An ethical minefield

There are two thought-provoking articles published side by side in today’s Sunday Times.

The first entitled ‘IVF baby boom for half century mums’ reports that births to mothers over 50 years old have increased by 55% in the past year. These are mainly as a result of relaxed fertility clinics’ rules on treating older women and IVF treatments using eggs donated by younger women. The eggs are normally donated as part of an ‘egg sharing scheme’ allowing the younger donors to receive, in effect, discounted IVF treatment.

Older mothers have to pay privately for this treatment as IVF is not available on the NHS to those over 39 years old. There is growing pressure on the NHS to raise this treatment ceiling as women are fitter and have a longer life expectancy than previous generations. In theory, a ‘middle aged’ mother could expect at least thirty more years of reasonable health as their children grow into adulthood. One of the doctors who treat over fifties patients states that his decision whether or not to offer treatment is based on ‘the woman’s health, the age of the father, the financial security of the couple and whether there is an extended family to help care for the infant’. Fairly arbitrary measures it would seem - if the woman’s health is good, why the question about the extended family? Equally surprising is that a clinician feels suitably qualified to undertake a means test to predict his patients’ financial stability (especially after they have no doubt paid thousands of pounds for several cycles of treatment)?

The second article ‘Online now: five mornings after pill’ reports on the availability of a new pill that can be taken up to five days after unprotected sex and bought over the internet. Family campaigners claim that the pill is, in effect, ‘an abortion agent’ and that under-aged girls will use this inappropriately as a form of contraception.

The rather unreassuring response from the company who market this drug is that purchasers have to complete an online diagnosis form which is reviewed by a doctor. They go on to boast that their doctors are regulated by the General Medical Council. Hardly as USP as in the UK, you must be licensed by the GMC to practice! So the doctors review online forms that could be completed by anyone and on the basis of this form they send the drugs ‘guaranteed next day delivery’ (a rather unfortunate choice of words)

As I read both these articles I couldn’t help thinking with some sadness that maybe the young girls buying the ‘five morning after pill’ will become the desperate women having their last chance at motherhood through IVF in three decades’ time.

The NHS – the good the bad and the ugly

Although the recent government spending review has provided ‘protection’ with a budget set to increase annually by 0.4% over the next four years, the NHS is still tasked with £20 billion in efficiency savings.

The NHS therefore continues to operate under close scrutiny and this is my personal snapshot of how things are looking right now.

The Good

Over the past 18 months I have worked with several NHS clients on service improvement projects, mainly in stroke and cardiac care.  During that time I have been extremely impressed with the quality of clinical expertise demonstrated in the Hospital Trusts and the commitment and dedication of clinical and administrative teams in the community.

These people genuinely and deeply care about their patients and continually strive to provide the very best outcomes possible. Whatever your political persuasion, and whether you measure ‘targets’ or ‘outcomes’ – we must acknowledge that survival rates and quality of medical intervention of patients continues to improve. I could quote many examples of the ‘extra mile’ travelled by NHS staff on behalf of the people in their care and have been humbled by the hours, way over their contracted agreements that some staff work. But….

The Bad

With every organisation, but particularly in the public sector (in my opinion) – there are three types of passengers and the NHS is no exception. These passengers, often managerial or administrative, challenge the positive outcomes and efficient practices of an ideal world. There are those who demonstrate ‘The Peter Principle’  where an employee rises to their level of incompetence. There are those who are genuinely committed, but do not have the background, intellect or capability to do the job for which they are employed. And finally there are those who fly just under the radar while taking home a reasonable salary for minimum amount of effort and substandard results. I have just two words to say about this. Performance Management.

The Ugly

These really are tough times for those working within the NHS. I suspect and hope that clinical teams will be adequately funded although poor IT support will continue to create a huge burden for them. According to the Chartered Institute for Personnel Development, workers in the state sector take an average of 10 days sick each year, 3 days less than their private sector counterparts.

The Trades Union Council general Secretary, Brendan Barber said ‘Many public service sector jobs are stressful at the best of times but now, with everyone across the public sector fearful for their jobs and the extra pressure of having to do more for less, it’s hardly surprising that the health of many workers is under threat.’

So the NHS employees are now facing what their private counterparts have known all along – that a job isn’t necessarily for life. For some, they are working on the ostrich principle – let’s carry on as though nothing is happening. Maybe that is the best way. The other, and more worrying approach is the ‘status epilepticus method of management – also know as ‘rabbit in headlights’ mode – not helpful.

