Copyrighted material_9781137496614 In Search of the Perfect Health System Copyrighted material_9781137496614 Copyrighted material_9781137496614 In Search of the Perfect Health System Mark Britnell Copyrighted material_9781137496614 © Mark Britnell 2015 All rights reserved. No reproduction, copy or transmission of this publication may be made without written permission. No portion of this publication may be reproduced, copied or transmitted save with written permission or in accordance with the provisions of the Copyright, Designs and Patents Act 1988, or under the terms of any licence permitting limited copying issued by the Copyright Licensing Agency, Saffron House, 6–10 Kirby Street, London EC1N 8TS. Any person who does any unauthorized act in relation to this publication may be liable to criminal prosecution and civil claims for damages. The author has asserted his right to be identified as the author of this work in accordance with the Copyright, Designs and Patents Act 1988. First published 2015 by PALGRAVE Palgrave in the UK is an imprint of Macmillan Publishers Limited, registered in England, company number 785998, of 4 Crinan Street, London, N1 9XW. Palgrave Macmillan in the US is a division of St Martin’s Press LLC, 175 Fifth Avenue, New York, NY 10010. Palgrave is the global imprint of the above companies and is represented throughout the world. Palgrave® and Macmillan® are registered trademarks in the United States, the United Kingdom, Europe and other countries. ISBN 978–1–137–49661–4 This book is printed on paper suitable for recycling and made from fully managed and sustained forest sources. Logging, pulping and manufacturing processes are expected to conform to the environmental regulations of the country of origin. A catalogue record for this book is available from the British Library. A catalog record for this book is available from the Library of Congress. Copyrighted material_9781137496614 For Reuben and Beatrix Britnell ‘The world is a book and he who does not travel reads only one page’ St Augustine Copyrighted material_9781137496614 Copyrighted material_9781137496614 vii Contents Foreword from Lord Nigel Crisp ix Preface x 1 The Perfect Health System 1 Country profles Part 1: Asia and Australia 14 2 Japan – Live long and prosper 15 3 South Korea – National pride and global ambition 20 4 China – Communist chimera? 25 5 Hong Kong – Demography, democracy and destiny 31 6 Malaysia – Reform some time, soon? 36 7 Singapore – Wealth and health 41 8 Indonesia – Largest single payer in the world 46 9 Australia – Advance Australia Fair 52 10 India – One country, two worlds 58 Part 2: Middle East and Africa 63 11 Qatar – Build and they will come 64 12 Israel – The best kept secret in global health? 69 13 South Africa – No more false dawns 74 Part 3: Europe 80 14 Russia – A distressed and distressing system 81 15 The Nordics – Decentralised welfare utopia? 86 16 The Netherlands – Competition and social solidarity 92 17 Germany – Doctor knows best 97 18 Switzerland – You get what you pay for 102 19 Italy – No longer ‘la dolce vita’ 106 20 Portugal – The price of austerity 111 21 France – Neither Beveridge nor Bismarck but the Republic 116 22 England – The NHS. In place of fear 121 Part 4: The Americas 129 23 Canada – At the crossroads 130 24 The US – Let’s face the music and dance 136 Copyrighted material_9781137496614 viii Contents 25 Mexico – Unfnished business 143 26 Brazil – Order and progress? 148 Part 5: Global Challenges 153 27 Universal Healthcare – Triumph of political will 154 28 Same Problem, Different Country – The paradox of change 163 29 Clinical Quality – The more I know, the less I sleep 170 30 Value Walks – There is no healthcare without the workforce 178 31 Patients As Partners – Renewable energy 186 32 Climate Change and Sustainability – Our dirty little secret 194 33 Ageing – Every cloud has a silver lining 202 Part 6: Conclusion 210 34 Conclusion – We wouldn’t start from here 211 Key Statistics at a Glance 224 Index 226 Copyrighted material_9781137496614 ix Foreword from Lord Nigel Crisp This book is a masterclass in brief and insightful commentary. If you have ever wondered what was distinctive about healthcare in Asia and the US, what sort of systems the advancing economies of Brazil and Mexico are developing, or how continental European systems difered from the UK and Scandinavia, this book will ofer you a short summary of the facts, enlivened with the personal obser- vations of the author. Like all foreign travel this book opens your eyes to new possibilities. Mark Britnell has flled an important gap here. His unique experience in the public and private sectors, as a payer and a provider, and his great success in leading local, regional, national and global organisations gives his assessments and opinions particular weight and authority. People from diferent backgrounds will fnd this book fascinating for the way it illuminates the nature