What Makes a Good Healthcare System?

Comparisons, Values, Drivers

Alan Gillies

• Publisher: CRC Press
• Year: 2018
• eBook ISBN:
  9781315344423
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

What Makes a Good Health Care System? Examines the various assumptions that underpin the different views of what makes a good health care system. The national systems in the UK, Australia and Canada are thoroughly examined.

CHAPTER 1

People in their daily lives

About this book

Health is a very political issue in today’s world. Politicians talk a lot about improving the healthcare system in their countries. They assume that they know what is a better system. They may even assume that they know how to make their system better. This book sets out to challenge these assumptions. It seeks to examine our assumptions about what is a ‘good’ system. It will do this by comparing three national systems from the United Kingdom (UK), Australia and Canada.

In each country, there is a different view of what a good healthcare system is trying to achieve. We shall consider these from the perspective of the current situation in each country, the policy documents which tell us where each country is trying to get to, and comments gathered from key stakeholders to introduce a note of reality.

However, before we get to our analysis of each country, we must establish a basis for our comparison. To start this we shall consider the needs of patients through four different individuals with diverse needs and expectations.

Andrew, 35, stressed-out executive

Andrew lives in Guildford, but works in London. He works typically 50 to 60 hours a week. This leaves him fairly tired and stressed, with little time for exercise. He considers himself to be careful about his health. Accordingly, he has reduced his smoking to 15 cigarettes a day, and restricts himself to one glass of whisky in an evening on his return home. He shares a bottle of wine with Jane, his wife, most Friday and some Saturday nights. He avoids food he considers unhealthy, such as fish and chips, hamburgers and the like. On mid-week evenings, he often eats pre-packaged meals if Jane is out.

Every so often, he fits in a game of squash with his best friend Gareth and walks to the station occasionally in the summer when he has time.

He has not had a day off from the office for ill health in the past ten years, and has not visited his general practitioner (GP) in that time. He did receive a letter from his GP inviting him to attend for a consultation last year, but did not consider it important enough to make space in his diary.

Anna, 15, teenager

Anna lives in Doncaster and is a healthy, active teenager who likes going out with her mates at the weekend. She worries about her weight and whether she is overweight. She is a vegetarian and eats a lot of salads. If she is feeling anxious about her weight, she will skip lunch.

She has been seeing the same boy for two months, and although she is not sexually active, thinks that her boyfriend Mike would like them to be.

She has only visited her doctor with her Mum, and does not know the name of her registered GP. She thinks that doctors are for when you are ill. There is a female GP in her practice, but she doesn’t know if she’s allowed to go and speak to her, and if so, whether you can do this if you’re not ill.

Harold, 75, old-age pensioner

Harold lives in Birmingham. He lives alone since his wife died a few years ago. He has difficulty getting about because of an arthritic hip. He is on the list for a replacement, but he has been waiting for nine months and he doesn’t yet know when he will get his operation. Meals on Wheels call three times a week to provide a hot meal and check on him. He gave up smoking ten years ago when he had problems with angina. He has a sweet tooth and likes cakes and biscuits. His old doctor retired six years ago and he was transferred to a newly qualified female doctor who he finds it more difficult to talk to. His children have moved away and the rest of his family are back in Jamaica, which Harold left back in the early 1960s when he came to England to look for work.

Daphne, 32, schoolteacher

Daphne lives in Northampton. She recently married David. They have been living together for eight years and have decided to start a family. Daphne has been preparing for pregnancy by stopping smoking and confining her drinking to a couple of glasses of dry white wine on a Friday night. She went to her doctor’s surgery for advice about the planned pregnancy, and instead of speaksing to her usual (male) doctor, she talked to one of the female partners in the practice.

Health needs

Each of our four characters has diverse needs.

Andrew considers himself to be basically healthy and health conscious. He sees the fact that he has not been to the GP for ten years as a measure of his health. He has taken steps to eliminate those factors placing him most at risk; he has cut down on his smoking, drinks moderately by his judgement and avoids high-fat foods. He looks on his exercise as positive, but thinks he does more than he actually does.

In reality, his smoking is still a risk factor and his drinking is probably too high. Home measures are notoriously large, so his nightly whisky is probably two to three units of alcohol per day and his weekly wine intake may add up to 12 units. This puts him between 26 and 33 units a week, which is at a level where problems may occur.

His exercise is too sporadic to be useful, and sudden bursts of exercise such as squash may be actually harmful. His diet, whilst not bad, seems unlikely to provide sufficient fruit and vegetables and may well be high in salt due to the pre-packaged meals, which may also provide too much fat.

Whilst none of these factors make it likely that he will drop dead tomorrow, they would be risk factors if combined with other factors such as:

• raised blood pressure
• family history of heart disease
• family history of diabetes.

In reality, Andrew is a fairly typical male in their thirties. The fact that he has neither the inclination nor the time to visit his GP to establish any level of risk means that he could be ignorant of the real level of risk.