We need to get this consultation process finished as soon as possible – and get on with what we do best. Look after the patients entrusted to our care.

NHS Reform – Consultation overload?

How many of us have, when questioned by our children, answered – ‘because I say so’ ? I’m sure that most of us have fallen into that trap!

The theme running through the US Healthcare Reform Act is ‘because I say so’  or, as the Act puts it - ‘mandatory’ – so although the interpretation of many of the aspects of this complex document still need clarification – the intent is clear – the new regulations WILL be implemented.

In the UK, the NHS outcomes will defined in terms of cost savings and quality initiatives, but where the axe will fall and how the measures will be introduced are subject to a comprehensive consultation process.

The government White Paper outlining the changes stresses that it ‘puts people in the driving seat, putting them in charge of making decisions about their health and care’  Fine words. The coalition is hot on ‘people power’. But how does this become reality and should it?

Several consultation processes were launched soon after the publication of the White Paper. Two public consultations ‘An Information Revolution’ and ‘Greater choice and control’, have both just been launched setting out proposals for ‘what we think is needed and asks how people think we should approach this huge task so we can start making shared decision-making a reality. We are seeking the views of the general population, NHS and care professionals, patients, service users, their families and carers.’  These consultations close in January 2011. In the meantime, four other consultations have already closed:

• Transparency on outcomes - a framework for the NHS
• Liberating the NHS: Local democratic legitimacy in health
• Commissioning for patients
• Regulating healthcare providers

But what does all this actually mean? NHS administrative staff, patients, clinicians, voluntary and patient organisations will all have had their say. But how is this translated into actions? Who makes the final decisions? Should the patient voice be louder than that of a clinician who is expert in his chosen field? And how can one be objective with these sensitive and significant decisions that will shape not only patient care, but healthcare professionals’ futures too?

I have absolutely no idea – but I suspect that, like in the USA – it will be ‘because we say so’

NHS Update

When I started this blog a few weeks ago, I intended to comment on all aspects of healthcare in the US and UK, and so far I have avoided the £105 billion question – the National Health Service. So this week I shall concentrate my postings on a summary of my interpretation of what’s going on with the organisation that is cared for us in the UK from the ‘cradle to the grave’ since 1948.

The NHS was developed on the basis that good healthcare should be available to all, and it was based on three core principles:

·         That it meets the needs of everyone

·         That it be free at the point of delivery

·         That it be based on clinical need, not ability to pay

These principles still hold, but the way that healthcare is delivered and responsibilities and accountabilities are shifting.

In July 2010, the coalition government announced its vision for change for the NHS in a paper entitled: ‘Equity and Excellence – Liberating the NHS’. This paper instigates a period of significant change and represents one of the most far-reaching re-structuring since the NHS was founded. http://www.dh.gov.uk/en/Healthcare/LiberatingtheNHS/index.htm

The NHS is tasked with finding £20 billion in cost savings while maintaining quality and range of services. The focus will be on ‘outcomes’ rather than ‘targets’ and the Health Secretary promises improved survival rates and leaner administration. The document outlines the plans for the government to give general practitioners (GPs) more power and responsibility for holding budgets and commissioning healthcare with the aim of aligning services more closely to patients needs. The key points are:

·         £80 billion budget to commission community, hospital and mental health services will move to the hands of GPs. The NHS budget stands at £105 billion and 80% of this will be given to GP commissioners.

·         Spending will be controlled by GP consortia who will be accountable to patients for the services they commission. The deadline for full financial responsibility of GP consortia is 2013.

·         An independent NHS board will be set up to oversee the commissioning of services

·         Independent providers such as consultants and private organisations will be invited to provide services to the NHS if their services are of a ‘high quality and meet NHS requirements.’

·         All NHS Trusts will become Foundation Trusts by 2013, providing greater autonomy.

·         The private income cap will be removed from Foundation Trusts, giving them opportunities to expand the services they offer to patients.

·         Process targets will be abolished and payment will be ‘by results’.

·         Monitor, the foundation trust regulator, will be given new powers, to regulate prices, promote competition and ensure that all providers generate efficient and financially sustainable services.

