The Palgrave International Handbook of Healthcare Policy and Governance

E. Kuhlmann, R. Blank, I. Bourgeault, C. Wendt, E. Kuhlmann, R. Blank, I. Bourgeault, C. Wendt

• Publisher: Palgrave Macmillan
• Year: 2016
• ISBN:
  9781137384935
• Topic: Politica e relazioni internazionali
• Subtopic: Politica pubblica

Starting with more general issues of healthcare policy and governance in a global perspective and using the lens of national case studies of healthcare reform, this handbook addresses key themes in the debates over changing healthcare policy.

Part I

Healthcare Policy and Global Governance

2

Healthcare Policy and Innovation

Richard B. Saltman

Introduction

The array of structural forces that define the content and determine the trajectory of health policy-making are both external and internal in nature: external in the sense of the economic, political, social, and cultural factors that shape policy options which national decision-makers then choose from; and internal in the sense of better health system strategies and mechanisms that make funders and providers more efficient and effective. This external/internal perspective can also be applied comparatively across countries, making it possible to identify underlying patterns of policy change and improvement as well as to underscore areas where past policy efforts have been less successful and further innovation is necessary. Much of what is now termed ‘governance’ in health systems involves steering a more effective path through this structural maze.

The characteristics of health sector innovation that follow from this framework are complicated and often uneven. Innovation in the health sector typically follows from dissatisfaction with the outcomes achieved by current programmes and management practices. Thus, new policy mechanisms and strategies are intended to improve overall performance in one or another area of health system activity.

However, health sector reform is rarely just a straightforward re-engineering process, as is sometimes implied in the management consulting literature (Hamel and Prahalad, 1996). In the health sector, responsible policy-makers, like physicians, are morally constrained to begin from the Hippocratic premise of ‘first, do no harm’. This core restraint can considerably reduce the range and scope of possible innovation, since there are always trade-offs and negative consequences that accompany any major governmental action, particularly in its implementation (Pressman and Wildavsky, 1970).

Thus, health sector reform is typically not the clean break that one can find in the industrial sector and that academic theorists as well as politicians of both left and right imagine that organizational innovation ought to deliver. Instead, policy-makers find themselves trying to minimize negative consequences of new initiatives while still achieving a measure of positive results. In practice, then, innovation in health policy typically refers to complicated half-measures that balance off advantages with disadvantages.

This chapter examines policy innovation in the health policy sector by reviewing some of the key institutional and organizational initiatives that have driven European policy-making over the past 60 years. Starting from the two broad institutional configurations that emerged in the 1950s and 1960s, the chapter explores how health systems have shifted their funding and delivery arrangements over time as both internal and external forces pushed them, first, into occasional and then, from the 1990s, into a continual process of institutional and organizational reform.

The post-Second World War social compact: Two static strategies

In the aftermath of the Second World War, there were two standard approaches to providing healthcare funding and services to the citizenry of recovering European states. One model was full tax-based funding combined with publicly operated hospitals and, at least initially, private general practitioners (GPs). This model emerged in its purest form in 1948 in the United Kingdom, with the national government fulfilling both funding and operating responsibilities (Oliver, 2005). The same basic model also emerged in Sweden by 1955, with long-standing regional (county) government funding of hospital care supplemented by a new national health insurance system to pay for private outpatient physician visits (Serner, 1980). Variations could be found in the other Nordic countries, as well as in Southern Europe – in Italy in 1976 and Spain in 1986.

The second standard model placed the main source of funding in some form of mandatory national social health insurance, coupled with a mixed public/private hospital system run by (variously) local and/or national governments typically in conjunction with religious and/or profit-making clinics. These social health insurance (SHI) systems also – like the tax-based systems in that era – had primary care based overwhelmingly on private for-profit GPs. While the German model long preceded the War, the Dutch variant was put in place during the War (by the Germans), while systems in France and Belgium had evolved from earlier configurations of not-for-profit private guild and religious-association-run mutual associations (Saltman and Dubois, 2004).

