acceleration in our understanding of how to improve health outcomes in a networked world, let’s call it “networked health science.”

Engagement is Relationships

Patient engagement is a key outgrowth of our understanding this new era. Providing realimprovements in cost and quality, patient engagement is rapidly becoming an accepted, if not integral, part of improving the U.S. Health Care System. Underscoring the meteoric rise of this new domain of understanding, the Health Affairs February issue is devoted to “The New Era of Patient Engagement.”

“Engagement” is a broad term that lies at the intersection between social science, behavioral science and technology. The essence is this: creating environments that allow people to stay focused on a goal while giving them the tools (often including social connections, information and communication) they need to achieve that goal. In terms of patient engagement, of course, the goal is better health.

The Center for Advancing Health describes patient engagement as “actions individuals must take to obtain the greatest benefit from the health care services available to them.” I think this definition falls short.

Patient engagement is often discussed in the context of technology used to enable action. When many people first hear about engagement in this context, the assumption is that the notion of relationships, such as doctor-patient relationships, are being somehow replaced by technology. But the idea is to enhance communication and, therefore, the relationship.

This is a critical distinction. The relationship is by no means secondary to achieving the goal. If you believe in the Fogg Behavior Model (a description of what is required to get an action to be taken or a behavior to change) we need to focus on both motivation and ability to get results and have people take action. The motivation comes from human connection, the ability comes from sharing information and improving communication.

Social science has shown that our real world and online social networks have a profound effect onour behavior. Actions, in terms of the Patient Engagement path defined by the Center for Advancing Health, are at the end of the engagement path, not the beginning. No patient is an island, and you can’t leave the network out of the equation, as we’ll soon see.

It’s not just about the provider.

When I wrote about engagement as the Blockbuster Drug of the Century, the examples I gave were in improving patient-physician communications. Often neglected in a fee-for-service health care universe, patient engagement with his or her provider is the area with perhaps the greatest room for improvement, but there are other relationships that can be improved with better engagement.

Excellent work by the research team at PatientsLikeMe indicate that patient-patient interactions can improve a patient’s perceived well-being. This suggests that engagement may soon be shown to improve outcomes along multiple dimensions: patient-to-patient, patient-to-physician, physician-to-physician, patient-to-care team, etc.

Writing about what an engagement “pill” might look like, Paul Wicks, Director of Research at PatientsLikeMe, shows the following graph from an epilepsy study.


The graph shows increasing numbers of connections on the PatientsLikeMe platform leads to increased perceived benefits by the patients across 20 different measures, appearing to plateau around 12 connections. If you’ve ever seen a dose-response curve of a medication, you’d find this graph to look incredibly familiar. Looking at these results, if the study of drug interactions is pharmacokinetics, perhaps we’ll need a new field of study called “communitikinetics”.

Is it the motivation or the ability that’s driving the change?

It’s both.

The number of Social Ties on the platform certainly helps with motivation and to stay on track. We’re beginning to see a similar effect with weight loss enabled by engagement on Twitter (hat tip: @EricTopol).

But the ability to enable patients with more information certainly matters as well. PatientsLikeMe invested early and often in user experience design (UX). Some of what came out of their investment in UX, separating them from from other communities, is the focus on data sharing and data visualization.

According to Wicks, “Every patient on PatientsLikeMe can see the complete health record of every other patient.” What PatientsLikeMe found during user experience design is that patients aren’t just looking for camaraderie and understanding, although that helps, they’re looking for actionable results.

Sharing results in this way makes them meaningful and provides digestible insights to lead toward what actions to take. But equally important, through the network of peers, they can have assistance in filtering what’s relevant for them. This is the essence of improved communication to achieve desired results. This study shows the importance of a patient’s network of engaged peers in addition to the technology that’s enabling that engagement.

The study also shows that effective data sharing is becoming a critical piece of engagement, communication and (I’ll be happy to wager) outcomes. As National Coordinator for Health IT Farzad Mostashari said at FutureMed last week, “We are just scratching the surface” of what information sharing can do.

Researchers and Data Sharing

At the same FutureMed, 16-year old cancer researcher Jack Andraka showed how he developed a pancreatic cancer test using carbon nanotubes and antibodies when he was 15.

How did a 15-year-old discover a new pancreatic cancer test? Much of Jack’s success is certainly attributable to his innate intelligence, hard work and persistence (he sent out letters to 200 labs before finally finding one that would let him do his research project), but he says none of this would have been possible without open access to journals that he read that gave him the foundation for the ideas he was able to test. Yes, we are, without a doubt, just scratching the surface of what information sharing can do.

Sometimes, it’s Still About the Provider

Ultimately, all this networked engagement and data sharing is attempting to match problems and solutions. The same is certainly true for physician sharing. That’s what Meaningful Use and payment reform are attempting to drive, but with the effect seen by patients, it may be worth exploring more deeply the notion of increasing communications not just from one doc to another, but within a community of physicians, taking advantage of some of the lessons learned by the designers at PatientsLikeMe.

At the VA and Kaiser, instances where information is networked and shared throughout the system, results suggest lower costs and better outcomes. Syndicom, which has a case-sharing platform for physicians to collaborate, claim they’ve seen better outcomes when physicians have collaborated in an online community. What will it take to redesign an EHR with these ideas in mind?