·         Management costs in the NHS will be reduced by 45% over the next 4 years, ‘cutting £1 billion in bureaucracy per year’.

These proposals are being discussed through a public consultation process and the impact of this consultation period will be discussed in my next posting. I shall also discuss my view on the planned shift of power to the GPs.

It was very easy to question the clarity of the U.S. Healthcare Reform Act, but let us not forget that changes closer to home are causing just as much anxiety and confusion.

UK Health Insurance Awards – London

I attended the 2010 Health Insurance Awards Dinner in London last night. You could be excused for imagining that 800 intermediaries, financial advisers and health insurance executives in one place would have the makings of a dull evening, but actually this glamorous black tie event is always a great party. It is one of the few nights of the year when I get to bed about the same time as the sun is coming up and I’m pleased to say that last night (or this morning) was no exception!

I was privileged to be on the judging panel this year and it is an honour that each of us took very seriously. We read through all the short listed entries prior to spending a day locked together in earnest discussions before choosing winners for 15 intermediary awards. Just for the record – this was an entirely democratic process, and each winner was selected by consensus based on the merit of their submission and the quality of their case study. The link below lists the winners.

http://www.hi-mag.com/healthinsurance/resource.do?id=his:winners

There was one intermediary organisation that won four awards and were highly commended for three others. Why? Because they produced well written, interesting entries which demonstrated that a) they had read the rules for submission (standard practice you would think, but some entries did not meet the criteria) b) they really listened to their clients’ requirements, analysed the issues and provided workable and cost effective solutions and c) they cared about the outcome!

Pretty basic advice for anyone planning to win awards, win new clients and keep the clients they already have.

One more point that I found very encouraging about the evening. Despite the doom and gloom surrounding the Government spending review plans announced two days ago – there was a very upbeat mood in the room. This may have been directly related to the size of the bar bills, but the fact that providers sponsored tables and can afford to pay those bar bills suggests that the health insurance and group protection industry will continue to be a significant economic force in this country, working alongside the NHS for the good of individuals and businesses alike.

Health Care Reform Webinar Details

I have had a few requests regarding the very informative webinar that I covered in a recent blog

A recording of this event is available on the Seyfarth Shaw Website

Using this link, scroll down to "Events," you'll see a link for an audio playback of "Health Care Reform:  Six Months Later." 

http://www.seyfarth.com/index.cfm/fuseaction/quick_link.quick_link_detail/object_id/4ead3b7d-3ca7-4efe-8e65-d20e3bc353c3

Drug addiction and hope

There was a news story in the UK yesterday http://www.bbc.co.uk/news/uk-england-london-11545519 regarding a 38 year old drug addict who has been paid £200 by an American Charity, Project Prevention, to undergo a vasectomy. The motive behind this move is ‘to prevent babies being physically and mentally damaged by drugs during pregnancy’

This has created quite a storm. Drugscope, a leading UK charity states ‘Project Prevention is exploitative, ethically dubious and morally questionable’. Speaking on the BBC, Harry Shapiro from Drugscope advised that ‘there are many routes into addiction and many routes out’ He went on to comment that one of the routes to a healthier life away from drugs was through stable relationships and the responsibility and joy that children can bring.

This got me thinking about hope. Is Project Prevention taking hope away from the addicts that they seek to sterilise? Are they endorsing these vulnerable people’s fears that they may never recover and lead a ‘normal’ life? Would this then become a self-fulfilling prophecy?

Worldwide, we have been captivated by the inspirational story of the Chilean miners’ rescue. It is no coincidence that the hub of the rescue mission was called Campamento Esperanza – Camp Hope. Where would these miners be now without the hope that kept the rescuers searching? And what about the hope of survival that kept these entombed souls positive and alive?

To quote Shakespeare – ‘The miserable have no other medicine but only hope’

Hope is often our strongest weapon in times of difficulty and stress. And hope is one of medicine’s most powerful tools. So let’s not write people off before their time. If a diagnosis is terminal, it doesn’t mean you are going to die tomorrow. If you are a drug addict today it doesn’t mean you can’t be on the path to recovery next week.

USA Healthcare Reform – time to bring on the lawyers

I recently participated in an excellent webinar presented by the Chicago office of Seyfarth Shaw LLP, a firm of attorneys.

It was my first webinar and although most of the participants were in their offices, around lunchtime - in London it was 6 pm so I could enjoy the experience in the comfort of my study with a lovely glass of Sauvignon Blanc.

