Why are we waiting?

Waiting Time Policies in the Health Sector What Works?

One could say quickly, waiting lists exist in NHS because prices are mostly absent and insurance plays a role. In consumer markets, waiting lists appear when there are creators of scarcity as Brandenburger-Nalebuff explained in his book as a specific strategy, or when there is a temporary mismatch between supply and demand. Since the solution in health care is not to introduce prices and forget insurance, we have to ask about the best practices on tackling such issue. The report by OECD says:

Supply-side waiting time policies, by themselves, are usually not successful. In the earlier OECD study on waiting time policies, the most common policy was to provide increased funding to health providers to decrease waiting times, and this type of policy continues to be a common approach. It has almost invariably been unsuccessful in bringing down waiting times over the long term. Generally, there is a short-term burst of funding that initially reduces waiting times, but then waiting times increase, and occasionally return to even higher levels when the temporary funding runs out. The other main supply-side policy is increasing hospital productivity, by introducing new payment methods such as activitybased financing (ABF) using diagnosis-related groups. This increases hospital productivity, but does not necessarily decrease waiting times.

The most promising tool is prioritisation within a waiting list. The cases of Norway and Australia are interesting examples to check. Nearer here we started with research, and finally a decree was prepared to be released. Unfortunately last April we received a phone call saying it was not possible to rule on waiting lists, that somebody would do it for us. At that moment I said that the intervention of health policy started. The answer today to the initial question - why are we waiting- is at least this one: we have made unnecessary political concessions and we should apply our legislation, we don't need the intervention from outside. That's it.

PS. Data on waiting lists at December 2012.

Vertical equity in waiting lists

Three years ago I explained that it was good to know that prioritisation was going to start on the waiting lists. It was only the anouncement. Afterwards, it came the uncertainty after a phone call. On March 7th, 2013 the headline post of this blog was: Still waiting after all these months.
Many theoretical efforts have been devoted to improve vertical equity in waiting lists, now it's time to apply them. The moment of truth arrives when somebody has to apply objective criteria, and this raises concerns on the  status quo. This is precisely what it comes to my mind when reading this document. I can't find any reference to shared decision-making with patients, taking into account their interests and social preferences. It emphasizes the autonomy of the physicians for waiting lists management, but this is absolutely not enough.
Finally, the document says that budget cuts have to finish. Is this a political or a professional statement?. Everybody should know that budget cuts are related to our critical economic situation, with an unacceptable fiscal deficit. Why is there no reference to this constraint?. Is this a political or a professional option?

Still waiting after all these months

Waiting lists may be considered the most prominent consequence of a publicly funded health system. Without price barriers, the queue for an operation may take months. Data to compare the situation of waiting lists between countries is not that easy to find. However, in the last report by OECD you can get the indicator of how many patients were waiting for more than 4 months in several countries. Take a look at this OECD report (p.42). Only one country in its worst year achieved 41% (UK).
Right now data show that we have the record.  The latest information (p.7) highlights that 100% of interventions for elective surgery required waiting for more than 4 months during 2012. This represents 1,63 more months than in 2011. That's a lot. The number of persons waiting is 93,2 per 10.000 inhabitants (70.814), but 5.000 patients that were on the list and tired of waiting declined the intervention once they were allocated them to a hospital (unfortunately, there is no information about the impact or how they have solved it).
Definitely, waiting lists is a hot topic. they should be fixed and indicators should be close to international standards. Right now we are far, too far away.

