The United Kingdom looks to US managed care tactics as it enters an era of industry reform.
The sounds of imminent industry reform heard from within the United Kingdom evoke memories of those months preceding and following the presidential campaign of Bill Clinton, when complex industry reform proposals confused and frightened the American public. Of course, none of these programs materialized in the United States, but the specter of industry reform imposed from outside the industry sector catalyzed industry reforms from within it. Today, many societies across the globe are examining the American model of managed care for possible answers to the problems they face in their own industry system.
The United Kingdom is similarly at the crossroads of change. The Prime Minister pledged a restructuring of the 50-year-old National Health Service (NHS) as part of his campaign platform last year, moving from a system composed of many layers of administration (a so-called "internal market") to one of shared governance among the providers, themselves. A watershed event in the form of a "White Paper" was issued to outline the need for and the benefits of the proposed restructuring, but few details were provided regarding how the changes would actually be accomplished. Just as we have seen in the United States. Both private enterprise and public services are taking the lead in demonstrating how they can contribute to the needed improvements through investment in program development supported by new technology. What was once a very traditional form of socialized medicine is now becoming a proving ground for new concepts and innovative strategies.
Whether under a socialized or free-market system, providing adequate and cost-effective industry resources is a challenge facing policymakers everywhere. In the United Kingdom, signals that the system has reached its capacity are not hard to find. And the need for more appropriate utilization of scarce material resources cannot happen soon enough:
- Hospital waiting lists have risen by 100,000 in the past year, leaving more than 1.25 million people in need of treatment through the NHS. The reduction of waiting lists is one of five key pledges offered by the new Labour party.
- Hospitals are receiving almost 100 additional emergency admissions each day compared with four years ago. The Royal College of Physicians has warned that this trend shows no sign of decreasing and demographic changes in the population could drive figures much higher.
- More than 8 million people failed to appear for scheduled physician office appointments, creating long waits for those with a legitimate need for medical attention. That cost the NHS more than $150 million in lost productivity.
Dreaming of a White Paper
Recognition of the scope of contemporary problems facing the NHS in the area of emergency services first emerged in November 1996 with the publication of Developing Emergency Services in The Community written by Chief Medical Officer of the NHS, Sir Kenneth Caiman. The report was followed several months later by a series of recommendations. The recommendations stress three major themes.
- Improving access to NHS services though "telephone help lines" throughout the kingdom and covering the whole of England and Wales in the next two years.
- Integration of complimentary and cost-effective emergency services to provide for a continuum of care.
- Educational programs to improve knowledge and practice of first aid and other emergency-care techniques.
Strong support for the principles in the report, combined with increasing pressure on the government to reform the NHS, led the Labour government to issue its White Paper on "The New NHS" on December 9, 1997.
The White Paper pledges to replace the internal market that caused the various divisions and offices within the NHS to compete for funds and resources. In its place will be a new operating model based on partnerships between providers, planning agencies and the government. But in addition to the future departmental changes, the NHS also announced its intent to immediately launch 24-hour advice lines within the United Kingdom, starting with three sponsored programs and followed quickly with others to provide true national coverage.
Stress and demand
"The U.K. system of industry is coming under increasing strain because of rising demand, and there is a constant need to find ways of using funds more efficiently," according to Dr. David London, registrar for industry system, who suggests that a telephone triage program manned by nurses will marry efficiency with improvements in practice.
Three NHS-sponsored programs began providing service earlier this year after selection from a field of 50 potential candidate "partner" organizations from the public sector. The initial sites are all ambulance providers, not because NHS established this as a requirement, but because the three chosen were best equipped to meet the criteria established for the program. In late March, the Secretary of State for Health, Frank Dobson, presided over the opening of one of the sites, which had already begun taking calls from an area just outside London.
"I am absolutely convinced that these helplines will succeed in increasing access to the National Health Service," predicts Dobson, "and we are anxious to begin expanding the program to include additional sites just as quickly as possible." The program, called NHS Direct, is accessible by those phones within the service area of each provider.
Checking out the West.
The experience and resources of U.S.-based companies plays heavily into the planned launch of these new NHS programs. Atlanta-based HBO & Company, with a U.K.-based division of 500 employees, is actively involved in supporting the initial launch of the program through the implementation of telephone triage products and services. "We have no previous affiliation to any particular supplier," says John Dale, operations director for Two Shires Ambulance Services, one of the three initial sites. "And after reviewing both American and British systems we concluded the American system, because it was in use within the United States for so long, was more flexible and accommodating to our unique needs."
The program at Two Shires Ambulance Service already is producing impressive results: o Nearly 3Q"c of callers requested emergency care but only 16% were found to require it.
