The objective of this report is to compare the healthcare systems of United Kingdom and Switzerland. This report has been divided into different chapters which are again subdivided into smaller sections and subsections to clearly differentiate between the comparisons, for the sake of greater understanding.
This report will initially give an idea about organisational structure, service delivery and financing of healthcare separately in different chapters that will assist any to know about basic structure and key points and thus can be an essential base to follow the further comparisons and analysis. Considering that both the countries are in transition, a small section has been added on decentralisation. Further proceeding in the report SWOT has been used to identify the potential strengths, weakness, opportunities seen and threats that exists. But in both systems strengths and opportunities seen, easily outweigh opportunities and threats. As both the nations have been investing hugely to work and aim to have best health systems that will stand well in terms of equity, efficiency and effectiveness. This report has done comparison in terms of finance, health expenditure and health workforces as these have been determinants for analysing health system in terms of equity, efficiency and effectiveness.
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Further this report has recommended quality improvement tools that can be implemented for making healthcare systems of United Kingdom and Switzerland more robust by nullifying the present weakness and threats that are seen at present. The two specific case studies added in the last section of recommendation demonstrate the drastic improvement in results given after these tools are implemented. Concluding part of this Critical studies paper will give the definitive action plan that is needed at this stage.
Chapter 1: UK Health System
Organisational Structure
The health Act 1999 gave way to many changes and was set out in White Paper in 1999. Enormous number of executive letters and guidance notes was issued to set details of the plans set by government. Many of the plans were continued as improved reforms of the previous ones.
The Department of Health (DoH) is directed by Secretary of State for health with five ministers. Separate responsibilities are carried by secretaries of State for Scotland, Wales and Northern Ireland.
Structure of the Department of Health:
Figure 1 - Derived from Department of Health (1998). The Government Expenditure Plans 1998-1999. Departmental Report. Cm 3912. London: The Stationery Office p102.
Figure 1 shows a sequence of well classified divisions as per specific work responsibilities e.g. Public Health, Social Group, Nursing Group, Research and Development. Then, there is office of Chief Medical Officer (CMO) responsible for offering expert medical advice. Lastly there is NHSE directed by chief executive, who is responsible for leadership and management responsibilities related to NHS. NHSE help ministers in developing health policies and work for managing resources effectively. NHSE has eight regional offices in the country and are responsible for implementing policies. NHSE serves as a crucial link between local levels to centre level.
Private sector
In 1996 there were 25 private medical insurers in UK of which 7 were non-profit and remaining were commercial insurers. As competition increased from the new entrants, non-profit associations experienced reduction in market share. There are 230 independent medical hospitals on supply side. 5 main groups i.e. General Healthcare Group Ltd, Nuffield Trust Ltd, BUPA Hospitals Ltd, Community Hospitals Group and PPP Columbia Healthcare Ltd dominate the current market with over 60% of hospitals and 65% total private beds.
NHS: NEW STRUCTURE:
Figure 2 - Derived from Department of Health (1998). The Government Expenditure Plans 1998-1999. Departmental Report. Cm 3912. London: The Stationery Office p103.
Service Delivery
It comprises of primary healthcare, secondary and tertiary care, social care, human resources and training.
Primary Health Care
These services are highly developed and are carried out by general practitioners with help of associated staffs.
General Practitioners
In UK 99% of population is covered by GP's, who provide round the clock service to the population. Patients may select GP's as per their choice, even as the choice is restricted to the geographical area. GP's act as gatekeepers in NHS. People do not have access to specialist doctors, unless required. They have to first consult with GP's and get the required referral from the GP if needed. As on October 1998, there were 27392 general practitioners practising in 8994 practices in England giving an average practice size of three GP,s. This practise size has increased to 63% comprising more than 4 doctors. At present less than 10% practices are single handed compared to 50% in 1952. The average patient list size in 1998 was 1866 which declined by 7% in last ten years. Each GP consults around 10000 patients per year, which has increased considerably over last ten years. GPs' are self employed and provide service under contract. The terms and conditions are set up by GP representatives and government. The last contract made in 1990 gave more choice to patients and more information was required to be given by practices regarding the services offered and payments were based on the performance. Central Medical Practices committee carries the responsibility of reviewing and controlling the spread of GP practices in the country. New practices can only be set up in the area which comes under the open category, whereas new practices can be set up in restricted area only in special circumstances.