The Signal and the Noise of Engagement

Future research should explore the “right size” of sharing to get the best results. Too much sharing and too much connection within a network will likely result in diminishing returns, where noise overcomes the signal. This may have been what happened with 12 connections or more on PatientsLikeMe. More research will tell, but in the meantime, focusing on what needs to be exchanged and choosing the right number and quality of connections (as happens via social networks like Twitter) will help amplify the important signals while minimizing the noise.

For me, the groundbreaking part of all this is that by opening up data resources, we’re creating options. The community helps us hone these options to the one that best fits the circumstances (amplifying signal, reducing noise).

This development of options within a community must instruct our policy and our decisions about the future health care system.

As one example, tethered patient portals may help inform the patient, but unless that information can be shared with a community and recombined with other information to provide the right context, it’s of limited value.

The single entry to a portal diminishes the ability of the hospital to build the relationships and the network with outside providers and patients who are so critical to improving care, and ultimately, more patients to the hospital.

Any person in finance can tell you that options have value. We’re going to get very good at valuing options in healthcare over the coming years as these options, driven by sharing information and the ability to develop relationships across vast distances, improve outcomes.

In the words of Vince Kuraitis, many institutions will come around to the idea and the need to establish a program of “Strategic Openness” and sharing. It’s the building up of a community that leads to success, and it’s ultimately in each stakeholder’s own self-interest to help in building that community. As I hope I’ve shown, that will often mean engagement through data sharing.

Just ask the marketers during the Super Bowl, 50% of commercials provided Twitter information. Big companies have learned that community engagement matters. Let’s hope our care providers figure it out sooner rather than later, for their sake and ours.

Note: I’ve paraphrased Michael Nielsen’s phenomenal book, “Reinventing Discovery: A New Era of Networked Science” for my title on this post. We’re uncovering new ways online health care communities can improve health and outcomes, similar to the communities of online scientists he describes that are accelerating new discoveries in several fields.

leonardMore from Leonard Kish


The case for change slidepack @Medici_Manager @WRicciardi

Our Time to Think Differently programme has made the case for change and highlighted the trends that will influence the way health and social care is delivered in future.

To help you explore and share this work, we are creating a series of downloadable slidepacks. We hope that they will inform your thinking and discussions about the future of care.

The first pack in this series explores the pressures on the health and social care delivery system and why it needs to change to meet the challenges of the future.

You can download a powerpoint version of these slides here: The case for change slide pack. These slides cannot be edited in this format, but you can copy individual slides across to your own presentations. Please credit The King’s Fund www.kingsfund.org.uk/think if you use the slides elsewhere.

King’s Fund http://bit.ly/15mI8Sk

How clinical commissioning groups are handling new responsibilities @Medici_Manager @muirgray

by Steve Kell http://bit.ly/1bxypvV

One hundred days have now passed since 1 April and the official birth of clinical commissioning groups (CCGs). As a GP and CCG chair it has been one of the most exciting, frustrating and meaningful periods of my career.

For most CCGs, delegated authority from primary care trust clusters, and therefore responsibility, had been in place for some time before April. However the process of authorisation and establishing organisations undoubtedly became a necessary distraction, with process and structure the focus.

Authorisation was essential to ensure we build robust, patient-focused organisations capable of fulfilling our statutory duties. CCGs were the only part of the new system to have been through this process, despite the number of new structures in the commissioning system. Since authorisation it has been good to get back to what we are here to do — commissioning health services and working with patients and practices to ensure we understand local services and their quality.

Bassetlaw CCG is a comparatively small CCG, with 12 practices and 112,000 patients in north Nottinghamshire. We have the same issues as many of our neighbours – high mortality and morbidity levels, areas of significant deprivation, obesity and substance misuse. We have a two-tier local authority system and we are members of Nottinghamshire health and wellbeing board. However, 90% of our patients use acute health services based in northern England – in South Yorkshire (including Bassetlaw hospital as part of Doncaster and Bassetlaw hospitals foundation trust).

Much of our time, therefore, is spent developing partnerships. Many of the commissioning organisations we work with are new, including NHS Englandpublic health teams and the health and wellbeing board. Practices and providers are important as pre-existing parts of the system, and have been essential in understanding our local health services and outcomes. We have built transparent relationships with our providers, openly discussing services, capacity and performance. We meet neighbouring CCGs regularly to discuss commissioning on a regional level such as cardiology services and networks.

Quality assurance forms a significant part of our role. Performance indicators and targets are a key part of this, but we have also reviewed issues raised by member practices and patients. Service development has been one of our most important work streams. It is essential that we seek continuous improvement in services for patients, and not simply monitor what we already have. GPs work closely with managers to improve pathways and we have successfully commissioned new musculoskeletal, dermatology, cardiac rehabilitation and community paediatric pathways for local patients.

As a CCG we have a strong sense of responsibility for our local population. Patient engagement is central to this. We have well established practice patient groups and groups within the CCG, and this role is led by our new lay member who has worked hard to ensure we have a new, meaningful approach. We have developed a series of summits with patients, carers and providers including extremely successful dementia and learning disability events.

We have a number of commissioning priorities as a CCG. Some, such as developing integration of services and pathways, have been enhanced by the development of an integrated care board chaired by the local authority. Some have arisen due to performance issues, such as A&E performance. We have worked closely with practices, visit A&E weekly and have commissioned increased capacity within the department and acute medical services with significant results. Targets are now being met and we have services with better access to senior staff over seven days and diagnostics.

