Posted on: 25 January 2012
‘Making health services much better: the right evidence in the right hands at the right time’
The Edward Kennedy Professor of Health Policy and Management, Professor Charles Normand gave his inaugural lecture ‘Making health services much better: the right evidence in the right hands at the right time’ this week (January 18th) in the Trinity Biomedical Sciences Institute. The following are extracts from the lecture:
At a time when the public discussion of health services is profoundly pessimistic and funding of public services is being cut, this lecture aims to be positive and hopeful. While there will be effects of the current spending cuts on services, it is important to focus on how the system should develop in the medium term. This will require measures to increase efficiency and to ensure that developments are focused on the highest priorities.
Dean of the Faculty of Health Sciences, Professor Mary McCarron, Professor Charles Normand, and Head of School of Medicine and Vice Provost for Medical Affairs, Professor Dermot Kelleher.
Health services are complicated, the organisation of health care is inevitably complicated, and the issues around ensuring appropriate access and equity are complicated. This means that improvements are likely to come from understanding the complexity and designing solutions that accept and embrace the complexity. It may be worth emphasising that if answers to important health service problems were simple they would have been implemented long ago. Despite the fact that planning and managing health services is one of the most challenging jobs, public discussion of heath policy and management has been largely an amateur sport. Use of evidence is optional, and opinions are given credibility regardless of their source.
Costs in the health sector have tended to rise in comparison to other parts of the economy, and there is a widespread impression that additional money makes little difference. My argument will be that there is adequate scope within existing resources to provide better care, with greater efficiency and fairer access. There has never been sufficient commitment to strengthening the management of health services in Ireland (or indeed in many other countries), and many visible problems could be removed with stronger management at all levels.
Long waiting times, long waiting lists and overcrowded facilities make the headlines. I will not really be addressing these issues directly since they are in principle quite easy to resolve (if challenging in practice). The energy that has gone onto large structural reforms, such as setting up the HSE, might have been better used on the more dreary problems of improving management of patient pathways, referral patterns, appropriately timed discharge from hospital, same day admission for surgery, setting staffing levels that reflect patterns of attendance and shifting to generic drugs, all of which need stronger management and have been shown to be sources of savings and efficiencies.
Some of the (very substantial) increases in public funding in the 1990s and 2000s could have reduced financial barriers to use of primary care and put in place more complete and more co-ordinated services. If nothing else this would have started the more important job of changing incentives to users and providers of care. At best it would have set the scene for serious improvements in the way we manage chronic disease, and especially multi morbidity.
The current programme for government contains ambitious plans for reform. While these reforms may bring important benefits (especially with regard to the development of better access to primary care) it will be argued that they can only be part of the solution, and will only bring significant benefits if the detailed and subtle needs to improve governance, incentives and controls are put in place.
The key requirements are to use the (extensive) evidence, to make changes where needed, and not to make changes where they are not needed, to challenge conventional wisdom where it is flawed, and to recognise that the underlying problems are often small, detailed and complicated.
To put the challenge into perspective, health services in western countries tend to cost around 8-10% of national income. There is no simple way to determine if this is an appropriate level of health spending but experience suggests that spending at this level is likely to be considered to be justified and to be affordable. In the US the figure is much higher, and this may be more difficult to sustain without doing harm elsewhere in the economy. It is worth considering how much can be achieved within this share of national income – it is argued here that much can be done from resources released from improved efficiency and from the economic growth that occurs in normal times.
While accepting the inherent difficulty in measuring efficiency in health services, the evidence shows that there are large differences between countries and within countries. While the recent funding reductions have used up some of the potential for efficiency gains, the evidence in Ireland suggests that there remains large scope to do things better. It is probably the case that the current scope for improvement can offset all the current and expected budget reductions (but probably not in the likely time scale).
In addition to the scope to reduce the current levels of inefficiency, at a reasonable estimate advances in technology and knowledge make it possible to lower the costs of services by 2-3% per year. Of course new technology and ideas also expand the scope of what can and should be done, and this will justify some additional resources. In reasonably times we can hope for economic growth of 2-4% per year. Taken together this allows for the possibility that the volume of health services can increase by around 5-6% per year without the share of GDP rising. With good policy making and good management this should be sufficient to accommodate the most important new opportunities to provide effective interventions and to accommodate the (limited) increases in needs from demographic change.
There is evidence that can support better setting of priorities, and to ensure that developments are based on new services that are cost-effective. There is also evidence on how payment systems and financial incentives affect the performance of health systems. We know that it can be safe and effective to develop services with staff with less overall training but with training to carry out specific tasks, and this can be especially helpful in strengthening primary care and chronic disease management. We know the likely effects of ageing (and that these are not going to overwhelm the hospital system but may require much more long term care services), and we know the (often unintended) equity effects of funding and access rules. Taken together the evidence can be usefully used to ensure that the health system has appropriate incentive to providers and users, that the pathways for patients are efficient and effective, and that the structures and reforms can be designed to improve performance and avoid the harmful effects of major change. Recessions do end, and we need to be prepared to work towards a more efficient and equitable health system.About Professor Normand
Charles Normand is an economist and are Edward Kennedy Professor of Health Policy and Management at Trinity College Dublin, and visiting Professor of Health Economics at the London School of Hygiene and Tropical Medicine. He is Chair of the Steering Committee of the European Observatory on Health Systems and Policies and is vice chair of the Board at St James’s University Hospital.
His research interests cover setting priorities in health services, financing of care, organisation and delivery of health care, health care human resources and the effects of population ageing on health systems, especially on end of life care. He is co-principal investigator on the Irish Longitudinal Study of Ageing (TILDA) and a former director of the Health Research Board PhD Scholar programme on Health Services Research.
He has carried out research and policy work in a wide range of countries including the UK, Ireland, Canada, Australia, Bangladesh, Singapore, countries in central and eastern Europe and the former Soviet Union, South Africa, Malawi, Tanzania and Ghana. He has co-authored a text book on health economics (2008) and the new edition of the WHO/ILO guidebook on Social Health Insurance (2009). He has authored or co-authored around 150 papers in scientific journals and has worked extensively on translation of research evidence into practice. He has supervised around 20 PhD students to a successful completion. He has sat on the Expert Group on Resources Allocation and Financing established by the Minister of Health in 2009 (the Ruane Report).