Why are we waiting? (2)

Yesterday we had the ooportunity of watching a documentary on waiting lists. The message was: there were 180 thousand patients waiting for surgery by the end of 2013 and this is the result of cutbacks on public health budgets.
Unfortunately the most relevant question was not asked. The documentary was created around a prejudice over the crisis and budget cuts, an ideological prejudice. Since they had the answer, why look for a question?
The right question any journalist should ask is: Why are there waiting lists? . And we have to remember that this is a fact and it is independent from economic crisis. You can check in this blog a former post on this issue.
Beyond such question, somebody should ask about the situation in other countries and the potential prescriptions for improvement. But the biased journalistic approach to a topic, requires the focus on a concrete ruling politician not on his policy.
If you want to know what happens in other countries, check here. If you want to know about potential solutions, check here. If you want to know how resources are allocated to providers, check here. (Yesterday somebody was saying that it is completely impossible to know how providers are paid (!), and the journalist was unable to check the internet (!)).
They forgot to say that health expenditure is strictly related to wealth creation. Public expenditure on health has jumped from 5% over GDP (2007) up to 5,6% over GDP (2011). Our government was spending 32% on health od the public budget, and right now is 40%. You may disagree about such level, but you must accept that has increased and we are poorer now than before.
Patients require solutions, and they also forgot in the documentary that avoidable hospitalisations is huge (!) (average 16%, range from 6% to 26%).
They also forgot that a methodology  has been proposed and adopted to prioritise waiting lists on a transparent way.
A wider and sound view about current challenges in health care would allow to understand reality and take better decisions. A new documentary should be recorded to replace it. This is my kind request to TV3.

Waiting guarantee(d)

International comparisons of waiting times in health care – Limitations and prospects

Waiting times are the natural barrier for access to health care in non-market health systems, where willingness to pay it is not the criteria to allocate resources. Regulators know it and they set up some guarantees, a maximum time for access, otherwise there is a need to find an alternative. While this system may appear an improvement, it may produce some distorsions in incentives.
In my opinion, waiting times should be reviewed on a prioritisation criteria, and may be after some guaranteed should be applied. General guarantees distort the aim of such process.
Anyway, we are still waiting for a regulation on prioritisation of waiting lists. Long time ago was anounced, and long time ago was blocked. There is no reason to delay it indefinitely.
If you want to have a look at international data, read this article and its methodological considerations:

The study shows the need for a more coherent approach to waiting times measurement, if  international comparisons are to be made. Currently, there are wide differences in what  countries measure and how they measure it, were they start the measurements and what measures are presented. Few international comparisons of waiting times have been published and none has solely relied on official national statistics.

 

With The Changing Lights, Stacey Kent attains an even higher level of accuracy 

of tone and delicacy of expression.

 Don't miss this concert!

Why are we waiting? (4)

Patients that are waiting for a health service deserve an explanation about the current situation and its potential solution. In former posts I have made some steps in this direction, but the final and definitive one lies on the resources available.
As far as we are publicly spending 1.095 euros per capita, we could ask if in the same State and under the same tax pressure, some people get more resources than us. Let's have a look at Euskadi,( p.5) any citizen there, will have 1.541 euros per capita for health care in 2014. Therefore, we can increase by 40% our health expenditures without increasing our tax pressure. With such an amount of resources we can forget forever the current waiting lists. In Euskadi, they have 0,8% of population waiting (p.6)  and last year the number of patients was reduced by 2,62%. We have 2,4% of population waiting, 3 more times than them, this is unacceptable and requires immediate action.
Fortunately there is a solution. We need only to disconnect as soon as possible, get all the money of our taxes as they do, and only 60.000 patients will wait instead of 180.000 as it is now. This is good news.

PS. Last Sunday this documentary forgot to tell this relevant information to patients. Once again, I repeat what I said: A wider and sound view about current challenges in health care would allow to understand reality and take better decisions. A new documentary should be recorded to replace it. This is my kind request to TV3.

La priorització de les llistes d'espera

 Managing surgical waiting lists through dynamic priority scoring

De ben poc serveix que els ciutadans tinguin cobertura obligatòria d'assegurança del risc d'emmalaltir si a la pràctica no hi ha possibilitat d'accedir als serveis en el temps i forma acurats. Les llistes d'espera són la mostra evident i contrastada de que hi ha un problema gros, molt gros. I sabem que el primer motiu pel qual la gent paga voluntàriament una assegurança privada és perquè hi ha dificultats d'accés a l'assegurança obligatòria pública. I ja hem arribat al 31% de la població.