There are significant challenges. Being allowed access to patient information is essential if we are to improve outcomes and commission effectively. Running cost, set at £25 per patient, is a blunt tool that does not take into account organisational size and fixed costs, or local health needs. CCGs, particularly those such as Bassetlaw, who have natural communities but are relatively small, are extremely lean organisations where clinical and managerial time is limited and we have learned to work as an efficient, effective team. It is essential that this is valued when we have assurance meetings and that reporting upwards does not distract us from our role.

We operate as just one part of a complex commissioning system. We need to ensure we are active partners alongside public health, regulators and NHS England, and that our clinical involvement and patient engagement lead to better outcomes.

After 100 days I’m optimistic. Clinical commissioning is delivering. The NHS needs it to succeed.

Dr Steve Kell is chair of Bassetlaw CCG and co-chair of NHS Clinical Commissioners Leadership Group

This article is published by Guardian Professional. Join the Healthcare Professionals Network to receive regular emails and exclusive offers.

NHS needs clinical leaders at all levels @Medici_Manager @muirgray @helenbevan

by Stephen Brooks and Anthony Surley http://bit.ly/13HjsXF

The Francis report into the Mid Staffs NHS foundation trust identified poor leadership as a key factor in the disastrous failures in patient care. It recommended the creation of a “leadership staff college to provide common professional training in management and leadership to potential senior staff”.

Since this college should have a “physical presence” – a virtual organisation is ruled out – it will take a long time to establish. It will take even longer to deliver skilled leaders and the college will be forced to focus on senior managers; it would be a miracle if such a college could make any measurable impact on the NHS in the next decade.

Yet it is clear that improving leadership skills needs to be addressed with greater urgency. The nature of healthcare and the way it is delivered is set for radical change over the next decade. These changes will mean leadership roles are devolved down to more junior professionals and across a wider range of disciplines. As a result, it is not only senior managers who will need leadership training but clinicians at all levels.

Strategic initiatives such as community-based care, the use of clinical pathways (the standardised care provided for specific conditions), telemedicine and the pressures of an aging population will increase the need for clinical leaders, often at junior levels, to co-ordinate the delivery of care to patients.

For GPs, the challenge will be to move away from a culture of referral to one where they take ownership for all of the patient’s care and provide strategic co-ordination of the care pathways used to treat patients with multiple conditions. Within this framework, the practical day to day treatment may well be managed by a more junior clinician.

They too require skills such as planning, prioritisation, decision making, influencing, as well as knowledge of multi-disciplinary team working, and the ability to mentor and learn from others. Leadership needs to be a central part of clinical education.

All these pressures underline that now is the right time for the NHS to give leadership training greater priority. A new body, Health Education England (HEE), has been established that operates through 13 local education and training boards (LETBs). Training strategies are under review and we should expect changes in the content and delivery of training within and across professions as LETBs flex their muscles.

As ever, some will say that a greater emphasis on leadership training might be desirable, but no money is available and boosting it would be at the expense of vital clinical training. There are two key responses to this. Firstly, HEE will spend £4.8bn annually – just 1% of that could provide initial training for up to 100,000 NHS leaders each year.

Secondly, leadership training would improve patient care not undermine it. Good leadership skills result in better clinical outcomes by ensuring that correct values and standards are maintained, that clinicians are motivated and can focus on using their talents for the benefit of patients.

To achieve a lasting boost in leadership, the LETBs need a two-pronged strategy. Firstly, they need to meet the immediate needs of the NHS by delivering training to the existing workforce. They need to work with employers to identify those in leadership roles and deliver appropriate training to them. The NHS has recently set up a leadership academy, which has made a start on developing programmes for some of the mid-level professionals.

To meet longer term needs, HEE and LETBs should work with royal colleges, universities and medical schools to build leadership skills into the initial professional training. It should be built around the core NHS values and ensure that newly qualified professionals start with skills they can build on as their careers develop.

This is essential because good leadership is necessary to deliver high quality 21st century healthcare. Just as patients would not want to be treated by untrained clinicians, they should not be expected to receive treatment in facilities led by those who have had no training in leadership.

Stephen Brooks is a specialist in people, change and leadership, and Anthony Surley is a specialist in talent management and healthcare atPA Consulting Group

This article is published by Guardian Professional. Join the Healthcare Professionals Network to receive regular emails and exclusive offers.

Does integrated care deliver the benefits expected? @RANDCorporation @Medici_Manager @pash22

Findings from 16 integrated care pilot initiatives in England


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I grandi ospedali sono più sicuri @Medici_Manager @WRicciardi

17 maggio 2013 di Denis Rizzoli http://bit.ly/10bEciV

Il rischio di morte per un intervento chirurgico è significativamente più alto negli ospedali di piccole dimensioni. È il risultato di uno studio condotto dall’ Agenzia sanitaria per i servizi regionali(Agenas) e il Dipartimento di epidemiologia del Lazio. Si chiama Volumi di attività ed esiti delle cure: prove scientifiche in letteratura ed evidenze scientifiche in Italia e vuole dimostrare quali sono le malattie curate meglio negli ospedali con alti volumi di attività. Le conclusioni parlano chiaro. Farsi operare in una struttura che svolge poche operazioni potrebbe essere fatale per almeno 14 diverse patologie: l’aneurisma dell’aorta addominale non rotto, l’angioplastica coronarica, l’artoplastica del ginocchio, il bypass aortocoronarico, il tumore del colon, del pancreas, del polmone, della prostata, dello stomaco e della vescica, la colecistectomia laparoscopica, l’endoarterectomia carotidea, la frattura del femore e l’infarto. Per dimostrarlo, hanno svolto una ricerca sistematica negli studi internazionali pubblicati. Questi risultati sono stati poi confrontati con i dati del Programma Nazionale Esiti 2012, già pubblicati da Wired nella mappa interattiva #doveticuri con le performance di tutti gli ospedali italiani, cliccabile qui sotto.