Nurses
These are registered general nurses who work within the practice. They play vital role in immunization, health assessment, and disease management. The employment of these nurses has increased over by four times in last ten years. There are 10358 general nurses, 10000 district nurses as on October 1998. Great emphasis has been given to create primary care teams which included GPs and nurses. This idea worked well in some areas but problems arised due to split management.
Secondary and Tertiary care
The health system in UK is hierarchical comprising three tiers. Of this the middle tier comprises of district general hospital (DGH). DGH form the base of the system, were introduced in 1960 and designed to provide service to population of around 200000. The idea behind founding DGH is that they provide good quality and lower cost services on the same site. Tertiary level hospitals offer highly specialized services in addition with secondary care to patients and operate at regional and supra-regional level.
Social care
It is defined as long term care for patients suffering with mental ailments, different learning difficulties and elderly people who cannot take care of themselves. This service is provided in homes and other community setups. There are 5.7 million carers in UK of which 1.7 give a minimum of 20 hours of caring per week. In these around 855000 give service for around 50 hours per week.
Human Resources and Training
There are three stages in medical education for doctors viz. undergraduate, postgraduate, continued medical education. The number of students entering medical education has increased from 4311 to 5091 in span of eight years from 1990 to 1998. The government is still planning to increase the seats by 1000 per year till 2005.To work as qualified nurse registration with Central Council for Nursing,
Midwifery and Health Visiting (UKCC) is mandatory which needs to be renewed every three years. As on March 1998 there were 637449 qualified nurses. Currently there is vast shortage of around 8000 nurses in UK.
Healthcare Financing
Figure 3 - Healthcare financing in UK Adapted from
http://www.euro.who.int/__data/assets/pdf_file/0011/96419/E68283.pdf (Accessed on 15/08/2010)
Pharmacists are reimbursed by the Prescription Pricing Authority, a special Health Authority of the Department of Health.
It is not yet entirely clear on what basis PCGs will be allocated funds by the health authorities. It is anticipated that it will initially be on the basis of historical activity and costs; however there are plans to develop local allocation formulas.
Most NHS hospitals have some facilities for patients to pay a supplementary charge for superior facilities known as 'amenity beds'.
Chapter 2: Switzerland Health System
Organisational Structure
Switzerland political system consists of liberalism and federalism which is seen in healthcare system. In liberalism state interfere only when private initiative fails to give desired results. (Jacobs, R et.al, 2000) Whereas in socialism, legislate can act only when they get support from the constitution who gives limited power in healthcare system. These both make the system more complex as many different players get involved. (aktuell 3:33, 1999)
Figure 4: Organizational structure and reform. Adapted from (aktuell 3:33, 1999) (Accessed on 15/08/2010)
Service Delivery
Federal Government is responsible for legal duties. Among that, related to healthcare are Eradication of communicable or very widespread or virulent diseases of humans and animals, exercise and sport promotion, provision of social insurance, disease prevention and health education and implementation of federal laws (Aktuell 3:33, 1999)
The other duties of federal government are: (aktuell 3:33, 1999)
Medical examinations and qualifications
Promotion of science, research and tertiary education
Genetic engineering, reproductive medicine, transplant medicine and medical research
Statistics
Environmental protection
International relations
Cantons in Switzerland are the 26 member states. In the past each canton was separate with its own armed forces, currencies and distinguished borders till 1848 when Swiss Federal State was formed. Cantons play a very independent role in service delivery in health system. Their responsibilities were categorised into four divisions viz. regulation of health matters, provision of health care, disease prevention and health education and implementation of federal laws.