Ja fa tretze anys que es va publicar un document sobre priorització de les llistes i onze d'aquest. També fa onze anys que el Parlament va demanar que hi hagués un temps garantit d'accés, i el 2015 es va publicar un decret que diu:

Els criteris que han de regular l’establiment de la priorització d’accés dels pacients per a les prestacions sanitàries que tenen establert un termini de referència són els següents:

a) L’impacte de la malaltia sobre la qualitat de vida, incloent-hi aspectes com l’afectació de la vida diària, la qualitat de vida, el dolor, la dependència i la càrrega per a la família.

b) Els riscs associats a la demora en la realització de la prestació, entre els quals s’inclouen la gravetat potencial de la malaltia, el risc de desenvolupar comorbiditat o complicacions greus, la reducció de l’efectivitat de la intervenció o de la prognosi desprès de la intervenció, a mesura que augmenta el temps d’espera.

c) L’efectivitat clínica de l’actuació, tenint en compte el grau de millora que la intervenció aconsegueix en temps real.

d) L’ús i consum de recursos sanitaris durant l’espera a causa de l’estat dels pacients.

e) Els criteris que estableixi el Departament de Salut derivats del consens de les societats científiques.

D'acord, necessitem criteris. Després es mostren al decret els processos amb garantia: oncològics, cirurgia cardíaca i cataractes, i altres intervencions amb termini de referència. Però no hi ha cap requeriment de transparència sobre l'aplicació d'aquests criteris.

Vull saber quant pacients estan esperant i miro el juliol 2023 i aquesta és la situació de la llista d'espera d'intervencions:

- Intervencions amb termini de referència: 153.431 pacients esperant

- Intervencions oncológiques: 2.201 pacients esperant

- Cataractes i pròtesis genoll i maluc: 30.795 pacients esperant

-Cirurgia cardíaca: 238 pacients esperant

Només per intervencions quirúrgiques hi ha 186.665 pacients esperant per ser atesos. Massa gent (2,5% de la població). El nombre de persones en llista espera a desembre del 2003 era de 66.567 (1% de la població).

L'any passat al mateix mes de juliol hi havia 177.856 pacients. En un sol any hem assolit una fita notable, augmentar la llista d'espera en un 5% més de pacients esperant per una intervenció quirúrgica. No hem trencat la tendència i això hauria de preocupar a tothom, però malauradament la letargia de la política sanitària fa que no passi absolutament res. 

A més a més caldria afegir-hi també, les llistes d'espera de proves diagnòstiques i consultes externes. I ens enduríem una altra nefasta sorpresa.

Cal fer-nos algunes preguntes. I a la pràctica com es prioritza? els criteris s'apliquen amb objectivitat? Però sobre això no en sabem res. L'altre dia llegia un article que em va semblar encertat perquè introdueix la priorització dinàmica i la formalitza en un model. Posa ordre a les idees i permet una aplicació ordenada del problema d'accés. A les conclusions diuen:

Under the DPS system, all stakeholders can place more confidence in the appropriateness of patients’ assigned priority. The system increases equity across all patient categories and provides consistent processes for clinicians to assess clinical need, while also including an effective and efficient means of implementation. As such, it is intended that implementation of the DPS system will increase public trust and confidence in the systems used to prioritise elective surgeries. Features of the DPS system could also be extracted to suit the needs of individual healthcare systems. For example, clinical factor selection forms may be used independently of the DPS system and could be an effective tool to aid current prioritisation practices, providing an objective metric for waiting list staff to gauge the severity of patients and better inform prioritisation decisions.

Doncs això, transparència i confiança en els criteris de priorització, això és el que cal, més enllà d'una solució estructural a un problema estructural d'accés. És a dir planificar millor l'oferta i millorar la gestió dels serveis.

