‘The NHS is famously bad at looking outward for lessons on how to respond to new challenges, preferring to find its own way...What I find intriguing and perhaps reassuring is the sense of familiarity I get from understanding the range of the responses used in countries with often quite different systems, contexts, underlying principles and histories. The NHS should feel greater confidence about using international evidence – the attitude of “not invented here” does not, I believe, hold water.’
Powerful stuff there from Steve Moore, a former PCT chief executive and one of the researchers on our International responses to austerity report. While I’ve been to many events and conferences where people spend too much time looking externally when we have great practice within our NHS, there is much we can learn from other countries.
We produced International responses to austerity to support our More than Money policy analysis last week, to look into how other countries are reacting to financial pressures. The report provides valuable insights on what we can do better to bridge the ongoing quality gap we face in the NHS. It presents case studies of six countries with publicly funded health care and significant financial challenges: Ireland, Portugal, Spain, Canada, Denmark and the Netherlands.
So what does the international evidence tell us?
Common responses to austerity
Despite the diversity of the countries, their health systems and how badly they have been affected by the financial crisis, common themes emerged.
Firstly – and perhaps unsurprisingly – all six countries have predominantly focused on short-term pressures, although most have attempted to combine this with some elements of structural reform, most notably restructuring hospital services.
Secondly, countries have used a similar, narrow set of strategies aimed at addressing the short-term financial pressure: introducing user co-payments, cutting the workforce, changing staff conditions, reducing services or reforming pharmaceutical pricing.
Many of these measures are unlikely to be sustainable in the long term. For example, staff cuts in Canada in response to the financial crisis of the 90s have since been largely reversed. Interestingly, approaching staffing reform with a long-term goal is potentially more sustainable (eg changing the workforce skills mix), however none of the countries are pursuing longer term workforce strategies.
What can we learn for health system reform?
While all countries introduced short-term cost containment actions, those with a pre-existing vision for health system reform were able to more effectively blend them with longer term goals.
Successful reform strategies had characteristics that many would find familiar: they were based on strong central leadership, and constructive and open stakeholder engagement; they were evidence based; and there was a strong connection to improving quality.
The success of structural changes in Canada and the Netherlands seems to be linked to the willingness of political and health system leaders to be open about the reform processes and engage in a genuine dialogue with professionals and the public. Importantly, a key factor appears to include the ability to align system reform with both health system values and principles and current political preferences. Easy!
Complacency towards evaluation risks wasting money
It’s striking that none of the countries examined appear to have put in place mechanisms to monitor the effects of their austerity measures, despite many leading to very significant reforms. And there’s limited evidence as to whether quality of care or population health more generally have been affected. Major changes – and in some cases significant cuts – are being made to health care without any programme to monitor or evaluate their impact. Robust evaluation is essential to provide explanations of what works and why. Without it we can’t hope to improve.
Accepting the caveat about the lack of evaluation, there is some evidence of which measures appear successful at reducing cost burdens in the short term – such as restricting salaries, recruitment and training – and some that are not, such as co-payments.
In my view, most of these interventions are likely to have a negative impact on quality with the exception of pharmaceutical pricing reforms, which could yield significant cost reductions without having a negative impact on quality. Most system reforms don’t have short-term impact and all have implementation costs, and in the longer-term costs are as likely to rise as fall.
Plan for the long term when addressing the short term
The financial crisis is acting as both a stimulus and a barrier to health system reform. Crises are seen to strengthen the case for change being needed, however increasing demands on staff reduces capacity for delivering such change.
We should remember that the health pressures we face have been exacerbated by recession, but not caused by them. We need to create strategic vision and targeted investment over time – the need for quick solutions is still here, but we need to ensure fixes don’t undermine long-term sustainability. Despite all the pressure to look only at short-term fixes, we really need to act long term, and urgently!
Jonathan is a Research Manager at the Health Foundation