Although both models underwent – depending on the country – occasional organizational and/or administrative adjustments, the two overall frameworks were essentially static in strategic terms. Each model pursued its core objectives (raising funds, allocating operating revenues, and providing services) in a conceptually and, most of the time, operationally consistent manner. This combination of difference and consistency directly reflected the external context that existed across Europe in the post-war period: consistent, often strong economic growth (more revenues to devote to health services); a relatively strong sense of national solidarity (a common normative consequence of those who survived a serious war); and, politically, newly empowered left-of-centre parties that envisioned a greater public role in the social sector (the rise of social democracy). This overall pattern led to the oft-made observation during this period that health systems in developed countries (except for the United States) typically followed one of two basic patterns: Beveridge Tax Based or Bismarckian Social Insurance Based (Glaser, 1991; Roemer, 1993).

One can chart the specific characteristics of these two largely fixed models across a variety of organizational dimensions:

• Funding was broadly state-managed (tax-funded) or broadly state-steered (SHI).

• Service Delivery/Production was preponderantly in publicly owned/operated institutions (often at regional or local government level) while primary care was mostly provided by private single-practice GPs.

• Capital was almost entirely publicly sourced.

• Medical Staff in hospitals had mostly fixed positions in lifetime posts, mostly as unionized public employees (one notable exception was hospital physicians in the Netherlands).

• Patients varied from little (tax-funded) to substantial (SHI) choice of provider, little if any choice of funder, and hardly any participatory role in clinical decision-making.

• Chronic care was split into clinical and custodial silos.

• Clinical technology (procedures, equipment, pharmacology) had steady but predictable growth.

• Information technology was stable, paper-file-based, location-specific.

The overall impression was of a relatively stable sector where mostly public or publicly steered funding and mixed public hospital/private primary care delivery were working at a broadly socially accepted standard. The main emphasis during this period – as might be expected given the post-war growth of medicine generally and a need for hospital beds in particular – was on building up institutional capacity, on expanding professional education, and on providing more and better acute care services. Indeed, in the United States, it was in this period (late 1960s) that the US academic and public health community started pointing to the European health sector as providing models of wellrunning, socially responsible health systems that the United States would do well to copy (Sidel and Sidel, 1978).

During this period, most European patients broadly accepted the clear social compact that both models provided. In return for collectively financed acute care, they accepted a lack of personal control over their path through the curative care system. The patient in this period, to use a Hegelian dichotomy, was mostly the object rather than the subject of their publicly run and/or steered health system. Public management focused on collective rather than individual concerns, with medical professionals making life and death decisions with little patient consultation and even less patient leverage. Most patients paid very little out of pocket for the clinical care they received from these health systems, however in return they did not have access to their medical records, they were not asked to approve of their participation in medical research or training, they were assigned their hospital physician – including surgeons – based on clinic rotations, and there were no codified patient rights.

The 1980s and 1990s: Incremental innovation

The onset of the computer era in the 1980s forced European health systems, like health systems elsewhere in the developed world, to confront a series of building internal pressures. The first was a need to slow the rate of increase in expenditures and to improve overall operating efficiency and productivity. A second was to introduce and strengthen patient choice of provider institution and/or physician as well as to better facilitate patient participation in clinical decision-making about their treatment. These two pressures had direct implications for a third worry, namely the continuing political viability of the elected officials who were responsible for managing these publicly operated health systems. All these concerns together led to a variety of then-innovative health system measures across Europe, many of which have now become part of the core health sector framework in many countries. Among these policy strategies were the following.

Purchaser–provider split supplemented by contract negotiations and/or money-follows-patient payment arrangement, drawing on the 1990s theories of New Public Management (NPM) (Hood, 1991; Kettl, 1993; Osborne and Gabler, 1992). This introduction of market-derived competitive forces into what had up to that point been exclusively top-down command-and-control structures of decision-making and managerial authority was highly contested, and in a number of tax-funded countries (United Kingdom, Sweden, Spain, Portugal) was fought out between political parties over a number of years (Figueras et al., 2005; Klein, 2013a, 2013b).