 

Joan Miró

Where is the trade-off?

The fallacy of the equity-efficiency trade off: rethinking the efficient health system

What goes first? An equitable health system or an efficient one?. You'll see in some textbooks this biased trade-off formulation.

 A more appropriate question would be, “what is more important for a population, a health system that delivers equitable (fairly distributed) health outcomes or a health  system that maximises health gains?” The difference between the meaningless first question (which does not contrast outcomes) and the potentially meaningful second question (which does contrast outcomes) is critical.

 On a continuum of health gains and equity, possible goals of a health system include:
✯ Achieving the greatest health gains for a given input without regard to whether this means concentrating the gains in one (social) group: a traditional health outcomes focus,

✯ Achieving the fairest distribution of health for a given input without regard to the actual level of health achieved: a non-traditional outcome focus on (one form of) health equity, and

✯ Achieving an appropriate balance between the greatest health gains for a given input subject to the constraint of fairly distributing the health gains across social groups: an outcome balancing health equity and health gains

If finally there is a prioritisation on waiting lists, we would focus on the third option. Unfortunately I wrote a post 5 years ago on the same topic...and still waiting for its application.

PS. The trade off started with A. Okun 40 years ago, from a macroeconomics perspective. Have a look at the anniversary at Brookings.

PS. "Public health refers to all organized measures (whether public or private) to prevent disease, promote health, and prolong life among the population as a whole. Its activities aim to provide conditions in which people can be healthy and focus on entire populations, not on individual patients or diseases. Thus, public health is concerned with the total system and not only the eradication of a particular disease." WHO dixit. Can you imagine asking citizens about a Public Health Survey?. The term doesn't make any sense. All over the world the common term is Health Survey if you want to ask people about their health perception, except in Catalonia. So weird, somebody should check it, maybe it's a mistake.

Why are we waiting? (3)

The communication vessels theory says that the pressure exerted on a molecule of a liquid is transmitted in full and with the same intensity in all directions (Pascal). This theory applied to hospital waiting lists is converted into the following one: those patients not attended in public hospitals will go to private ones. In order to increase private market share, the public system has to worsen. This is the malevolent theory partly explained in this documentary.
All theories require some support from facts and data. Private health insurance -duplicate coverage- has increased from 23,0% of population (2007) to 24,3% (2011). And discharges per 1000 inhabitants were 25,9 in private hospitals, and 98,7 in publicly funded ones (2007), on the other hand 26,3 and 89,0 respectively (2011). Therefore, there is a 1,3 points of increase in insurance and 0,4 points in hospital discharges in private hospitals. People may contract more insurance slightly but such increase is not reflected equally in discharges. If you want to look for previous trends you'll find other increases of private insurance of 1 pp without any public cutback.
The efforts to relate crisis and cutbacks to communication vessels between public and private is another example of confusion between concurrent facts and causality. Somebody should demonstrate clearly such relationship before broadcasting it on a TV program, otherwise his reputation is at risk.
The additional argument of unfair competition of public hospitals when the provision of privately funded  services requires once again to be proved. Unfair competition as we know it, it's what law defines. I can't see any provision with such possibility in the current law. Otherwise may be considered a comment without a clear definition of what we are talking about. If you add such comments in a documentary it may seem that it is relevant, and once you check it in detail you'll see that those that talk about unfair competition are asking to be contracted by public funding at the same time. Does this make any sense?.
Once again, I repeat what I said: A wider and sound view about current challenges in health care would allow to understand reality and take better decisions. A new documentary should be recorded to replace it. This is my kind request to TV3.

Reforma sanitària gaèlica

FairCare. Fine Gael Proposals to reform the health service and
introduce universal health insurance

Irlanda és un país que ha patit un sotrac econòmic que se l'ha buscat més que altres. I ara davant les eleccions sorgeixen propostes electorals diferents. Els de Fine Gael, el partit que pot resultar majoritari vol fer això:

‘Fine Gael has committed to abolishing the HSE by 2016 and introducing a Universal Health Insurance (UHI) system based on the successful Dutch model.”

