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In Search of the Perfect Health System by Mark Britnell
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First published November 26, 2015
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March 5, 2017
The book presents an attempt of a comprehensive analysis of the healthcare sector. The author, an accomplished bureaucrat from the British National Health Service and now a Senior Partner for KPMG, tries to present in an easy-to-read format a global perspective of the healthcare sector, its different designs, its challenges and possible solutions.
The book can be divided basically in three different sections:
1. The first is a comprehensive description of healthcare systems around the world. The author, based on his expertise as healthcare bureaucrat and now partner for a global consulting firm, analyzes healthcare systems from developing and developed countries, trying to understand where they stand out and what they are lacking. It is clear his bias towards a socialized system NHS-style -- from where he got his training as administrator --, and part of his criticisms and comments are based on that, especially his calls to consolidate the market into a few number of providers. However, the descriptions are elucidating and they can work as a good starting point for readers to delve deeper into what happens around the world in the healthcare sector.
2. The second part relates to the global challenges facing the industry now and in the future. Here, his bias is more evident both in the choice of topics to talk about and which arguments are used to defend them. His appraisal for universal healthcare [1] is stressed out and used to defend that all global countries should follow this policy prescription -- with the caveat of understanding that some cultural changes would be needed. However, in different parts, he makes the case based on thin arguments such as associating almost completely the positive trends in life expectancy around the world to the results of health systems, ignoring data that suggests other possibly more important contributing factors like reduction in criminality [2], increased calorie intake [3,4], improved availability of clean water and sanitation systems [5].
Furthermore, he does not deal with important aspects associated with increased demand to healthcare such as opportunity costs and a regulatory environment that stifles innovation. He does not mention different perverse incentives that can arise for a combination of universal healthcare free at the point of delivery and with comprehensive coverage. Dealing with trade-offs, especially the "unseen" ones, is the most important factor when debating how to draw a pubic policy. Ignoring or simply disregarding trade-offs leads to a terribly designed policy that needs to be changed constantly to address avoidable problems.
Another important point that he ignores -- and lots of different authors also do -- is that a system will usually work to attend the demands of costumers -- those who pay the bills -- and not the consumers -- the users of the services. This can explain why even a "perfectly" designed NHS strategy can fail to achieve patient outcomes or might not be well regarded by those who have to wait longer hours, days or months to receive care. When you detach the payment from the receiving side of the good or service, you usually get lower quality, change that does not focus on the patient -- but on things perceived as important by bureaucrats --, and a system that is not responsive to new needs -- such as an ageing population.
It is important to note that his analysis on how to improve things on an individual hospital level are much more precise and relevant. The need of empowering staff, patients and the network they are in is not only urgent, but the most important thing that can be done to deal both with the short and long terms shortages of healthcare professionals, or changes in how care is designed. Therefore, chapters 28 to 31 should be read carefully and the ideas present there ought to be taken into serious consideration.
Chapter 32, that deals with the need for energy efficiency in hospitals and redesign of the care networks in order to avoid waste and pollution, would be as effective without the use of a climate change-based rationale -- probably would work even better with people who have strong biases on this topic. Those in favor of a climate agenda would be satisfied with his policy proposals addressing issues like reducing carbon footprint and waste production. Those against would agree with the idea of reducing costs by shifting to more efficient energy management systems, and having care networks that are designed to be closer to patients.
In chapter 33, he could have analyzed some of the causes for why we see the increased "need" in designing artificial care networks for an ageing population, such as the breakdown of family structures where kids do not care for their parents. An analysis on how to deal with the perceived problem should also look at what is causing it and how we can address the imperfect incentives system that leads to this situation. Understanding the causes of the problem, we can have a better perspective on how to foster a more efficient use of the technological resources and personnel.
3. The last section of the book is a set of conclusions trying to draw possible paths to move the healthcare sector forward. Again, his appraisal for universal healthcare systems is presented, now supported by widely debunked statistics such as the Oxfam studies about wealth distribution [6]. In addition, he gratuitously criticizes developed nations for "not doing enough" for the poor nations, ignoring that usually is the regulatory environment of the developed nations that makes research takes more time and that lowers the speed of important innovation for poor nations.