Quali sono gli interventi più sicuri in un grande ospedale? 
L’ infarto è una delle patologie che fa più vittime con una media nazionale elevata: il 10,28% dei pazienti è morto entro 30 giorni dall’intervento, nel 2011. In questo caso, tuttavia, l’ospedale in cui si viene operati può fare la differenza.

È bastato incrociare la percentuale di decessi per infarto in ogni struttura (sull’asse verticale) con il numero di casi trattati nello stesso ospedale (sull’asse orizzontale) – escludendo però i centri con meno di 6 casi l’anno perché statisticamente fuorvianti. La curva risultante mostra che il numero di morti crolla fino a circa 100-150 casi l’anno e continua a diminuire al crescere dei ricoveri, come mostra il grafico tratto dallo studio di Agenas. È errato tuttavia parlare di una soglia di interventi oltre la quale si può ritenere un ospedale sicuro. “ Nei casi che abbiamo studiato, la mortalità continua a diminuire al crescere dei volumi quindi non è possibile trovare un punto esatto, una soglia minima”, spiega Marina Davoli del Dipartimento epidemiologia del Lazio. Forse non è un caso se tra gli ospedali con l’indice di rischio per infarto più alto (66,67%) nel 2011 ci siano strutture con un volume di 7 casi l’anno, come l’Ospedale Civile di Giaveno, in provincia di Torino, oppure l’ Ospedale di Pieve di Cadore, Belluno, con un volume di 9 interventi annuali. Tra i centri più virtuosi, invece, c’è una struttura con 891 casi l’anno, l’ Azienda Ospedaliera-Universitaria Careggi di Firenze, che ha un indice di rischio del 6,47%.

Anche per i malati di tumore si presenta un rischio analogo. Per esempio, il 5,88% dei pazienti operati di cancro allo stomaco sono morti nel 2011 ed è una delle malattie oncologiche più pericolose. Anche per questo intervento si è più sicuri in un grande centro.

I dati sulla mortalità di ogni struttura sono stati collocati sull’asse Y, mentre il numero di interventi effettuati sull’asse X. I pazienti che non sopravvivono dopo 30 giorni dall’intervento si riducono drasticamente negli ospedali che operano fino a circa 20-30 casi all’anno e la curva continua ad abbassarsi al crescere dei volumi di attività. Anche qui, uno dei centri con l’indice di rischio particolarmente alto (50%) è l’ospedale Rummò di Benevento con volume di 8 casi, mentre tra i più virtuosi c’è il Policlinico Universitario Agostino GemelliRoma, con una mortalità dell’0,62% e un volume di 96 interventi l’anno.

Passando alla frattura del femore, non ci sono sorprese rispetto ai casi precedenti. Questo intervento ortopedico è piuttosto pericoloso per i pazienti più anziani. Nel 2011, sono deceduti in media il 5,91%.

Il rischio di morte entro 30 giorni diminuisce a picco nelle strutture che operano fino a 100 interventi all’anno e continua a diminuire lievemente fino a stabilizzarsi.

Perché gli ospedali piccoli sono più pericolosi?
Riguardo ai motivi per cui il rischio di morte cala negli ospedali con più ricoveri gli esperti sembrano essere tutti d’accordo. “ È una relazione già ampiamente documentata dalla letteratura internazionale – spiega Carlo Perucci, direttore di Agenas – nella chirurgia c’è una linea d’apprendimento riguardo alla manualità e alle competenze. Più si lavora, più si diventa bravi”. Anche la numerosità delle equipe è un fattore determinate. “ Oltre alle abilità del singolo medico, c’è anche l’organizzazione. Un ospedale grande ha affrontato più casi particolari e quindi ha più medici specializzati in singole variazioni della stessa patologia”, illustra Stefano Nava, primario di pneumologia all’ Ospedale Sant’Orsola diBologna. Infine, anche il maggior numero di attrezzature sembrano giocare a favore dei grandi centri. “Solo le strutture con alti volumi, possono avere tutta l’infrastruttura necessaria per affrontare il problema”, prosegue Perucci. “ Se un paziente ha un trauma cranico e va nell’ospedale più vicino che non ha imaging o il radiologo non è reperibile, è chiaro che perde tempo. Il fattore tempo è fondamentale per molte patologie”, conclude Nava.

La mappa # doveticuri di Wired, dove sono contenuti le performance di tutti gli ospedali italiani, è stata scelta tra le finaliste dei Data Journalism Award, il premio del  Global Editors Network (Gen) dedicato alle migliori inchieste di data journalism. Da quest’anno anche i lettori possono esprimere la loro preferenza sul sito datajournalismawards.orgFate sentire la vostra voce.

