Nord-norsk helsevesen mot 2020

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1 Nord-norsk helsevesen mot 2020 Olav Helge Førde

2 Disposisjon Om medisin, helsevesen og spåkunst Kva driv utviklinga? Kva blir utfordringane i Nord Kva er hindringane for ei god utvikling?

3 Finanskrisa vil avgjere? Feature Health Economics The credit crisis and health care John Appleby, chief economist With the current financial turmoil affecting the cash flow of governments, business, and individuals, John Appleby assesses the likely effect on the NHS It is hard to resist apocalyptic phrases (indeed, the use of the word apocalyptic) in describing the effect of the credit crunch on the world s banking and financial systems over the past year. But it is not just the somewhat unreal and mystifying world of credit default swaps, naked short selling, and eyewatering bonuses that has been affected. As has become much clearer

4 Hoping for immortality Copyright 2000 BMJ Publishing Group Ltd. Abbasi, K. BMJ 2000;320:194

5 Prototype - Design EUROPEAN NEWSLETTER ON NEW AND EMERGING HEALTH TECHNOLOGIES WP7

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8 Begrep Emerging technology - generally a technology that is not yet adopted by the health care system: pharmaceuticals will usually be in phase II or phase III clinical trials or pre-launch, medical devices will usually be prior to marketing, or within 6 months of marketing, or marketed but <10% diffused or localised to a few centres

9 Begrep Early warning system - a stable unit with reliable connections and sources which aims to: identify new and emerging health technologies, filter and prioritise those technologies most likely to have a significant future impact and make an assessment of either potential impact or clinical and cost effectiveness. An early warning system and an early warning assessment may be an integral part of the prioritisation process for health technology assessment (HTA) activities. Horizon-scanning is the identification phase of an early warning system

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11 Kva driv utviklinga av helesektoren? Ny teknologi Nye metodar/nye indikasjonar

12 Kva driv utgiftene opp? Inflasjonen i sektoren; ca. 7% per year ( ) Nye metodar ny teknologi: 12-33% Omfang og intensitet av behandling+demografi: 60-80%

13 Kva driv utviklinga av helesektoren? Ny teknologi Nye metodar/nye indikasjonar Kommersielle interesser Utnyttinga av eit utvida helsebegrep

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16 Kva driv utviklinga av helesektoren? Ny teknologi Nye metodar/nye indikasjonar Kommersielle interesser Utnyttinga av eit utvida helsebegrep Industrien sin dominans og innverknad på medisinsk forskning

17 Reputations for sale? Fiona Godlee, editor, BMJ BMJ 2007;334 (27 January), doi: /bmj

18 Feature What have we learnt from Vioxx? Harlan M Krumholz, Harold H Hines Junior professor of medicine and epidemiology and public health1, Joseph S Ross, instructor2, Amos H Presler, research associate3, David S Egilman, clinical associate professor4 BMJ 2007;334: (20 January), doi: /bmj

19 News US guidelines often influenced by industry Janice Hopkins Tanne - 26 January 2007 Many clinical guidelines for doctors in the United States are influenced by the pharmaceutical industry and special interest groups, according to an article in the New England Journal of Medicine.

20 FDA proposes higher fees for drug approvals to cover postmarketing surveillance Janice Hopkins Tanne BMJ : 177. [Extract] [Full Text] Ghost writers need to be more visible Keith Dawes BMJ : 208. [Extract] [Full Text] Inside big pharma's box of tricks Joe Collier BMJ : 209. [Extract] [Full Text]

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22 Kva driv utviklinga av helesektoren? Ny teknologi Nye metodar/nye indikasjonar Kommersielle interesser Utnyttinga av eit utvida helsebegrep Industrien sin dominans og innverknad på medisinsk forskning Økonomiske insentiv

23 Kva driv utviklinga av helesektoren? Ny teknologi Nye metodar/nye indikasjonar Kommersielle interesser Demografiske endringar

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25 Kva driv utviklinga av helesektoren? Defensiv medisin Auka kjøpekraft og consumerism Svekka gate-keeper funksjon og auka forventningar Medikalisering

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27 % of population Cholesterol 5mmol not already included BP 140/90 mmhg or under BP treatment

28 Statin til heile folket? Published 12 November 2008, doi: /bmj.a2523 Cite this as: BMJ 2008;337:a2523 News Trial stopped early after rosuvastatin found to cut the risk of heart attack and stroke by 44% in healthy people Roger Dobson Statins reduce the risk of cardiovascular events by 44% in people who do not have high cholesterol but have raised high sensitivity C reactive protein, a study has shown (New England Journal of Medicine 2008;359: , doi: /nejmoa ). Results from the JUPITER trial (Justification for the Use of Statins in Primary Prevention Intervention) also show that rosuvastatin reduced heart attacks alone by 54% in the same group of people. The combined primary end point was myocardial infarction, stroke, arterial revascularisation, hospitalisation for unstable angina, or death from cardiovascular causes. The manufacturer of rosuvastatin, AstraZeneca, described the 44% drop in cardiovascular events as the greatest relative risk reduction seen in a large placebo controlled study of statins, but there were warnings about the implications. John Abramson, author of Overdosed America: The Broken Promise of American Medicine and a clinical instructor at Harvard Medical School, said that the impact would be... [Full text of this article]

