Is national public health care the answer to priority setting - PowerPoint PPT Presentation

Is national public health care the answer to priority setting challenges? Input from Norway Olav Valen Slåttebrekk, Deputy Director General The Norwegian Directorate of Health Photo: Johnér og Rebecca Ravneberg

The Norwegian Directorate of Health: • Provider of technical and legal advise to the Ministry • Implementing agency for health sector policies • Administrative agency for health sector laws and regulations 2

Norway Much like Sweden • • Somewhat different on the edge of Europe Small & rich • • Generous welfare state High health care spending • 25.10.17

Facing some new challenges • Reduced income from oil Reduced income from • investments • Ageing population Reduced work force • 25.10.17

The Norwegian Health Service Nationally • • Ministry of Health and Care Services • Directorate of Health • Regionally • 4 Regional Health Authorities 19 Health Trusts • Local level • 426 municipalities More information at: European Observatory on Health Systems and Policies, Norwegian report 2013

‘The richest country in the world should not need to prioritize in health care’ S aying no in health care: “This is so painful to talk about that it has been sup- pressed for a long time. Health But now we must be frank“ sector budget Health Director Bjørn-Inge Larsen 2010 25.10.17

Reality: What are the benefits forgone? ‘ important in assessing whether the Health health expected to be gained from its use exceeds the health expected to be sector forgone elsewhere as other NHS budget activities are displaced’ Claxton et al 2012 25.10.17

Available measures for priority setting • National guidelines • Legal measures • Data and documentation • Established criteria • Financing • Fora for decisions and discussions 25.10.17

Patient Rights Act (1999) Regulation on Priority Setting (2000-03) • Legal right to emergency care • Elective services – Referrals: Individually assessed within 10 days – Criteria for priority setting – If criteria are met • Legal right to receive health care within an individually assessed deadline | 9 25.10.17

Principles for priority setting • On the agenda since mid 80s Principles outlined in official report 1997 • • Revised criteria 2016 Limited to hospital sector • White paper in progress on primary care • 25.10.17

The 3 criteria • Health gains – Effectiveness of an intervention – More health gains is always better • Resources spent on the intervention – Less resource use is always better • Severity of the condition – The larger your total lifetime health loss, the higher your priority 25.10.17

Fora for decisions and discussions • The National System for The main components of the National System introduction of New Health Technologies in Specialized Healthcare • The National Priority Council (2007-2017) 25.10.17

Experiences Yes Nei Total 2014 8 6 18 2015 17 0 18 2016 10 13 31 The national system that assess new drugs and other interventions is valuable. We ensure the patients all over the country equal access, and we ensure that they get effective treatment. Larv Vorland, CEO Northern Health Authorities April 5th 2017

National clinical guidelines • Published by the Directorate of Health • Evidence based • Prevention • Diagnostic • Treatment • Rehab • Organization • Cost/effectiveness 25.10.17

Priority guidelines 15

The priority guidelines should be used Priority guidelines are installed on the digital platform in all • hospitals • Supporting digital learning program • Some of the hospitals/ regional health authority have made the program obligatory for specialists evaluating referrals to the hospital There has yet not been a comprehensive evaluation of the use • of the priority guidelines. 16

Financing as a measure for priority setting • As resource allocation mechanism between regional health autorities Cap on out of pocket payments • • Activity based financing 25.10.17

Available measures – Does it work? • Legal measures! • National guidelines! • Established criteria ? • Data and documentation? • Fora for decisions! and • Financing!? discussions? 25.10.17

Percentage of patient with legal right to specialized health care, each regional health authority 100 90 80 70 Helseregion Sør-Øst 60 Helseregion Vest 50 40 Helseregion Midt-Norge 30 Helseregion Nord 20 10 0 1.tertial 2008 – 1. tertial 2014 Kilde: NPR rapportgenerator 19

Differences gain attention in public Dagens medisin Dagbladet 18.10.2017 25.10.17

Differences among Norwegian Health Trusts in waiting time before the first visit 2012-17 100 93 92 92 90 90 88 86 90 83 80 79 80 74 72 71 75 75 74 72 66 66 66 66 70 64 66 64 59 58 63 57 57 55 60 59 63 56 61 55 55 55 54 49 54 53 51 51 50 50 55 49 54 48 53 47 46 47 40 46 43 37 37 41 39 37 30 35 34 33 33 33 31 30 29 28 27 20 24 22 21 10 0 2012 2013 2014 2015 2016 2017 2012 2013 2014 2015 2016 2017 2012 2013 2014 2015 2016 2017 2012 2013 2014 2015 2016 2017 Somatic care Mental health - adults Mental health - children and adolescents Substance abuse

Number of recipients of primary health care services at home or institutions 160 137 140 125 121 120 103 102 97 95 88 102 100 85 85 83 82 93 71 83 80 66 75 73 73 69 70 68 67 68 64 64 60 57 69 61 60 57 57 57 56 56 40 52 51 50 46 45 42 20 0 1-1999 innb 2000-4999 innb 5000-9999 innb 10000-19999 innb 20000-49999 innb 50000-99999 innb 100 000 innb + 1-1999 innb 2000-4999 innb 5000-9999 innb 10000-19999 innb 20000-49999 innb 50000-99999 innb 100 000 innb + Unadjusted Adjusted by needs

Challenges Priority by decibel • • Cancer • Mental health 25.10.17

Total spending on specialist health care Percent of change in fixed prices from 2006. 70 62 Somatic care 60 50 Percent of change from 2006 Mental health 40 37 30 Substance abuse 18 20 17 10 Ambulances and 10 patient transportation 0 Total expenditures -10 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

Priority by decibel • Challenges • Cancer • Mental health • Geography • Urban vs rural areas 25.10.17

Some reflections • Priority setting is a complex and controversial exercise Transparency is important and access to high quality data • National instruments are in place • • Extension to primary health care needed Open discussions among the clinicians and management about • variation is in itself very important • Money talks – also in health care – Beware of possible unintended effects of payment systems 25.10.17

What are the determinants of good health? • Most important outside health sector • Education • Employment • Participation in society Increase attention to children and youth health • • Increasing mental health issues among youths • Immigration health

Thank you! 25.10.17