Statement by Professor Malcolm Grant, Chairman of the NHS Commissioning Board @Medici_Manager @NHSCB

28 February, 2013

The Chair of the NHS Commissioning Board, Professor Malcolm Grant, today (Thursday) made the following statement at the organisation’s public board meeting held in Manchester.

He said:

“I want to make a statement about the Chief Executive. We stand at the moment poised at the commencement of one of the great momentous changes in the NHS. We will see the abolition of 161 statutory bodies and the creation of 211 new clinical commissioning groups.

“But this isn’t just a structural change. This is about a change in culture, it’s about a devolution, it’s about unleashing the power of commissioning – perhaps for the first time in the history of the NHS. It’s a complex, a hugely complex institution. The NHS treats in the order of 1 million people a day. There is no other organisation on earth with that reach and with that complexity, and with that function of being a remarkable, not just healthcare organisation but social support organisation that goes to the very heart of British society.

“The wakeup call that the Francis report has given us has drawn attention to numerous failings within the NHS – not just within Mid Staffs, but of a system which has from time to time focused upon the wrong things and has had dire consequences for those who have been unfortunate enough to be adversely affected by it.

“There has been a search amongst many people who suffer a sense of dismay and shock from the events that have been disclosed by Francis’s report – a search for accountability and in particular a focus upon the work of David Nicholson who through much of that period was a senior executive in Strategic Health Authorities. Indeed he held, because of the turmoil of reorganisation of that day, he held no fewer than seven jobs in six years within the NHS – culminating in his appointment in 2006 to be the Chief Executive of the NHS.

“David’s current formal position is that until 1 April he is employed 50% by the Government as Chief Executive of the NHS, and 50% by us, the Commissioning Board. With effect from 1 April his employment transfers 100% to the Commissioning Board. I have been deeply worried by speculation in the media about his future. Over the recent weeks I have reflected on several occasions with David about what has been said in the press. I have discussed it personally with each of the Directors of the Commissioning Board and I have discussed it collectively with the Non-Executive Directors of the Board.

“We have come to a clear view that David Nicholson is the Chief Executive of the Board. He is the person who we wish very strongly to lead a strong Executive Team on the Board. He is the person whose command of the detail of the NHS and his commitment and his passion to its future, we believe to be fundamental to the success of the Board. This is not, as it were, a statement of vulnerability but a statement of strength. We look David to you, to provide us with the leadership as we take through this exceptionally challenging set of changes. Thank you.”


Never Too Young to Lead @Medici_Manager @muirgray

The young people in your company are ready to lead. Here’s how to prepare them for the responsibility. http://bit.ly/X57bD8

Never too young to lead
“We expect to lead and be led. In the absence of orders I will take charge, lead my teammates, and accomplish the mission. I lead by example in all situations.” — Navy SEAL Creed

My first combat mission with my Navy SEAL platoon was to secure a hydroelectric power plant in Northern Iraq. My role on this mission was to guide the helicopter pilots over the landing zone and manage the fast rope insertion for our assault team. At the time, I thought this was a lot of responsibility for a new guy. What I figured out after we nailed our landing, and after many other successful missions, is that age has very little to do with leadership ability.

The SEAL Teams are a relatively flat organization. Everyone goes through the same grueling training, and everyone is trained to lead regardless of age or rank. In the business world, emergent leadership is about team members taking the initiative to accept more responsibility and perform work outside of their general roles. If we, as leaders, encourage and promote this type of drive, our young team members will be ready to rise within the organization, and our companies will be better off for it.

Here are four ways we can prepare our young people for leadership:

  • Showcase their talent. Don’t hide your young leaders. Show them to the world. Let them be the face of your company. Encourage them to contribute to the company blog or industry publications, take training courses, speak at conferences and trade shows, and collaborate on ways to improve company systems and offerings.
  • Manage them, not their work. If you have the right people in the right jobs, don’t micromanage their efforts. Set boundaries and then back off. Allow them to be innovative and develop systems, processes, and methodologies that will get the job done. Doing this will not only result in a more confident team and better retention, but will give your team members a sense of ownership that they wouldn’t get by simply following orders.
  • Let them fail.  While providing guidance and leadership, we must also allow for failure. Encourage your young leaders to take calculated risks when appropriate. When things don’t go as planned, use that as a coaching opportunity to help them understand how to succeed in the future. Any successful entrepreneur knows that they have gained the most wisdom through their mistakes.
  • Link their effort to tangible results. Real leaders want to know exactly how their role affects the growth of the company. As you develop leaders, give them goals and milestones to hit so they understand the roadmap for success. Ensure that they know exactly how their efforts and results drive the company forward. As they develop in leadership roles, they will know how they got there and where they need to go next.

Let’s encourage our young team members and provide them the resources for success. If we can build our emerging leadership teams from loyal employees who started at the bottom, then our companies will be stronger and have a more loyal foundation for growth.

