The document summarizes key findings from the Euro Health Consumer Index 2015 report. It finds that treatment results continue improving across European countries. Wealthier countries perform better on the index, though some less wealthy nations achieve good value for their healthcare spending. The Netherlands again tops several subcategories due to its managed "chaos" system with choice, competition, and decentralized accountability. Ireland's performance could be improved by switching to performance-based financing and decentralizing responsibility from central administrators.

1. Future Health Summit
Dublin, May 27, 2016
Prof. Arne Björnberg, PhD
info@healthpowerhouse.com
Ireland In the
Euro Health Consumer Index 2015

2. The Big Problem
Almost all European public healthcare suffers
from the same endemic condition: “MD”
This is not to suggest that the basic problem is
Medical Doctors – “MD” stands for
“Management Deficiency”
If Mr. O’Leary of Ryanair, or Mr. Kamprad of IKEA, would learn in
detail how the typical European big hospital is being run, they
would probably need to be admitted acutely!

3. Comparing healthcare systems performance in 35 countries from a consumer/patient view.
Since 2004, more than 40 index editions, available for free.
Index projects financed through unconditional development grants, similar to medical faculty
sponsored research.
About
Health Consumer Powerhouse
Europe
Euro Health Consumer Index 2005, 2006, 2007, 2008, 2009, 2012, 2013, 2014, 2015
Euro Consumer Heart Index 2008, 2016
Euro Diabetes Care Index 2008, 2014
Euro HIV Index 2009
Euro Patient Empowerment Index 2009
Nordic COPD Index 2010
Tobacco Harm Prevention Index 2011
Euro Headache Index 2011
Euro Hepatitis Index 2012
Euro Vision Scorecard 2013
Euro Pancreatic Cancer Index 2014
Sweden, others
Health Consumer Index Sweden 2004, 2005, 2006
Diabetes Care Index Sweden 2006, 2007, 2008
Breast Cancer Index Sweden 2006
Vaccination Index Sweden 2007, 2008
Renal Care Index Sweden 2007, 2008
Smoke Cessation Index Sweden 2008
COPD Index Sweden 2009, Nordic 2010
Advanced Home Care Index Sweden 2010
Euro-Canada Health Consumer Index Canada 2008, 2009
Provincial Health Consumer Index Canada 2008, 2009, 2010
All Hospitals Index Sweden 2011

4. EHCI 2015
Important trends
Treatment results in European healthcare keep improving
essentially everywhere!
Wealthy countries do better in the EHCI – the “equity gap” more
obvious than in previous years
Closing slightly in 2015?
Savings on pharmaceuticals the most obvious effect of austerity
Some patterns remarkably stable over time – waiting lists a mental
condition?
Accessibility has no correlation with finances, mainly because operating a
healthcare system without waiting lists is inherently cheaper than having
them!
“Big Beveridge” have problems delivering!

6. Sub-discipline Weight (points out of
1000 for full score)
Doing well
Patient rights, information and e-
Health
150 Netherlands, Norway, FYR Macedonia,
Iceland
Waiting times / Access 225 Belgium, Switzerland, Czech Republic,
FYR Macedonia
Outcomes 250 Netherlands, Norway, Iceland,
Switzerland, Finland, Sweden
Range & Reach of services
provided
150 Netherlands, Sweden, Finland,
Denmark, Norway
Prevention 125 Norway, Finland, Germany, Iceland,
UK, FYR Macedonia
Pharmaceuticals deployment 100 Finland, Germany, Ireland, Netherlands
EHCI 2015 sub-disciplines
A total of 48 indicators in six sub-disciplines
And we have really tried to be inventive and make the Index more
challenging, but there is no stopping The Netherlands!

8. What can Europe learn from
The Netherlands?
”Chaos” systems, where patients can
choose where to seek care, do better than
”planned” systems;
but ”chaos” needs to be managed, and the NL
does that very well!
Choice and competition! (and remember that
this has to have a ”grandfather” function managing
the system!)

9. So what could be the improvement potential for
the European Champions?
The Netherlands tops 4 sub-disciplines; some potential
for improvement on Accessibility, but no country ever
did that before (except The NL in 2014)!

10. Macedonia no longer winning only because of limited finances! Estonia,
Czech Republic, Croatia Finland, Iceland and the NL(!) seem to give good
value for money in healthcare!

11. GP gatekeeping does not contain costs!

12. ”Structural Antiquity” Index for healthcare systems

13. Savings potential if Dutch healthcare would
approach the in/out-patient mix of Sweden
EUR 8 billion/year?
i.e.; the high Dutch costs are more due to
how healthcare is operated – not due to a
payment or administrative ”model”

14. Accessibility in EHCI 2015
Europe is divided into
”waiting list territory”
(Red) and ”non-waiting list
territory” (Green).
This is independent of
GDP/capita.
Has improved since 2013!

15. Accessibility not really related to number of
doctors!

16. Money does not necessarily buy better access to healthcare …
CHBE
CZMK
SE
IEUKPL
for the rather fundamental reason that it is cheaper to operate a
healthcare system without waiting lists!

17. If you spend enough time
looking at this graph, you
will discover that
particularly countries in
the top keep improving.
Inequity seemed to be
increasing in Europe
after the financial
crisis, but there are
signs of a slight
recovery in 2015.

18. Treatment results keep improving!
The large number of Green scores is because
cut-offs were kept from 2014, when several
countries were below the Green cut-off.

19. Treatment results keep improving!
In EHCI 2006, there were 9 Green scores,
using the same cut-offs

20. Money does buy better Treatment Results

21. And yes; wealthy countries have better Outcomes –
but not all!
Outcomes in EHCI 2015

22. Ireland in the EHCI 2015
685 points and 21st place
Doing rather well on medical treatment
results
Among the bottom four on Accessibility

23. CEE abortion rates on their way down.
The indicator does not reward high abortion rates!
Women should have the right to abortion,
but abortion as a contraceptive is not a good idea!