Whether Dutch model is successful is a question of course, but parking that issue – he set out three phases for reform should the party be in a position to form a government (it will likely have to be in a coalition with the Labour Party

Phase 1 (2011-14): Fine Gael will reform the current system to bring down waiting lists and build a stronger primary care system.

Phase 2 (2014): Fine Gael will change the way hospitals area paid. Block grants will be replaced by a system based on the numbers of patients they treat – ‘money follows the patient’. This will increase productivity by between 5% and 10%.

Phase 3: (2016): Fine Gael will begin the introduction of UHI. However, we know this is a long term project and bedding down all of reforms will take place during the following five years.

Tema a seguir d'aprop. Pot ser la reforma holandesa una taca d'oli que s'escampa?. En aquest article acabat de publicar es mostra l'estat de situació.

PD. Per cert, si algú vol saber com una llengua parlada per 1 milió de persones acaba que només la parlen 85.000 que miri el gaèlic. Avís per a navegants.

Eco

David Cameron puts reputation on the line with five pledges on the future of the NHS

Miro el Telegraph i canviant els noms penso que podria passar ben aprop. L'embolic que s'ha muntat amb la reforma del NHS obliga a en Cameron a sortir i defensar-ne la reputació i les cinc garanties pels ciutadans. Això és el que diu:

The Prime Minister will promise to keep waiting lists low, maintain spending, not to privatise the NHS, to keep care integrated and to remain committed to the “national” part of the health service.
Such is the concern in Downing Street at the damage the issue of NHS reform is causing the Government, that Mr Cameron will put his reputation on the line with a personal pledge to protect its core values. It represents his boldest attempt yet to assuage criticism from his Liberal Democrat Coalition partners and from many health professionals over the impact of the reforms.
In his speech, the Prime Minister will admit that he is willing to act on their concerns after listening to the “profession and patients” during a two-month exercise which was held after Mr Cameron called for a “pause” in the Health Bill’s passage.

PS. I al Lancet trobareu en McKee et al. sobre l'impacte de la reforma en la salut pública britànica i què caldria fer per evitar el desgavell.

PS. Els detalls sobre el projecte de pressupost de salut 2011 els podeu trobar aquí

Physician self-referral: a call for action

Physician Self-referral: Regulation by Exceptions

In 2002 a new agreement was published in internal medicine reviews on Medical Professionalism in the New Millennium: A Physician Charter. Some years ago I posted the same issue. Today, I would like to highlight three points again:

• Commitment to professional responsibilities. As members of a profession, physicians are expected to work collaboratively to maximize patient care, be respectful of one another, and participate in the processes of self-regulation, including remediation and discipline of members who have failed to meet professional standards. The profession should also define and organize the educational and standard-setting process for current and future members. Physicians have both individual and collective obligations to participate in these processes. These obligations include engaging in internal assessment and accepting external scrutiny of all aspects of their professional performance.

• Commitment to maintaining trust by managing conflicts of interest. Medical professionals and their organizations have many opportunities to compromise their professional responsibilities by pursuing private gain or personal advantage. Such compromises are especially threatening in the pursuit of personal or organizational interactions with for-profit industries, including medical equipment manufacturers, insurance companies, and pharmaceutical firms. Physicians have an obligation to recognize, disclose to the general public, and deal with conflicts of interest that arise in the course of their professional duties and activities. Relationships between industry and opinion leaders should be disclosed, especially when the latter determine the criteria for conducting and reporting clinical trials, writing editorials or therapeutic guidelines, or serving as editors of scientific journals

• Commitment to maintaining appropriate relations with patients. Given the inherent vulnerability and dependency of patients, certain relationships between physicians and patients must be avoided. In particular, physicians should never exploit patients for any sexual advantage, personal financial gain, or other private purpose.