Navy SEAL combat veteran Brent Gleeson is the co-founder and CMO at Internet Marketing Inc., No. 185 on the 2012 Inc. 500. His leadership approach is inspired by the unrivaled SEAL training and the Navy SEAL Creed. @brentgleeson

In difesa del Servizio Sanitario Nazionale @Medici_Manager

Elena Granaglia

Il welfare state non è nato solo per finalità, per quanto cruciali, di equità. È stato ed è anche strumento di stare bene per tutti. Per opporsi all’austerità non basta difendere il pubblico a partire delle inefficienze del privato. Occorre tenere conto anche delle inefficienze del pubblico e, in troppe occasioni, il SSN si rivela al di sotto delle proprie potenzialità.

Quasi 30 miliardi di tagli lineari al finanziamento del SSN nel periodo 2012-2015: questo è il risultato delle politiche di austerità per la sanità nel nostro paese. L’obiettivo è quello della stabilizzazione, nel tempo, della spesa sanitaria pubblica in termini addirittura nominali (dunque, della riduzione in termini reali).  I tagli, vale la pena ricordare, giungono non dopo anni di facili piè di lista per il settore. Se si guardano gli ultimi dati Ocse (2012), si scopre una realtà assolutamente ignorata nel nostro paese: nel periodo 2000-2010, il trend di crescita della spesa sanitaria complessiva è stato il più basso fra tutti i 34 paesi Ocse. 

Certo, gli sprechi esistono nel SSN e su questo torneremo più avanti. Altrettanto certo è che la stabilizzazione in termini nominali possa realizzarsi in alcuni anni (successe nel 1993 e ri-successe nel 2011). Se assurta a obiettivo strategico di un servizio sanitario pubblico, in particolare, in un contesto di crescita delle attese di vita e di sensibile progresso tecnologico[1], l’effetto non può che essere il peggioramento della sanità pubblica e progressiva estensione del finanziamento privato.

Il punto è riconosciuto dai fautori dell’austerità sanitaria. Semplicemente, si tratterebbe di un effetto inevitabile del nostro debito pubblico e dei più complessivi vincoli di bilancio. O, nei termini spesso usati nel dibattito pubblico, il vecchio welfare state sarebbe per noi una creatura del passato che non ci possiamo più permettere.

Le obiezioni all’estensione del finanziamento privato tendono a focalizzarsi sulle implicazioni equitative: la penalizzazione dei più poveri è evidente ogni volta che si espande il ricorso alle risorse private. Potremmo solo aggiungere che l’impoverimento prodotto dalla crisi insieme al costo dei servizi sanitari rischia oggi di rendere poveri, ai fini dell’accesso alla sanità, un numero di individui ben superiore al 13% segnalato tale dall’indicatore di povertà relativa nel nostro paese.

In questa sede, vorrei portare l’attenzione su alcuni problemi, più trascurati, di efficienza, l’efficienza avendo a che fare con valutazioni di benessere anche per i più avvantaggiati, a prescindere da implicazioni distributive. In sintesi, il finanziamento privato rischia di fare stare peggio anche chi avrebbe le risorse per accedere alla sanità privata. In questo senso, sarebbe l’opposto di quella che gli inglesi chiamano una win win solution, l’inefficienza accompagnandosi alla iniquità.

Due sono le ragioni principali.
La prima concerne il prezzo da pagare: nel privato, esso tende ad essere più elevato per molte prestazioni, seppure non di qualità superiore.
L’altra concerne il rischio di incompletezza assicurativa: il mercato assicurativo non è in grado di assicurare una protezione continua nel ciclo di vita. Come noto, l’assicurazione copre rischi non certezze: se ci si ammala, la patologia di cui si soffre cessa di essere assicurata al rinnovo della polizza (e come sa chiunque sia andato ad acquistare una polizza sul mercato, la durata della polizza diminuisce drasticamente al crescere dell’età). Individui con precedenti malattie non potrebbero, pertanto, assicurarsi anche quando hanno risorse necessarie all’eventuale acquisto della polizza, con la conseguenza di dovere rinunciare alla cura pur avendo le risorse per pagare l’assicurazione oppure di doversi pagare la cura di tasca propria, rinunciando così ai benefici dell’assicurazione in termini di ripartizione del rischio.

Ma, se è così, perché sottrarsi al finanziamento pubblico per pagare di più privatamente e non avere la copertura assicurativa per la quale si sarebbe disposti a pagare? È questo comportamento ad apparire irrazionale, esattamente al contrario di quanto affermano fautori del finanziamento privato quali Giavazzi ed Alesina[2], secondo cui “che senso ha tassare metà del reddito delle fasce più alte per poi restituire loro servizi gratuiti? Meglio che li paghino e, contemporaneamente, che le loro aliquote vengano ridotte. Con ciò che risparmiano, i «ricchi» potrebbero acquistare polizze assicurative, decidendo liberamente quanto assicurarsi”.

Naturalmente, il ricorso al finanziamento privato può assumere configurazioni diverse e una valutazione approfondita richiederebbe di distinguere fra di esse. Un conto, ad esempio, è un finanziamento privato che ha come attori principali i cittadini. Un altro è un finanziamento centrato su imprese coinvolte in forme, anch’esse variegate, di welfare aziendale e contrattuale, seppure la tendenza di questi ultimi anni sia ad una drastica diminuzione dell’assunzione di rischi da parte delle aziende e ad un’accentuazione, a seguito della  maggiore flessibilità del lavoro, delle difficoltà nella portabilità dei benefici da parte dei lavoratori[3].