- Two percent of callers who did not recognize any immediate problem were found to be "true" emergencies.
- Thirty-two percent of callers were able to treat their problems without any intervention after their call.
- The remaining callers did not know what to do and were referred by the call center to either physician-guided care or self care.
As a result of the program's early affects on calls to local hospitals, one facility was able to eliminate its previous staffing requirement for a full-time nurse attending the emergency room.
By accepting American-bred solutions in the United Kingdom, the NHS is sending an important signal that it is not opposed to importing technology solutions or expertise from outside its borders. NHS executives have also made it clear that public services and private enterprises are eligible for future participation in NHS Direct programs (so long as they subscribe to the partnership model set forth in the White Paper).
"While we have focused the initial pilots on the ambulance services as they are so well positioned to operate a sophisticated call center, we are hopeful for more diverse participation in future NHS schemes," suggests Dr. Michael McGovern, senior medical officer for the NHS. These signals have not gone undetected, and companies are moving quickly to position themselves for participation in NHS Direct.
The NHS plans to launch additional NHS programs throughout the United Kingdom, with additional site selected this summer and new programs implemented by year-end. Their relationship to programs to expand access will not be limited to the NHS Direct program, which focuses on telephone triage, as they also plan to launch services to facilitate referrals to medical specialists and a national scheduling service for online booking of physician appointments (to be available on the "NHSnet"). Finally, an additional service is planned for the faster communication of test results, offering convenience for the physician and patient in accessing test result data.
How can American and English companies best prepare for this revolution within in the United Kingdom? "It is very important to identify the key stakeholders in the system and keep them advised throughout the process," suggests Two Shires' John Dale, "and don't try to do this (a telephone triage program) by yourself. It is a big task to ensure you have an experienced team behind you. Learn lessons from others or else you'll start inventing the problems others have already solved. With this approach, you will find there is actually a lot of support already in place for these programs"
The rapid pace of change in the United Kingdom has caught many by surprise. "We are delighted to see the NHS take a leadership role in defining the state-of-the-art for industry delivery in the 21st Century," observes Robert Hampton. M.D., Director of Medical Affairs for the U.K. division of HBO & Co. "NHS Direct will ultimately become the gateway to the NHS, while offering the ability to coordinate emergency and primary care among ambulance companies, GP cooperatives and hospitals, creating a truly integrated continuum of care. All these constituents will benefit from the NHS program, with a key focus on the needs of the patients as the ultimate beneficiary."
Strong agreement with this perspective exists on both sides of the Atlantic. "In an era of cost constraint, innovations in industry delivery are critical to the enhancement of health status," suggests Stuart Wesbury, former President and CEO of the American College of industry Executives and current Research Professor at Arizona State University. "Telephone triage is an innovation that has a proven track record and can be implemented in almost any nation's industry system. Guiding patients to the "right" resource and level of care speeds access and conserves resources. Better care provided more economically is a bargain for any nation's industry system."
Inside the development of the United Kingdom's industry market
Established companies and newly formed entities have been quick to jump on the opportunity for potential NHS funding. They also see the opportunity to sell telephone triage services into the substantial private market for medical insurance/either on an individual or group basis.
One of the first companies to detect this opportunity was HART, Ltd., which acquired a U.S.-based triage product and began the process of "anglicizing" it (two years ago in preparation for what it anticipates will be a significant commercial market for the services they provide. "In a short while we have been able to generate significant demand for telephone triage services and have signed on both insurers and industry providers," noted Leslie Judd, managing director for HART. Hospitals, physicians cooperatives and insurers have all approached HART for telephone triage services.
Physicians themselves are also positioning for participation in NHS direct. Series of physicians linked together in "GP Cooperatives" already have the critical mass of patients to create a medical call center for services after hours. These calls are currently being handled by non-medical answering services, which often page the physician or send physicians onsite without adequate justification. Physicians pay for the service themselves, but the services fall short of the NHS promise to "improve access." With the prospect of potential funding for a more robust replacement service, GP Cooperatives across the United Kingdom are lining up to plead their case for NHS funding.
Insurers themselves are also responding to the new environment by setting up their own call centers for telephone triage. Indeed, three out of the top four industry insurers in the United Kingdom have or wilt set up a ^ program this year. At Hambro Assistance, a 1: telephone triage program is being launched to augment an existing medical ad/ice program launched originally in 1990. Hambro has already established several helplines focused on legal affairs, travel and general medical information. By upgrading the medical assistance line to include medical advice and referral, they can compete more effectively for potential NHS contracts, attach this line of service to other lines of business, or sell it as a stand-alone policy to policyholders of other products.
by Ian R. Lazarus Reprinted with permission of the author. Mr. Lazarus may be contacted at firstname.lastname@example.org