24. What could Ireland do to advance
in the EHCI?
Switch from what is basically block grant to performance-
based financing
Decentralize responsibility and accountability:
”We have indentified 4000 staff
redundancies, but the cost of dismissing
them is higher than the cost of keeping
them.”
What might be the real problem in that
quote was that the ”we” were not the
heads of clinic of Irish hospitals, but a
rather small group of centrally located
administrators.
In a communiqué from the HSE in connection
with the publication of the EHCI 2015, it was
stated that the HSE and MoH are working on
reducing the wait for a specialist appointment
to <18 months?
Misprint? Should be weeks? If not, even
reaching the target would mean the worst
accessibílity in Europe!

25. THANK YOU -
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26. MORE SLIDES

27. Sometimes money buys worse healthcare
Clinic dialysis is over-remunerated, and
home dialysis is under-remunerated?

28. Sometimes money buys even worse healthcare!
Are there other reasons for the low German transplant rate
than the profitability of clinic dialysis?

29. An example of a LAP Indicator; ”Level of Attention to the Problem”.
Wealthy countries can afford admitting patients on weaker indications,
but there are deviations!
Greek hospitals have press gangs
roaming city streets?

30. Greeks can somehow carry on spending on
drugs and hospital admissions
There is no evidence which supports that public health

31. Restrictivity with new drugs

32. The 2013 indicator on use of
antibiotics

33. The 2014 indicator on use of antibiotics
(WHO report) – who do we trust?

34. The 2015 indicator
on use of
antibiotics: ECDC
data.
Who do we trust?

35. New in EHCI 2015 report:
Regional variations within countries
The 4 countries of the United Kingdom
have separate NHS’s
The regions of Italy all report to the same
Ministry of Health

36. England and Scotland have
separate National Health Services!!!
Scotland has 10 % higher healthcare spend per capita
Could be fair; the public health situation is more
troublesome in Scotland
NE England, with similar public health situation, has
now also been given 10% more money!
The two systems are basically the same measured on a
scale intended for 36 European countries!
Scotland 710 – England 718 (2014)!
Scotland sadly not providing the open hospital results
data of NHS Choices
There is scant evidence for having separate sets of
administrators making a difference at all for anything!

37. England and Scotland are very close on
most measurements
The four countries of the UK might have separate NHS
administrations, but there still is one British Medical
Association!

38. Italy has the biggest economic difference between
regions of any one country:
Lombardy has 3 times the GDP/capita of Calabria
Much larger variation between regions than in the UK
Having, on paper, one healthcare system does not create
equity!
30-day case fatality rates of Acute Myocardial Infarction (AMI), broken down by LHA.
Similar patterns are seen in other indicators of the quality of acute hospital care.
Thirty-day mortality after a stroke varies from ~7% in Bolzano to almost 20% in
Molise.

39. ”Bismarck Beats Beveridge”
Bismarck systems dominate the top of EHCI ranking
Beveridge systems offer conflicts between loyalty to citizens and loyalty to
healthcare system/organisation (“politician home town job preservation”)
lack of business acumen in Beveridge systems; efficiency gains and cutbacks
frequently not differentiated!
small Beveridge systems (the Nordic countries) can compete
“Chaos” systems do better than centrally planned
100’s of thousands of professionals take better decisions and drive development
better than central bodies
incentives driving quality and productivity are essential!

40. ”The verdict of the people on the medical profession.
Swedes are less satisfied with attitudes and communication skills of
doctors, says international comparison. Norway and Sweden bottom of
11 countries compared.” (Dagens Medicin 2012-02-29)
The cherished notion that ”In Sweden, we provide holistic
medicine – in contrast to ’assembly line medicine’ down on the
Continent ” lacks evidence!.

41. Websites with comprehensive information about all
registered pharmaceuticals 2013 (OTC and Rx)
Austria: www.austriacodex.at/avmain/ http://pharmaweb.ages.at/index.jsf
Belgium: http://www.bcfi.be/, www.pharma.be
Croatia: http://www.almp.hr/?ln=hr&w=lijekovi
Czech Republic: www.zdravotnickenoviny.cz/scripts/modules/catalogue/search.php?catalogueID=2
Denmark: http://medicin.dk/
Estonia: www.raviminfo.ee
Finland: www.fimea.fi/lakemedel/produktresumeer/humpl
France: www.doctissimo.fr
Germany: www.onmeda.de
Greece: www.galinos.gr/web/drugs/main/lists
Hungary: www.ogyi.hu/drug_database/
Ireland: www.medicines.ie
Italy: www.prontuariofarmaci.com
Latvia: http://www.zva.gov.lv/index.php?id=375&sa=375&top=334
Lithuania: www.vaistai.lt
Malta: http://medicinesauthority.gov.mt/products/search.htm
Netherlands: www.cbg-meb.nl/CBG/en/human-medicines/geneesmiddeleninformatiebank/default.htm
Norway: www.legemiddelverket.no/custom/Preparatsok/prepSearch____80333.aspx?filterBy=CopyToConsumer
Portugal: www.infarmed.pt/infomed/inicio.php
Romania: www.anm.ro/en/html/pharmacopoeia.html
Slovakia: www.liekinfo.sk
Slovenia: www.zdravila.net
Sweden: www.fass.se
Switzerland: www.kompendium.ch
U.K.: http://emc.medicines.org.uk/

42. Why do we not see clearer traces
of the financial crisis?
Healthcare traditionally weak at
measuring output/outcomes.
“The good old days that never were”
Underlying improvement forces are
very strong!