Anche se consideriamo in aggregato l’andamento della spesa sanitaria nei paesi Ocse, il dato è univoco. I paesi caratterizzati da un maggior finanziamento privato spendono di più. L’esempio paradigmatico è quello degli Usa arrivati, nel 2010, a spendere per la sanità il 17,6%, pur avendo quasi 50 milioni di cittadini non assicurati e oltre 80 milioni di assicurati solo a tratti nell’anno. Occorre, però, considerare anche il caso della Germania, spesso richiamata come esempio di paese virtuoso. Negli ultimi anni, la spesa sanitaria tedesca è cresciuta relativamente poco rispetto alla media Ocse: il tasso medio annuo di incremento reale nel periodo 2000-2010 si situa attorno al 2%, pochissimo sopra il valore del SSN (1,9%).  Inoltre, il divario fra noi e loro in termini di Pil si è leggermente attenuato. Nel 2000, la Germania dedicava alla sanità il 10,4 del Pil e noi l’8%, mentre ora i valori sono rispettivamente l’11,6% e il 9,3%. Allo stesso moso conta il dato iniziale: la Germania nel 2000 dedicava alla sanità 2,4 punti in più del proprio Pil. Inoltre, l’incidenza della spesa sul Pil risente, inevitabilmente, della dinamica di quest’ultimo (decisamente sfavorevole per il nostro paese). Per neutralizzare tale dinamica, se si considera la spesa sanitaria media in dollari a parità di acquisto, allora la differenza fra Italia e Germania risulta ben più marcata. La Germania è passata da un valore di 2678 nel 2000 a 4338 nel 2010, mentre per l’Italia i valori sono rispettivamente 2064 e 2964[4].

Alla maggiore spesa sanitaria generata dal finanziamento privato andrebbe poi aggiunta la spesa pubblica per le agevolazioni fiscali, raramente, il finanziamento privato configurandosi come solo tale. Vi è quasi sempre un aiutino, nascosto, in termini di minore imposizione tributaria.

Per la questione dei rischi di incompletezza assicurativa, basta ricordare Medicare. Anche in un paese favorevole al finanziamento privato, quali sono gli USA, gli anziani, a prescindere dal loro reddito, sono assicurati dal pubblico e una ragione cruciale ha a che fare esattamente con il contrasto all’incompletezza dei mercati assicurativi.

Il che non nega che le assicurazioni private possano, in alcune situazioni, essere vantaggiose: ad esempio, per chi, relativamente sano, affronta un primo episodio di malattia o ha un buon contratto di lavoro. Per questa ragione, la libertà di acquistarle va garantita, anche per prestazioni sostitutive di quelle del SSN (nel liberale Canada, le assicurazioni sanitarie per prestazioni sostitutive sono state, invece, a lungo, vietate). Inoltre, i super-ricchi potrebbero comunque preferire una restrizione del perimetro pubblico, per pagare meno imposte, incuranti di dovere spendere un po’ di più e di dovere accedere ai risparmi in assenza di assicurazioni complete. Ma, per il grosso della cittadinanza, inclusi i ceti medi relativamente abbienti, la perdita di benessere derivante dalle politiche di austerità rischia di essere davvero consistente. Non dimentichiamo quanto ci ricorda con forza Barr[5], il welfare state non è nato solo per finalità, per quanto cruciali, di equità. È stato ed è anche strumento di stare bene per tutti.

Molti articoli a difesa del pubblico finirebbero con l’ultima affermazione. Penso sia sbagliato. Per opporsi all’austerità non basta difendere il pubblico a partire delle inefficienze del privato. Occorre tenere conto anche delle inefficienze del pubblico e, in troppe occasioni, il SSN si rivela al di sotto delle proprie potenzialità. Non potendo entrare nel dettaglio della questione, mi limito a rilevare una causa forse anch’essa sottovalutata, ossia, una carenza (anziché un eccesso) di pubblico, in questo caso, sul piano della dedizione collettiva alla produzione di un bene cruciale per i cittadini. Basti pensare, da un lato, ai molti medici sempre pronti a lasciare lo spazio pubblico per svolgere il secondo lavoro nelle strutture private in concorrenza con il SSN e, dall’altro, ai tanti medici dediti al lavoro pubblico, invece, esposti a contratti di lavoro precari e/o a norme che scimmiottano quelle tipiche delle organizzazioni a scopo di lucro.

Elena Granaglia, 
Professore ordinario di Scienza delle Finanze, presso la Facoltà di Giurisprudenza dell’Università di Roma Tre.


  1. Per una sintesi sul ruolo delle attese di vita e del progresso tecnologico, cfr. rispettivamente Gabriele S. Non bisogna temere l’invecchiamento. Nelmerito.com, 12.12.2012 e Tediosi F.Sanità, invecchiamento e progresso tecnologico. Nelmerito.com, 24.12.2012
  2. Alesina R, Giavazzi F. C’era una volta lo stato sociale. Il Corriere della Sera, 13.09.2012.
  3. Cfr. Hacker J. The Great Risk Shift. Oxford: Oxford University Press, 2006.
  4. Per tutti questi dati, cfr. Oecd Health Data 2012 e per una rassegna delle principali cause dei maggiori costi del privato, cfr. Maciocco G. Appunti per un programma elettorale. Salute Internazionale, 17.12.2012.
  5. Barr N. The Welfare State as Piggy Bank. Oxford: Oxford University Press, 2001.