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30 Meir ressursar betre helse? In an Op-Ed published in The New York Times on Monday, July 20, 2006 ("Too Many Doctors in the House"), David C. Goodman, M.D., M.S., the director of the Dartmouth Health Workforce Program, argues that plans to increase the size of the physician workforce in the United States are "like prescribing more drugs for an already overmedicated patient, [and] may only make things worse." Goodman argues that the per capita supply of physicians is unrelated to the quality of care provided, and "will continue to fill more hospital beds, order more diagnostic tests -- in short, spend more money. But our resources would be better directed toward improving efforts to prevent illness and manage chronic ailments like diabetes and heart disease." The research findings were published by the journal Health Affairs in its March/April 2006 issue.

31 Kva driv utviklinga i sektoren? Ny teknologi Nye metodar/nye indikasjonar Kommersielle interesser Demografiske endringar Defensiv medisin Auka kjøpekraft og consumerism Svekka gate-keeper funksjon og auka forventningar Medikalisering Kriseforståelse Manglande heilskap i helsepolitikken (politisk populisme?)

32 Felles bakgrunn for den internasjonale helsetenestekrisa Sterk vekst i etterspurnaden etter helsetenester Kostnadsvekst Uakseptable ventelister Styringsimpotens og behov for å vise politisk handlekraft Kriseforståelse

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34 Helsetenestereformer har ofte vore svaret

35 Flommen av helsetenestereformer Desentralisering ( GB, Spania, Canada, Sverige) Re-sentralisering (Norge, Danmark) Nasjonal helseforsikring (Frankrike, USA?) Privat helseforsikring (Nederland, Australia) Kvasi-marknad reformer ( Alle land) Bestillar/utførar skille Levrandørkonkurranse Kostnadsdeling Valfridom for pasientar

36 Erfaringar med reformene Transaksjons-kostnadane ved reformene er i regelen store Vedtatte reformer blir ikkje gjennomført Mange reformer blir reversert, ofte med politisk grunngjeving (eller etter val) Kvasi-marknads løysingar har ikkje vore noen stor suksess Konkurranse svekkar samarbeid og kontinuitet, og gjer beslutningslinjer uklare Konsekvensane av reformene er minst for pasientane

37 Om helsepolitikk og sentralstyring Increasingly centralised decision making, driven by a political imperative for constant reform, has left us victim to "a patchwork of mutually contradictory ideas struggling for dominance." Fiona Godlee, BMJ editor and Nigel Hawkes, health editor, The Times BMJ 23. sept 2006

38 Opprør mot nye reformer "The real issue is the relentless and ill thought out avalanche of change, directives, and guidelines that have flooded down," he said. "Much of it is change for change's sake. It is time for people to say `enough is enough.'" Barry Monk, consultant dermatologist at Bedford Hospital NHS Trust

39 The Practice of Reform in Health, Medicine and Science, Eds Margaret Pelling, Scott Mandelbrote Ashgate, 55, pp 376 ISBN Rating: Healthcare reform has become a global phenomenon. Countries around the world are reshaping their health systems. The modified systems are often based on Western models and are subject to terms of "conditionality" imposed by supranational funding bodies. Many European countries seem to be locked into a continuous cycle of reform akin to Maostyle perrmanent revolution. Reform has become routine, and "reform fatigue" is widespread. A major health policy conference to be held in Israel later this year is entitled "Are we in a post-reform era? Its thesis is that reform ideas have been recycled to the point that genuinely new approaches are scarce or non-existent.

40 Kva så? Top down macro-reformer er ikkje løysinga Reformer må vere målretta Økonomiske insentiv er virkningsfulle, men må vere varsamt avstemt med det faglege insentivsystemet Trua på styring gjennom lovregulering og bestillerdokument er for optimistisk

41 Kva driv utviklinga i sektoren? Ny teknologi Nye metodar/nye indikasjonar Kommersielle interesser Demografiske endringar Defensiv medisin Auka kjøpekraft Svekka gate-keeper funksjon og consumerism Medikalisering Kriseforståelse Manglande heilskap i helsepolitikken (politisk populisme?) Kva kan vi gjere med drivarane i nord? Drivarane er enten internasjonale eller har hovudvirkefelt der pasientane møter sektoren!

42 Physician agreement with different cost-containment policies Closing some hospital beds* Emphasis on Evidence Based Practice* Restriction of expensive treatments and examinations* Administrative decision to prioritize some patient groups* Using direct treatment fees* Classification of referrals by degree of urgency Waiting lists for elective surgical operations over 5 1 to 4 none UK Switzerland Norway Italy

43 Korleis blir så Nord-norsk helsevesen mot 2020? Eg stygt redd for redd for at den er om lag som i dag Men enno dyrare Langt fleire blir behandla og meir intensivt Krisa i helsetenesta er forverra Politikken har abdisert? Eller kan vi gjere noe?