Semi-autonomous hospitals that compete inside the public sector and with private hospitals for patients and revenues (Saltman and von Otter, 1992). The introduction of self-governing trusts in 1991 in England, for example, was a key aspect of the national government’s reform strategy and went through numerous changes and re-conceptualizations over the next decade, eventually becoming the current version known as Foundation Trusts (Edwards, 2011). One key aspect of these new, partially independent organizations concerned their ability to raise private capital for renovation and new construction. While strict limits were initially placed on outside capital, these have slowly eroded in countries like the United Kingdom, Estonia, and Czech Republic, as pressures to build new facilities outweighed concerns about strict public control over facilities and capacities.

Incentive-based pay arrangements for physicians and/or medical teams, initially resisted but under political pressure tolerated (or co-opted) by personnel labour unions. These initially involved creating productivity corridors for increased salary levels, and in some countries such as Sweden evolved into individual salary contracts for physicians. In the United Kingdom, the 1991 contract for GPs set aside 10 per cent of compensation to be tied to fee-for-service payment for medical activities that were preventive rather than curative in nature (Boerma and Dubois, 2006).

Re-structuring primary care into publicly operated health centres with teams of primary care physicians, clinical and public health nurses. This model rapidly became dominant in Sweden by the end of the 1970s, while it was introduced step-wise starting from rural areas in 1970s and never became completely dominant in Finland. Additional public clinics were established in Copenhagen and, later, London, as well as in newer tax-funded national health services in Italy (1976) and Spain (1983). Among SHI systems, while a smattering of clinics were established in lower income urban districts in the Netherlands, Belgium, and France, most primary care remained firmly in the hands of independent, private, for-profit GPs (Boerma and Dubois, 2006).

Prevention became a regular part of health policy thinking, and ‘moving upstream’ started to influence policy decision-making and service design decisions. Primary health centres with an emphasis on preventive care were set up in Sweden and Finland (see point above), and in the United Kingdom, payment to GPs became partly tied to preventive acts (also see above). In home care, countries like Sweden and Finland paid family members or neighbours to take care of the elderly in their homes (preventing the need for more nursing homes), also providing state-paid respite care and call-in lines for care advice (Genet et al., 2012).

Increasing patient choice of funder in SHI systems, particularly in Germany from 1993 but also in Israel from 1996, introduced greater competition among sickness funds and/or private insurers to attract new subscribers. Since subscribers bring their SHI funding with them when they switch to a new sickness fund, the introduction of patient choice of funder also introduces a measure of contestability among existing sickness funds and insurers, since dissatisfied subscribers have the potential to move in the future (Oduncu, 2013).

Case-based reimbursement systems to replace per diem arrangements that were seen as unnecessarily expensive and which rewarded longer rather than shorter hospital stays. In 1983, the United States had adopted a system of case-based management for its national social insurance programme for the elderly (Medicare). This case-based payment framework, with regional and national variations, started spreading through European health systems, as national political decision-makers sought ways to rein in expenditures that were increasing faster than the rate of general economic growth in the overall economy (Busse et al., 2011).

Technological innovation made possible increased day surgery through laparoscopic interventions that reduced inpatient bed use and also reduced surgical complications for patients. These measures were only slowly introduced in tax-funded health systems, however, as they required capital investment in new or renovated facilities (endoscopy rooms, day-surgery centres) as well as changes in labour union contracts to allow altered staff working conditions and/or locations.

As suggested above, the range and speed of uptake on these innovative policies varied considerably across countries and, in internally decentralized systems like those in the Nordic region, within different regions inside these countries as well. These internal differences reflected not only differing needs among large as against small regions or urban as against rural but also differing domin...

Table of contents

• Cover
• Title Page
• Copyright
• Contents
• List of Tables and Figures
• List of Boxes
• Notes on Contributors
• Introduction
• Part I: Healthcare Policy and Global Governance
• Part II: Health Policy Reform: Global Trends, Local Road Maps
• Part III: Health Human Resources Policy and Workforce Governance
• Part IV: Concepts of Health Policy and Governance
• Part V: Areas of Health Policy and Governance
• Part VI: Healthcare Policy and the Equality Gap
• Index