4 essential elements of true health reform @kevinmd @Medici_Manager

 | POLICY | http://www.kevinmd.com/blog/2012/12/4-essential-elements-true-health-reform.html

I recently said I would describe the essential elements of “true reform.” I realize others might add or subtract from my list, but here it is – at least for today:

Payment reform. I put this first because no matter what form or structure healthcare takes, without payment reform it will be doomed to failure. And by “payment reform” I mean switching from the “fee for service” model I discussed in an earlier column – which basically pays more for doing more whether or not it is needed – to some kind of “outcomes” payment system.

There are many “outcomes” payment ideas – bundling, global, etc. – but they are all designed in theory to force providers to live within a certain budget for a given patient. Obviously, this is a huge culture change and will require many years – and many mistakes – to figure out.

But I think it is probably the most essential ingredient of true reform. (I would also include malpractice reform in this category; by switching to a no-fault system we would remove a large incentive to do unnecessary testing and treating.)

Electronic records. While I recognize there are many issues (privacy, compatibility, etc.) to be yet worked out before electronic records can become near universal in our hospital and personal healthcare, I believe it will be impossible to intelligently cut costs and improve safety without them. Imagine, again, the U.S. commercial airline industry in this country without computers able to “talk to each other” with the same language no matter the location.

Comparability data. And once such a computer system is widely in place, we can start making better use of “outcomes” data – i.e., data from studies that tell us what works best at the lowest cost.

Another name for this would be “cost effectiveness” data but those two words strike fear – understandably – in the hearts of doctors and patients who assume that means choosing the cheapest option regardless of quality concerns.

Right now there is a paucity of such data – in part because the “medical industrial complex” has often fought true comparison studies. But the need for such data will only grow as cost issues become paramount.

Primary care. Ultimately, all of the above will only work well in the setting of good primary care – meaning a place and professionals readily available, at least by phone, when a person thinks they (or a member of their family) might be sick.

The phrase so often used to describe this “place” today is “the medical home.” Obviously a “medical home” – like any home – can physically exist in many different kinds of settings ranging from a traditional office to a clinic to a setting in a hospital.

But the key ingredients of such a home, in my judgment, are the traditional three A’s: availability, affability, and affordability.

Timothy Johnson trained as an emergency room physician but switched careers in 1984 when he joined ABC News as its first full time Medical Editor. Although he retired from that role in 2010, he continues as Senior Medical Contributor.  He blogs atTimothy Johnson, MD: On Health.

The NHS deserves better than this dash to market @Medici_Manager @WRicciardi @fgodlee

Fiona Godleeeditor, BMJ

With apologies to those for whom it holds no interest, I am writing for a second week about England’s NHS (doi:10.1136/bmj.f1850). We are now only days away from the introduction of new NHS regulations. Drafted in February, hastily revised by the government last week because of fierce criticism, and due to be enacted in a few days’ time, they are designed to open up the NHS in England to competition by for-profit corporations. TheBMJ has a reputation for anti-market sentiment when it comes to the provision of healthcare, and views on the new regulations are polarised. So to balance last week’s coverage we have commissioned a debate aiming to reflect both sides of the argument and inform readers about what’s going on.

Does April 1 mark the beginning of the end of England’s NHS? David Hunter says it does, and he invites those who think this is just left wing scaremongering to take a close look at what is happening in other health systems where similar marketisation is underway (doi:10.1136/bmj.f1951). Julian Le Grand, former advisor to Tony Blair during the New Labour healthcare reforms, says the fear of competition is misplaced, especially since “large chunks of the NHS are already private and have been since 1948.” (doi:10.1136/bmj.f1975) We should direct our fears towards austerity measures, he says, not the market.

I asked last week whether people understand what is happening. Clare Gerada confirms my view that we don’t. In her editorial she says that we are dealing with “a set of regulations that no one understands and that seem to conflict with the previously stated intentions of the government that wrote them.” (doi:10.1136/bmj.f1977). Even someone as engaged and impressive as the chief executive of NHS London, Ruth Carnall, admits to confusion. In a recent tweet quoted by Gerada, Carnall says, “I’m supposed to know what’s going on re all of this. I don’t.” And she’s not alone. The House of Lords committee responsible for scrutinising the regulations concluded last week that there is “no common understanding” of the new rules, saying that the Department of Health has given “insufficient time” to set the system up properly and enable thorough scrutiny.

Gerada herself is in no doubt about what the new regulations mean. They allow for “the wholesale dismantling of the NHS and privatisation of the supply, organisation, planning, finance, and distribution of healthcare.” Nor does she doubt the consequences. The regulations will leave general practitioners “bearing the brunt of the public’s wrath, while much of the health budget is handed over to the for-profit commercial sector, services are closed, and entitlements to universal healthcare are eroded.”

The government wants the regulations in place when the National Commissioning Board takes over England’s NHS on April 1. But members of the House of Lords may still be able to limit the extent of subsequent privatisation by forcing a debate at the end of April (doi:10.1136/bmj.f1983). If they succeed, this will be a once in a lifetime chance to influence the future of England’s NHS, and we must seize it on behalf of present and future generations.

Cite this as: BMJ 2013;346:f1994

Follow BMJ Editor Fiona Godlee on Twitter @fgodlee and the BMJ@bmj_latest