Municipalities implement cantonal health laws for health policy. In addition they also provide services like home care, care of elderly people and community-based health services. Some of the municipalities give contracts to independent organizations for providing healthcare services while some other run their own hospitals. They are also responsible for providing obstetric services, counselling for pregnant women and providing dental care to school children.
Health Insurance
There are 109 insurance companies providing compulsory health insurance. There is a very strict regulation by law on health insurance companies and those who fit into this law are authorized to provide compulsory health insurance and are registered with Federal Office for Social Insurance. Regulations followed are that no profit should be made and no person should be denied health insurance. These insurance companies are members of "Association of Swiss Health Insurance Companies" and have formed cantonal and inter-cantonal associations for settling and negotiating fees with the healthcare service providers. The main functions of this association are public relations, working on reformation of fee schedule, maintaining statistics, conducting discussions with service providers related to fee structure, and conducting training in insurance sector to upgrade the skills of the workforce.
Training Associations
The Swiss Medical Association controls and conducts specialization training for doctors who are members of association. All doctors are member of cantonal medical association who settle issues regarding fees schedule with cantonal associations of health insurance companies.
Swiss Dental Association is a works for dental medicine. It plays key role in implementing new treatment methods, legal matters and public relations in association with medical colleges.
All pharmacists are members of Swiss Pharmacists' Association whose main functions are similar to others; with addition to these it provides scientific information for pharmacies as well.
Swiss Association of Hospitals work for maintaining the interests of all hospitals and also provides management training to managers in healthcare. All private hospitals are members of Swiss Association of Private Hospitals, whose main responsibilities are public relations, giving legal advice, IT and political representation. Private hospitals are also members of cantonal hospital associations.
The number of voluntary and consumer organizations who work specifically for certain diseases. Some of them are Swiss Cancer League, Swiss League against Rheumatism, Swiss Lung Association and support organizations for people with AIDS.
Healthcare Financing
Figure 5: Finance allocation flowchart: European observatory on health care system: Healthcare in Transition. http://www.euro.who.int/document/e68670.pdf (Accessed on 03/05/2010)
Chapter 3: Decentralization
Decentralization and regulation in the internal market in UK
Reforms and subsequent measures are being designed to increase efficiency and quality by this technique. This idea will transform the organisation from a vertically integrated one to that of contractual relations and will be firmly based on purchaser and provider division. The contractual relationship is shown by dotted lines in figure 4 below. However this format provided limited autonomy. As pointed in the figure below both the purchasers and providers were liable to NHS executive who operated a very stringent performance management system.
Accountability
----------------------------- Contract
Fig 6: Source: Derived from Department of Health (1998) The Government Expenditure Plans 1998-1999. Departmental Report. Cm 3912. London: The Stationery Office p103.
Decentralization and regulation in the internal market in Switzerland
Federal government is increasing its hold considerably on health care system in recent years and particularly on health insurance which have affected enormously the framework of healthcare delivery and financing. The health insurance law obliges cantons to provide hospitals and limit the providers to be reimbursed. Thus we can see some centralization of power at federal level which is going to continue. Even discussions of transferring more responsibilities to federal government are in progress. At the same time new proposals of increasing the powers of canton and transferring state regulation to market regulation for health care are being made.
Chapter 4: SWOT Analysis
SWOT of UK Healthcare System
Strengths
Although not a monopoly, there is no real competitor for the NHS.
Whilst private hospitals are available throughout the UK, the Accident and Emergency service is unique to the NHS.
The fact that there is continual monitoring of waiting lists is proof that the demand outstrips supply
The NHS has been established since 1948 and continues to grow and expand upon it's services.