Anna is much more health conscious in her own way. She receives much advice from reading teenage magazines and believes that her diet is helping her keep her weight down, which is a priority for her. Whilst she does not have an eating disorder, anxieties over putting on weight are likely to take priority over eating a balanced diet. As a vegetarian she may be deficient in protein and also some key nutrients. Living at home, where her mum makes limited provision for her vegetarianism, may exacerbate this problem.

Anna also recognises a need for access and advice on contraception and possibly in broader matters to do with her relationship. In the absence of understanding or feeling able to access the formal healthcare system, she is likely to use more informal modes of advice – peers, magazines etc. – and possibly less than ideal or no contraception if she decides to sleep with her boyfriend.

Harold has more traditional healthcare needs. He needs an operation, and is currently waiting for the procedure. His limited mobility, in the mean time, creates other care needs and reduces his quality of life. It will force him into a sedentary life-style, which may create other health problems. His sweet tooth may put him at risk of diabetes, and the risks arising from a diabetic coma for an elderly man living alone are significant.

His colour and ethnic background, together with his inability to relate to his new GP, may also create barriers and prevent him accessing all the healthcare advice and services that he might need.

Daphne has adopted a planned approach to her pregnancy. She has taken advice from both her GP practice and other more informal sources such as books, magazines and her friends. She has an increased awareness of health issues because of the impact upon her baby. She is also aware that the proposed pregnancy will have a major impact on her own body. In contrast to Andrew, who is of similar age, she has been in regular contact with the healthcare system due to her use of the contraceptive pill in the past and her cervical smears, which she has been having done regularly. As part of the checks for her repeat prescription of the contraceptive pill, she has received checks on her blood pressure.

For now, we will leave Andrew, Anna, Harold and Daphne in their respective lives, but we shall return to them later.

Quality as a measure of ‘goodness’

When we talk of defining how good a healthcare system is, we generally do this in terms of quality assurance. Quality assurance is the process of measuring performance against a defined standard and seeing how it compares. This idea has its origins in engineering and science where defining standards can be relatively straightforward.

Figure 1.1

Consider the measurement of temperature. In order to measure temperature, first we plunge our thermometer in melting ice. We can mark the mercury level as 0°C. Similarly, we can place it in a cloud of steam and mark this as 100°C. We then divide the difference by 100 to make our temperature scale. This forms the basis of an internationally agreed scale of ‘hotness’ which is consistent and objective.

In science and engineering, it is sometimes possible to measure quality in this objective way. For example, the quality of a batch of ball-bearings may reasonably be defined in terms of a simple set of physical parameters:

• diameter
• roundness
• metallurgical composition
• hardness.

For each of these parameters, we can agree acceptable ranges and measure whether each individual ball-bearing meets the requirements.

There are times when it is suggested that we can measure the quality of healthcare in the same way. We can’t. But there is a more fundamental problem. The scientists have a consensus over what temperature is. It is a measure of ‘hotness’. In quantitative terms, it is a measure of the kinetic energy of the molecules making up whatever you are measuring the temperature of.

If we move to our ball-bearing example, things are a little less clear. Standards may now be defined in terms of a range of parameters. The relative importance of each parameter may vary according to context, but each can be measured objectively, and frankly the relative importance is not likely to be controversial.

In healthcare the measures are often not objective, and the relative importance is both critical and may well be controversial.

To take one example, consider Harold and his hip operation. How shall we measure the quality of this procedure? Here is a range of measures that are used in practice:

• How long does Harold have to wait to see a specialist who decides he needs an operation?
• How long does Harold have to wait once the specialist decides he needs an operation?
• How many people like Harold are treated in his local hospital each year?
• How many people like Harold have to wait to be treated more than one year?
• How likely is Harold to catch an infection whilst in hospital for his operation?
• How likely is Harold to be readmitted as a result of catching an infection whilst in hospital for his operation?
• How many days will Harold have to spend in hospital to have his operation?

Here is a range of measures that may not be used, but might be of more use to Harold:

• How much mobility will Harold get back after the operation?
• How long will it take him to recover from the operation itself?
• How long will it take him to get used to his new hip?
• How often will someone visit to check if he’s OK whilst he’s recovering?

Now multiply this by all the Harolds, Daphnes, Annas and Andrews in the country, all their ...

Table of contents

• Cover
• Title Page
• Copyright Page
• Contents
• Preface
• Acknowledgements
• Acronyms and abbreviations
• 1 People in their daily lives
• 2 People meet the healthcare system: two case studies
• 3 What is a good healthcare system?
• 4 Using the model to analyse healthcare systems
• 5 Values underpinning policy development
• 6 What is the reality in the UK?
• 7 What is the reality in Australia?
• 8 What is the reality in Canada?
• 9 Driver 1: finance
• 10 Driver 2: scandals
• 11 Driver 3: ideology
• 12 So what is a good healthcare system?
• References and further information
• Index