One point on which he is completely wrong is the case of Ebola, where he argues that rich countries did not care about the disease because "it was considered ... to be a disease of the poor". However, the Ebola serum used to treat rich and poor patients alike was under development in the US and Canada for more than two decades [7], even without any previous outbreaks that had resulted in safety concerns to the developed world.
He also provides no strong evidence to the claim that "a dominant payer and pricing system is more able to pursue the triple aim of better health, better care and better value for the population at large". This conclusion comes only from his own biases, and contradicts elements that he cites in the same paragraph such as the fact that innovation can be slower in those systems. If a system takes longer to develop and adopt new tools, how can it be good at providing better health, better care and better value in the long run? Additionally, literature about reference pricing versus bargain power of single (or large) payer systems show that consumers can drive price reductions when they are made price conscious and have constrained -- but available -- resources.
Next, he criticizes fee-for-service schemes and promotes the idea of fee-for-value (pay for performance), disregarding evidence suggesting that there are no significant savings and better outcomes with this idea [8-10]. The real problem on the payment side is the use of third-party payments, where consumers and costumers are different entities and the real cost is hidden from the patient. There is enough literature to support the argument that price conscious (or more precisely price aware) patients will get the care they need, will have the same health outcomes and end up saving money -- an example is the RAND Health Insurance Experiment [11].
He then moves towards analyzing what can be done on a micro level to improve care, mentioning again that we should improve the participation of patients in the care process, that we ought to give more control to staff while making them more accountable, and that care networks shouldn't be as fragmented as they are in present. He then finishes the book by talking about five disruptive forces that can impact how care is delivered and how the systems are designed in a good and interesting description.
Overall, it is a good book that could have presented more data to support the claims of the author, especially when he is proposing policy changes. Also, he could have given space to other views if he wanted to present a broader analysis of the system and perspectives for it.
For those who do not know much about healthcare policy and are satisfied with somewhat appealing "moral" arguments, his case for universal healthcare is enough. For those who already defend the need for this type of policy, he does not present any new arguments that could contradict stablished beliefs. Lastly, for those who do not agree with the idea of government taking control over the healthcare sector, the reading provides different aspects to be studied, understood and confronted in case of debates or discussions, even though I do not believe his arguments are persuasive enough to convert people from this side of the conversation.
Notes:
[1] Universal healthcare, as shown throughout the book, does not mean healthcare for all, but a government scheme to distribute the costs of care among the residents of a given country. It is a program that does not deal with increasing the supply of goods or services in the healthcare sector, but on how to cross-subsidize the use of the existing goods and services. Its goal is to "cover" the entire population, which means protecting the people from financial distress in case of hospitalization.
[2] https://www.diw.de/documents/dokument...
[3] http://www.fao.org/docrep/003/y6265e/...
[4] http://blog.euromonitor.com/2014/03/e...
[5] http://www.nature.com/scitable/conten...
[6] http://fusion.net/story/39185/oxfams-...
[7] http://www.historyofvaccines.org/cont...
[8] https://www.nytimes.com/2014/07/29/up...
[9] http://content.healthaffairs.org/cont...
[10] http://healthblog.ncpa.org/whats-wron...
[11] When analyzing the RAND study, we need to pay attention to the results to different groups: those with access to health insurance from employer sponsored schemes had the same health outcomes regardless of insurance design (with or without co-payments and deductibles), and saved money when on plans that presented high out-of-pocket expenditure. Those who were poor and likely to be on welfare programs -- such as Medicaid -- might suffer with higher out-of-pocket costs, a problem addressable with subsidized health savings accounts in schemes similar to that from Singapore.
http://www.rand.org/content/dam/rand/...
The book can be divided basically in three different sections:
1. The first is a comprehensive description of healthcare systems around the world. The author, based on his expertise as healthcare bureaucrat and now partner for a global consulting firm, analyzes healthcare systems from developing and developed countries, trying to understand where they stand out and what they are lacking. It is clear his bias towards a socialized system NHS-style -- from where he got his training as administrator --, and part of his criticisms and comments are based on that, especially his calls to consolidate the market into a few number of providers. However, the descriptions are elucidating and they can work as a good starting point for readers to delve deeper into what happens around the world in the healthcare sector.