 After reading JAMA article on physician self-referrals in US, definitely I have to say that this principles are far to be applied. The size of the resources coming from self-referrals is continously increasing despite the existing regulation for decades. The article puts a lot of expectations on changing the payment system, from fee-for-service towards value-based payments to curb the situation. I'm not so confident on this tool, because its implementation is far from optimal.
Anyway this is a difficult issue, and the same happens to dual practice in general. Some weeks ago a new resolution on how to handle conflicts of interest between public and private care was released. Two different concerns appear on my mind. The first is when any patient that decides to start a private treatment, then there is no option to go back to the public sector. He rejects explicitly public coverage. This statement may be appropriate for those patients on public waiting lists, but its application to other situations may be fuzzy. The second relates to information by the healthcare faciliy to patients about benefits and rights. I'm uncertain about how this can be applied without biases, without interference of physicians. My suggestion would be to use more transparent and centralised ways to inform patients through internet.
Unfortunately what I missed is precisely any regulation on physician self-referrals, the core of the problem. This affects publicly funded -in case of dual practice- and private care. Somebody should have a clear position on that. In my opinion, it should start by physicians associations. Self-regulation is a better starting point than any ban on this practice. As you may deduct easily, the general application of the former physician charter would solve this issue.

Commercialism in health and medicine

Buying Health: The Costs of Commercialism and an Alternative Philosophy

There are only three topics of health policy in the newspapers (unfortunately): waiting lists, copayments and privatization. As soon as one topic drops from the agenda, the informational cascade starts with the following one. The last one, privatization is still a concept in need of definition and measurement. I already covered this issue last year and I don't want to repeat it.
Today I would like to insist that beyond a new framing of the concept, maybe we have to change the scope and the term. The right term could be commercialism. We have to understand better how and when commercialism is undermining professionalism.
Jerome Kassirer wrote an excellent piece (US oriented) in Cambridge Quarterly of Healthcare Ethics some years ago that it is still a reference for today. His words:

Professionalism is fundamentally a pact with society. In recognition of certain behaviors and attributes, society confers professional status on us. These privileges are not bestowed, but are earned, and they must be renewed repeatedly for the status to be preserved. Professional behaviors include technical competence that is valued and that adds value, a commitment to self-improvement, a commitment to selfmonitoring and self regulation, and a commitment to use the unique knowledge and competence for the best interests of our patients. This last requirement should include a commitment to resolve conflicts of interest in our patients’ favor.

Is money trumping professionalism? Certainly the pharmaceutical money tsunami is having major adverse effects. It tends to distract faculty into emphasizing profitable research and to neglect their teaching duties. It replaces openness with secrecy, it privatizes knowledge, and it replaces part of the social commons by commercializing discovery. In many instances, it downplays knowledge as a social good. It has also created a culture within which the design of studies is sometimes jiggered to create positive results, in which unfavorable results are sometimes buried, where communication of results is sometimes hindered for commercial reasons, and where bias in publications and educational materials has gone completely unchecked

Maybe there are excessive generalizations, but take it as a general statement to be confirmed by facts and data.
Churchill and Churchill go beyond the usual scope. Their recent article abstract says:

This paper argues that commercial forces have steadily encroached into our understanding of medicine and health in modern industrial societies. The impact on the delivery of personal medical services and on common ideas about food and nutrition is profound and largely deleterious to public health. A key component of commercialization is reductionism of medical services, health products and nutritional components into small, marketable units. This reductive force makes both medical services and nutritional components more costly and is corrosive to more holistic concepts of health. We compare commercial and holistic approaches to nutrition in detail and offer an alternative philosophy. Adopting this alternative will require sound public policies that rely less on marketing as a distribution system and that enfranchise individuals to be reflective on their use of medical services, their food and nutrition choices, and their larger health needs

I deeply agree with such perspective.