44 Utfordringar Vi må få orden på økonomien

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47 $ PPP Total expenditure on health care pr. inhabitant pr. year USA Norge Danmark Sverige Storbritannia Finland År Source: OECD Health Data 2006

48 Helseutgifter, etter hovedformål i 1997, 2002 og Prosent HC 1.1 Sykehustjenester - heldøgnsopphold HC 1.2 Sykehustjenester - dagopphold 2,4 3,6 3,8 HC Legetjenester mv. 21,4 19,1 19,8 HC 2.1 Rehabilitering - heldøgnsopphold 1,6 1,5 1,5 HC 3.1 Sykehjemstjenester - heldøgnsopphold 15,6 16,8 16,6 HC 3.3 Hjemmesykepleie mv 6,5 8,3 9,4 HC 4.1 Røntgen- og laboratorietjenester 3,7 3,2 3,7 HC 4.3 Ambulanse og pasienttransport 2,5 2,5 2,8 HC 5 Medisiner og medisinsk utstyr og hjelpemidler 14,9 15,3 12,9 HC 6-7 Forebyggende arbeid og helseadministrasjon 2,9 3,1 2,9

49 BMJ 2007;335: (21 July), doi: /bmj Editorials Health for London: showing England the way? Plans to focus hospital services and build polyclinics will have to overcome inertia and rivalries Last week saw the launch of Healthcare for London: A Framework for Action, the findings of a review led by Sir Ara Darzi, chair of surgery at Imperial College. 1 The review was commissioned by NHS London in 2006, but its contents have assumed a greater significance with the recent appointment of Sir Ara as a junior minister, charged with a wider review of the health service throughout England. 2 The terms of reference for that review make clear the government's determination "to ensure that the future of the NHS is clinically led" and that vision is pre-eminent in his London report. The review has been based largely on the views of clinicians, concentrated into six working groups of "clinical innovators" drawn from a range o

50 Utfordringar Vi må få orden på økonomien Vi må svekke trua på at meir helsetenester alltid er betre enn mindre

51 HOME SEARCH CURRENT ISSUE PAST ISSUES COLLECTIONS HELP Pr evious Volume 349: Please sign in for full text and personal services October 23, 2003 Number 17 Medical Care Is More Always Better? Nex t Elliott S. Fisher, M.D., M.P.H.

52 Pr evious Volume 349: October 23, 2003 Number 17 Nex t Hospital Use and Survival among Veterans Affairs Beneficiaries Carol M. Ashton, M.D., M.P.H., Julianne Souchek, Ph.D., Nancy J. Petersen, Ph.D., Terri J. Menke, Ph.D., Tracie C. Collins, M.D., M.P.H., Kenneth W. Kizer, M.D., M.P.H., Steven M. Wright, Ph.D., and Nelda P. Wray, M.D., M.P.H.

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55 BMJ 2002;324: ( 19 January ) Papers Getting more for their dollar: a comparison of the NHS with California's Kaiser Permanente Richard G A Feachem, director, a Neelam K Sekhri, chief executive officer, b Karen L White, programme development officer. a a Institute for Global Health, University of California, San Francisco and Berkeley, CA 94105, b Healthcare Redesign Group, Alameda, CA Correspondence to: R Feachem rfeachem@psg.ucsf.edu Objective: To compare the costs and performance of the NHS with those of an integrated system for financing and delivery health services (Kaiser Permanente) in California. Methods: The adjusted costs of the two systems and their performance were compared with respect to inputs, use, access to services, responsiveness, and limited quality indicators. Results: The per capita costs of the two systems, adjusted for differences in benefits, special activities, population characteristics, and the cost environment, were similar to within 10%. Some aspects of performance differed. In particular, Kaiser members experience more comprehensive and convenient primary care services and much more rapid access to specialist services and hospital admissions. Age adjusted rates of use of acute hospital services in Kaiser were one third of those in the NHS. Conclusions: The widely held beliefs that the NHS is efficient and that poor performance in certain areas is largely explained by underinvestment are not supported by this analysis. Kaiser achieved better performance at roughly the same cost as the NHS because of integration throughout the system, efficient management of hospital use, the benefits of competition, and greater investment in information technology.

56 Utfordringar Svekke Vi må få orden på økonomien Vi må svekke trua på at meir helsetenester alltid er betre enn mindre Vi må svekke trua på at status quo er framtida Få fagmiljøa med på Mobilitet Å tenke tenester og ikkje senger og kvadratmeter Skape oppslutning og tryggleik i omgjevnaden

57 Kvifor bør vi satse på samhandling og ein desentralisert struktur for tenesteleveranse? Fordi sjukdomspanorama krev det

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59 Kvifor bør vi satse på samhandling og ein desentralisert struktur for tenesteleveranse? Fordi sjukdomspanorama krev det Fordi vi meir og meir av tenesteleveransen blir gjeven poliklinisk og som dagbehandling Fordi befolkninga krev nærhet og tryggleik Fordi vi har mange små og de-sentrale institusjonar Fordi vi er gode på helsenett og telemedisin Fordi vi betalar dyrt for pasientreiser Fordi den kler nordnorsk geografi Fordi den vil få allmenn(?) oppslutning

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