2. The second part relates to the global challenges facing the industry now and in the future. Here, his bias is more evident both in the choice of topics to talk about and which arguments are used to defend them. His appraisal for universal healthcare [1] is stressed out and used to defend that all global countries should follow this policy prescription -- with the caveat of understanding that some cultural changes would be needed. However, in different parts, he makes the case based on thin arguments such as associating almost completely the positive trends in life expectancy around the world to the results of health systems, ignoring data that suggests other possibly more important contributing factors like reduction in criminality [2], increased calorie intake [3,4], improved availability of clean water and sanitation systems [5].
Furthermore, he does not deal with important aspects associated with increased demand to healthcare such as opportunity costs and a regulatory environment that stifles innovation. He does not mention different perverse incentives that can arise for a combination of universal healthcare free at the point of delivery and with comprehensive coverage. Dealing with trade-offs, especially the "unseen" ones, is the most important factor when debating how to draw a pubic policy. Ignoring or simply disregarding trade-offs leads to a terribly designed policy that needs to be changed constantly to address avoidable problems.
Another important point that he ignores -- and lots of different authors also do -- is that a system will usually work to attend the demands of costumers -- those who pay the bills -- and not the consumers -- the users of the services. This can explain why even a "perfectly" designed NHS strategy can fail to achieve patient outcomes or might not be well regarded by those who have to wait longer hours, days or months to receive care. When you detach the payment from the receiving side of the good or service, you usually get lower quality, change that does not focus on the patient -- but on things perceived as important by bureaucrats --, and a system that is not responsive to new needs -- such as an ageing population.
It is important to note that his analysis on how to improve things on an individual hospital level are much more precise and relevant. The need of empowering staff, patients and the network they are in is not only urgent, but the most important thing that can be done to deal both with the short and long terms shortages of healthcare professionals, or changes in how care is designed. Therefore, chapters 28 to 31 should be read carefully and the ideas present there ought to be taken into serious consideration.
Chapter 32, that deals with the need for energy efficiency in hospitals and redesign of the care networks in order to avoid waste and pollution, would be as effective without the use of a climate change-based rationale -- probably would work even better with people who have strong biases on this topic. Those in favor of a climate agenda would be satisfied with his policy proposals addressing issues like reducing carbon footprint and waste production. Those against would agree with the idea of reducing costs by shifting to more efficient energy management systems, and having care networks that are designed to be closer to patients.
In chapter 33, he could have analyzed some of the causes for why we see the increased "need" in designing artificial care networks for an ageing population, such as the breakdown of family structures where kids do not care for their parents. An analysis on how to deal with the perceived problem should also look at what is causing it and how we can address the imperfect incentives system that leads to this situation. Understanding the causes of the problem, we can have a better perspective on how to foster a more efficient use of the technological resources and personnel.
3. The last section of the book is a set of conclusions trying to draw possible paths to move the healthcare sector forward. Again, his appraisal for universal healthcare systems is presented, now supported by widely debunked statistics such as the Oxfam studies about wealth distribution [6]. In addition, he gratuitously criticizes developed nations for "not doing enough" for the poor nations, ignoring that usually is the regulatory environment of the developed nations that makes research takes more time and that lowers the speed of important innovation for poor nations.
One point on which he is completely wrong is the case of Ebola, where he argues that rich countries did not care about the disease because "it was considered ... to be a disease of the poor". However, the Ebola serum used to treat rich and poor patients alike was under development in the US and Canada for more than two decades [7], even without any previous outbreaks that had resulted in safety concerns to the developed world.
He also provides no strong evidence to the claim that "a dominant payer and pricing system is more able to pursue the triple aim of better health, better care and better value for the population at large". This conclusion comes only from his own biases, and contradicts elements that he cites in the same paragraph such as the fact that innovation can be slower in those systems. If a system takes longer to develop and adopt new tools, how can it be good at providing better health, better care and better value in the long run? Additionally, literature about reference pricing versus bargain power of single (or large) payer systems show that consumers can drive price reductions when they are made price conscious and have constrained -- but available -- resources.
Next, he criticizes fee-for-service schemes and promotes the idea of fee-for-value (pay for performance), disregarding evidence suggesting that there are no significant savings and better outcomes with this idea [8-10]. The real problem on the payment side is the use of third-party payments, where consumers and costumers are different entities and the real cost is hidden from the patient. There is enough literature to support the argument that price conscious (or more precisely price aware) patients will get the care they need, will have the same health outcomes and end up saving money -- an example is the RAND Health Insurance Experiment [11].