and complex- ity of healthcare. He shows that healthcare is a social and cultural construct: the health system of a country is a product of history, politics and culture quite as much as it is of science, education and resources. Changing or reforming the health system is therefore as much a social and cultural movement as a business and management challenge. You can’t just transport a system from one place to another – but we can all learn from each other. I have written elsewhere about what we can learn from the poorest countries, and this is represented here by the description of ‘jugaad’ innovation in India. However, it is the descriptions of countries in the East such as Hong Kong, Japan, South Korea and Singapore that are most intriguing to Western eyes. Their mod- els have led to astonishing improvements: South Korea, for example, imple- mented universal healthcare in just 12 years and life expectancy has shot up to European levels. These countries are now, however, encountering the health problems of age and afuence. We can all surely learn from their experience and from how they mobilise to take on these new challenges. We can also, sadly, learn from the Russian experience described here in bleak but realistic terms. Mark Britnell has all the heart and passion of a healthcare professional combined with the head of a man who leads a successful global enterprise. He infuses the book with his own humanity and ofers insights forged through experience. Therefore we should all listen when he calls for collective action to tackle the challenges of healthcare and draws attention to the way other industries have collaborated in information technology, communications and much else to develop new and better services. It is a timely and important challenge to us all, and one we must rise to if healthcare is to become sustainable. Copyrighted material_9781137496614 x Preface ‘Like all great travellers, I have seen more than I remember and remember more than I have seen’. Benjamin Disraeli. Prime Minister of the United Kingdom, 1868 and 1874–80. Over the past six years I have had the privilege of working in 60 countries on nearly 200 occasions. I have travelled the circumference of the world 70 times over and worked with hundreds of public and private sector organisations and governments of varying political persuasions. Quite literally, I have engaged with thousands of clinicians, executives and patients from every walk of life. It is an honour to have met so many inspiring people across the world who want to provide outstanding care to the patients and populations they serve. Three years ago two friends and colleagues – Lord Nigel Crisp, Chair of the All- Party Parliamentary Group on Global Health, and Sir Robert Naylor, Chief Ex- ecutive of University College London Hospitals – suggested that I capture, in a series of essays, my reflections on the countries I have worked in (but not clients because of confidentiality). This short book, written in a personal capacity, is the result and I am grateful for their encouragement. In between running a glob- al health practice, visiting countries and client engagements, I have scribbled notes and ideas on planes, trains and automobiles at crazy times of the day and night (the only benefit of jet lag) and turned them into a series of observations. As we all have busy jobs, each chapter can be read in the time it takes to drink a cup of coffee. This is not an academic treatise and has been written for practi- tioners that have an interest in policy, and policy-makers who want to support better practice. I also hope that patient groups and politicians dip in and out of this book, as well as students in global health. The 25 country chapters selected for this book cover 80 per cent of the world’s economic wealth, 60 per cent of its population and 50 per cent of its land mass. I have chosen these countries because they are both striking and familiar to me. The themes have been selected because of their global importance and the Copyrighted material_9781137496614 Preface xi extent they represent common concerns across health systems, countries and continents. As KPMG’s Global Chairman for Health, I prepare for each country I visit through detailed briefings which come in five parts: the political, social and economic context of the country; its healthcare policies and practices; the declared strat- egy of the system or organisation in question; the characters involved; and the possible solutions required. The job can be pulsating and the time zones punish- ing but the learning is unique. I have tried to be even-handed with the facts but these inevitably change as the world turns and health services move on. That said, the underlying foundations of most countries’ health systems are sturdy and do not shift quickly; it is highly unusual for a country to dramatically change its health status, health service, funding or strategic thrust.