Weaknesses
Unable to cope with the demand due to the increasing population
Possibly the management of the linkages of the chain, per the resource analysis
Opportunities
To use marketing strategies to raise the profile of the NHS
Increase of private investment
Threats
Image of the NHS being affected by the work of contractors
Staff turnover high
SWOT of Switzerland Healthcare System
Strengths:
Qualified and skilled staff and experienced managers
Well developed primary healthcare
Good network of well equipped hospitals
Transparency in healthcare sector
Well managed insurance sector
Balanced finance
Strong IT development
Weakness:
Varied goals and targets from canton to canton
Increase in cost of healthcare
Poor coordination between the government and cantons
Opportunities:
Changing society
Good Economic growth
Technology development
Freedom to select provider
Threats:
Demographic change
Income inequalities
Ageing population
Increasing expectations of population from healthcare system
Chapter 5: Systematic Analysis
This section of the report will give us the statistical data which will assist in further analysing the efficiency, equity and effectiveness of health systems of the two nation's viz. Switzerland and United Kingdom. Indicators included are based on the relation shown with global health. These indicators will show the current status of the health systems based on health service coverage, risk factors, health workforce, expenditure, health inequities.
Comparison - Equity in finance of healthcare
Healthcare reform has always been on agenda in policy making. This included a so-called internal market programme in UK and Switzerland has proposed to increase the role of taxation in healthcare finance. The cross-country comparison mainly focussed expenditures, but has considered efficiency issue in much broader sense. Little is known about equity regarding healthcare financing and delivery systems and about its implication to the health system. McLachlan and Maynard (1982) and Mooney (1986) claimed that public attaches greater importance to equity as compared to efficiency in healthcare. Equity is a goal that is pursued by all policy makers in healthcare system. But what is meant by equity? And how it should be measured? Policy makers gave much importance to equity than to efficiency.
McLachlan and Maynard (1982), for example, have suggested that '. . . equity, like beauty, is in the mind of the beholder.'(p. 520).
1) Cross-country differences in health care financing systems
Countries finance the health system from two or more sources viz. General taxation, social insurance, private insurance and out-of-pocket payment.
Country
Taxation
Social Insurance
Private Insurance
Out-of-pocket payment
United Kingdom
General central
government tax revenues
used to fund NHS
Some general social insurance contributions
used to fund NHS
Taken out as
supplementary cover to NHS cover
Charges for prescribed
medicines, dental care and
ophthalmic care
Switzerland
General federal, cantonal
and communal
government tax revenues
used to subsidize basic
cover provided by sick funds and to fund public
hospitals
Compulsory contributions
to the national accident
and disability insurance
Non-compulsory health
Insurance premiums paid sick funds. Premiums not related to earnings, but vary according to age at time of entry into
sickness fund, gender and comfort of
Inpatient care. Sick funds are private but subsidized and regulated by the
federal government
Persons with basic sick
fund cover face 10% coinsurance
for ambulatory
care and deductible for
first physician visit of
Episode. 95% of dental
care paid for out-of-pocket
Figure 7: Differences in healthcare financing. Adapted from Wagstaff et al., 1989
2) Share of Total Revenue
Figure 8: Healthcare financing sources Adapted from Wagstaff et al., 1989
Note: CH- Switzerland; UK- United Kingdom
Taxes are used to finance healthcare and contributions are compulsory for every individual and are directly related to earnings. Switzerland depends on out-of-pocket payments and private insurance premiums for collecting their finance. Whereas in UK 13.5% are private of which 64% are from out-of-pocket.
3) Healthcare Financing Triangle
Figure 9: Healthcare financing Triangle A. Adapted from Wagstaff et al., 1989
Note- CH- Switzerland; UK- United Kingdom
The difference between healthcare financing in between UK and Switzerland is shown in above Fig. 9. Switzerland is to the bottom left- hand corner indicating as 100% private finance system. In contrast United Kingdom is closer to the diagonal and hence indicates as 100% public finance system.