He then moves towards analyzing what can be done on a micro level to improve care, mentioning again that we should improve the participation of patients in the care process, that we ought to give more control to staff while making them more accountable, and that care networks shouldn't be as fragmented as they are in present. He then finishes the book by talking about five disruptive forces that can impact how care is delivered and how the systems are designed in a good and interesting description.
Overall, it is a good book that could have presented more data to support the claims of the author, especially when he is proposing policy changes. Also, he could have given space to other views if he wanted to present a broader analysis of the system and perspectives for it.
For those who do not know much about healthcare policy and are satisfied with somewhat appealing "moral" arguments, his case for universal healthcare is enough. For those who already defend the need for this type of policy, he does not present any new arguments that could contradict stablished beliefs. Lastly, for those who do not agree with the idea of government taking control over the healthcare sector, the reading provides different aspects to be studied, understood and confronted in case of debates or discussions, even though I do not believe his arguments are persuasive enough to convert people from this side of the conversation.
Notes:
[1] Universal healthcare, as shown throughout the book, does not mean healthcare for all, but a government scheme to distribute the costs of care among the residents of a given country. It is a program that does not deal with increasing the supply of goods or services in the healthcare sector, but on how to cross-subsidize the use of the existing goods and services. Its goal is to "cover" the entire population, which means protecting the people from financial distress in case of hospitalization.
[2] https://www.diw.de/documents/dokument...
[3] http://www.fao.org/docrep/003/y6265e/...
[4] http://blog.euromonitor.com/2014/03/e...
[5] http://www.nature.com/scitable/conten...
[6] http://fusion.net/story/39185/oxfams-...
[7] http://www.historyofvaccines.org/cont...
[8] https://www.nytimes.com/2014/07/29/up...
[9] http://content.healthaffairs.org/cont...
[10] http://healthblog.ncpa.org/whats-wron...
[11] When analyzing the RAND study, we need to pay attention to the results to different groups: those with access to health insurance from employer sponsored schemes had the same health outcomes regardless of insurance design (with or without co-payments and deductibles), and saved money when on plans that presented high out-of-pocket expenditure. Those who were poor and likely to be on welfare programs -- such as Medicaid -- might suffer with higher out-of-pocket costs, a problem addressable with subsidized health savings accounts in schemes similar to that from Singapore.
http://www.rand.org/content/dam/rand/...
November 5, 2023
International perspective - takes a whole country and writes a short summary of their health system.
Uses life expectancy, percentage of GDP spent on health care, and other metrics to provide comparisons, but then gives a bit more detail about how it’s funded (e.g. taxation, privately, insurance); how it’s configured (primary/secondary); and a bit about workforce.
Acknowledges that history and political context are important, as well as cultural influences. Each section is very brief, and in my view can feel a bit over simplified.
Could be better at noting the determinants of health and the impact these will have. Sometimes feels like the author hasn't recognised the contribution that public health makes.
Might be interesting to see how things have changed since 2015. Also interesting that the author applied to be the NHS England CEO in 2019 (I think) and was unsuccessful.
Uses life expectancy, percentage of GDP spent on health care, and other metrics to provide comparisons, but then gives a bit more detail about how it’s funded (e.g. taxation, privately, insurance); how it’s configured (primary/secondary); and a bit about workforce.
Acknowledges that history and political context are important, as well as cultural influences. Each section is very brief, and in my view can feel a bit over simplified.
Could be better at noting the determinants of health and the impact these will have. Sometimes feels like the author hasn't recognised the contribution that public health makes.
Might be interesting to see how things have changed since 2015. Also interesting that the author applied to be the NHS England CEO in 2019 (I think) and was unsuccessful.
June 29, 2020
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February 5, 2024
Vert interesting and well worth the read.
December 11, 2024
A good overview of various healthcare systems around the world. There is a lot of condensed information in here, so it is not what I consider light reading. But readers who are not already experts in public health will benefit from reading this fine book. I also recommend "The Healing of America" by T.R. Reid. In any case, I think mark Britnell should write a second edition of this book some time in the 2030s or beyond explaining how countries around the world deal with or fail to deal with demographic aging and shortages of medical professionals. How climate change affects public health would also be worth exploring.
Displaying 1 - 5 of 5 reviews