4) Comparative Differences in progressivity of financing systems
UK is comparatively progressive in healthcare financing. Switzerland has private finance system and has most regressive structure..It is thus quite surprising as to how much private insurance and out-of-pocket payments are when they are used to finance the whole health care expenditure for the whole population of the country. On the other hand some nations operating on social insurance model (France, Netherland) are less regressive as compared to Switzerland because in social insurance there is less likelihood of making out-of-pocket payments. Indeed UK relies mainly on tax-financed system and is counted as least regressive financing in healthcare system. On standard note of assumptions taxes are considered to be the progressive means of raising the finance in any country. The total progressivity of taxation depends upon tax and careful mixing of taxes. It should be kept in mind that direct taxes are progressive and indirect taxes are regressive in nature. In other words if direct taxes are not quite progressive than there is strong emphasis on indirect taxes for financing health system. The same is applicable in case of Switzerland, where there is only private insurance, which is more regressive way of raising the revenue. As it is assessed on basis of earnings of population. No doubt private insurance premiums are adjusted with the risk involved; premiums can actually be related to income negatively. Hence many policy makers are giving greater emphasis on public financing to reduce the regression of healthcare system and might transfer them into progressive finance system.
Comparison of Health Expenditure
No.
Health Expenditure Ratios (a)
Year
Switzerland (k)
United Kingdom
1
Total expenditure on health as % gross domestic product
2000
2006
10.3
10.8
7.1
8.2
2
General govt. expenditure on health as % of total expenditure on health(b)
2000
2006
55.6
59.1
80.9
87.3
3
Private expenditure on health as % of total expenditure on health(b)
2000
2006
44.4
40.9
19.1
12.7
4
General govt. expenditure on health as % of total government expenditure
2000
2006
17.1
18.5
14.7
16.3
5
Out of pocket expenditure as % of private expenditure on health
2000
2006
74.1
75.3
69.5
91.7
6
Private prepaid plan as % of private expenditure on health
2000
2006
23.6
22.3
16.7
7.8
Figure 10: Comparison of Health Expenditure
http://www.who.int/whosis/whostat/EN_WHS09_Table7.pdf (Accessed on 25/08/2010)
Figure 10 above shows us the variation between the expenditures of two countries viz. Switzerland and United Kingdom. It is seen from the statistics that as Switzerland has private health system, the government spending is comparatively less than that of United Kingdom where private spending is not up to that scale.
Comparison of Health Workforce
No.
Health Workforce (a)
Year
Number/Density (per 10000 population)
Switzerland
United Kingdom
1
Population ('000s) (k)
2007
---
7484
60769
2
Physicians
2000-2007
Number
Density
28812
40
126126
23
3
Nursing and Midwifery personal
2000-2007
Number
Density
79153
110
740731(g)
128 (g)
4
Dentists
2000-2007
Number
Density
3847
5
25914
10
5
Other Health Service Providers
2000-2007
Number
Density
4269
6
1205694(g)
208(g)
6
Hospital Beds (c)
Per 10000 population
2000-2007
Number
55
39
Figure11: Comparison of Health Workforce http://www.who.int/whosis/whostat/EN_WHS09_Table6.pdf (Accessed on 25/08/2010)
http://www.who.int/whosis/whostat/EN_WHS09_Table9.pdf (Accessed on 25/08/2010)
Chapter 6: Recommendation
Use of Quality Improvement Tools to Deliver Better Health Care
After seeing through the comparative statistics of the two countries, it is recommended that both of these nations should try to implement the quality improvement tools in order to deliver better healthcare. Quality improvement is important in healthcare service delivery. It is an important continuous process by all stakeholders (taxpayers, patients, healthcare providers) to improve the quality continuously. It is a contested concept, and is defined by individual actors according to their particular experiences, value systems, and deeply held assumptions." (Sutherland and Dawson 1998: S20-21).The following are some tools that can be implemented on larger scale. Some case studies are also included in the last part of this chapter to demonstrate how effective these tools can be?
1) TQM/CQI (Total Quality Management/Continuous Quality improvement).
2) Business process Reengineering (BPR).
3) Institute for healthcare improvement (IHI) and rapid cycle change.
4) Lean Thinking.
5) Six Sigma.
NHS in UK and Switzerland are going through the transformational change. Keeping the main aim of serving the life-long needs of citizens by reducing burden of diseases, providing community services, improving access to care, eliminating health inequalities, delays and waiting lists. To acquire these goals, multiple strategies are required on various fronts of the health system. Fundamental redesign with incremental improvement of the present services is what is required to be done by both countries. In this section of report, more concentration is done on Lean thinking and Six Sigma as compared to others. As both of these have given promising outcomes when integrated.
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1) TQM/CQI (Total Quality Management/Continuous Quality improvement)
It is-"An integrated, corporately-led programme of organizational change designed to engender and sustain a culture of continuous improvement based on customer-oriented definitions of quality" (Joss and Kogan 1995:37). US statistician Deming developed TOM/CQI in 1950s, but became more prominent in 1990. Essential factors needed for effective implementation are management involvement and terms that improvement in quality should be within the healthcare. More emphasis is given system as a whole rather than those using this. As per TQM/CQI, when preference is given to quality the cost will go down and overall productivity will improve. This model can be well applied in Switzerland Health System.
2) Business process Reengineering (BPR)
It is defined as"…the fundamental rethinking and radical redesign of business processes to achieve dramatic improvements in critical, contemporary measures of performance, such as cost, quality, service, and speed."(Hammer and Champy 1995: 32)
BPR originated in US in 1990. It gave more emphasis on radical thinking and to start a new design process from the beginning. NHS applied BPR in 1990 and supported this new tool financially for two years. The setback that affected BPR was from insufficient cooperation from healthcare persons who controlled majority of the processes, which made outside persons access to data very difficult.
3) Institute for healthcare improvement (IHI) and rapid cycle change
Rapid cycle change was introduced by an US Institute for Health Improvement. It was tested in healthcare processes by Plan-Do-Study-Act (PDSA) tool which is adapted from Shewhart's Plan-Do-Check-Act tool from the 1970s (Kilo 1998; Ketley and Bevan 2007)
Plan- Plan of the change that is to be implemented.
Do- Carry out the change.
Study-Study and analyse the outcomes before and after the change.
Act-Act according to information and plan the next cycle.
This model is dependent on collection of data and then tests in small scale, which give a positive end results which when collected together become a large result and is much easier to implement. The main PDSA advantage is that it takes less time and investment and also requires less training. The NHS Cancer Services Collaborative was the first NHS programme to implement this IHI model. This model reduced time required for getting first line of treatment to 50% in 65% of the total projects where it was implemented. This model can be well tried in UK health system on a much broader scale to reduce its waiting lists of patients.
4) Lean Thinking
Patrick Dawson (1994) stated that organisational change is an altogether new way of working and thinking. This is why Lean should be considered in UK and Switzerland as both are going through transformational changes. The main aim of this thinking is to reduce waste and increase the efficiency to attain an edge over competitors by using less number of employees. As such there are no threats from other competitors in UK, but in Switzerland where the system is private and many healthcare providers are there this 'Lean Thinking' can be implemented.
The change brought here has five dimensions. viz.
1) Character of change- In this point the type of change that is needed is identified. E.g. Technological, cultural, etc.
2) Temporal dimension- In this point pace at which, change is needed and can be made is decided.
3) Scale of change- In this whether incremental or transformational change is needed is decided.
4) Political dimension- Whether the change planned is accepted or not is decided.
5) Intentionality.
Lean changes the culture of an organisation and progresses at a very slow pace, but the outcomes are observed much early. It is of both viz. Incremental and transformational types, politically accepted in case of NHS-UK and but obvious is intentional.
Triggers are both internal and external. Internal triggers are hospital bed capacity, pressure on healthcare staff, and increasing waiting lists. External triggers are political involvement (which holds true for bot
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