The Healthcare Reform initiatives in the US continue to fascinate me and this six month update, presented by a specialist legal team was both informative and vexing. The first speaker, Leon Sequeira spoke with the gravity of a kindly physician breaking some serious news to his patient – ‘Do not base your business plan in the belief or hope that a particular part of the act will be repealed’.

Employers are racing to their legal counsel to see if they really do have to comply with the list of mandatory healthcare provisions outlined in the Act. As I mentioned in a previous blog – this is shaping up to be a crippling financial burden for many employers with more that fifty full time equivalent staff.

I suspect that in the UK, compensation and benefits directors tend to only need legal advice for pension disputes, and one off issues. But in the US, a lawyer may be their new best friend. Crossing the minefield of this 2000 page piece of legislation is a treacherous and expensive journey, when you consider that failure to comply could result in a $100 per day per employee fine!

There are several lawsuits pending in various states, questioning the legality of the mandatory elements of this Act. In a nutshell the question being asked is ‘Can congress force an employer to buy something like health insurance?’

The webinar lasted for 90 minutes but the time flew. There is still a great deal of clarification required, although in some areas the Act is highly specific. One example is the form that notice requirements must be issued – I have to congratulate another speaker, Ben Conley, for managing to say ‘culturally and linguistically appropriate’ five times without a stutter!

So the controversy rumbles on – and as employers attempt to unravel the true financial impact on their organisations, legal firms may emerge as the main winners of this particular adventure.

Claire Rayner 1931 - 2010

I was saddened to hear of Claire Rayner’s death yesterday. She was a talented broadcaster, journalist, author, ‘agony aunt’ and patients’ campaigner.

Many years ago, I was privileged to share a platform with Claire, when we were both speakers at a healthcare event. I was very young and quite nervous and this effervescent, warm and formidable woman was very kind to me and generous in her praise.

‘Passionate’ is an over used adjective but Claire truly was passionate about patients rights and ensuring that everyone had access to vital information on health and wellbeing. She happily broke through taboos in the 80’s, speaking and writing frankly on sexual, emotional and physical matters never before discussed openly in the popular media. As her husband Des stated yesterday, ‘Right up until her death she was being consulted by both politicians and the medical profession about the best way to provide the health services the nation deserved and nothing mattered more to her than that’

Apparently Claire left a message for the PM in a statement to be issued after her death:

‘Tell David Cameron that if he screws up my beloved NHS I’ll come back and bloody haunt him’

I can imagine that despite failing health, Claire would have still managed a wry smile with that comment.

And I have no doubt that she meant every word…

Employee Benefits Exhibition – London

Back in the 80’s I worked for an American healthcare company who paid fantastic wages (golden handcuffs), but provided few benefits apart from Private Medical Insurance. At a staff forum, the finance director was asked what he considered should be offered as staff benefits. He smiled wryly and said ‘continued employment’.

How times have changed. A couple of weeks ago I attended the ‘Employee Benefits Live’ – a showcase for benefits and rewards professionals across the UK. In its 12^th year, there were more exhibitors than ever.

In these tough economic times, you could be excused for expecting employee benefits to be curtailed. But as the variety of providers represented demonstrates – benefits are here to stay.

The first thing that struck me as I wondered round the exhibition stands, was how the same benefits continue to be popular – health insurance, screening,  pensions, wellness, group risk solutions. Several global intermediary organisations were there and, perhaps a little naughtily, I asked a fresh faced young man on one of the stands what he could do for my company in terms of health and wellbeing advice. He thought that I was a reward director and launched into a passionate description of everything that could be done to keep my staff well and motivated, along with reducing claims costs and sickness absence. It was exactly the same speech that I used to give my clients when this young man was still in short trousers! This doesn’t mean his advice is wrong – but that so much has stayed the same in wellness over the past 20 years.

There has been progress in other directions. Flexible benefits offerings are on the up and, along with voluntary benefits and incentive schemes, are beginning to capture the imagination of reward specialists.  Will writing, cinema tickets and even a wildlife park (the baby meercats were adorable) were on show and can give employees everything from peace of mind to some fun.

But two exhibitors particularly impressed me. Global Corporate Challenge is a ‘unique, fun and incredibly effective way of getting employees more active’. Essentially, a company signs up for a challenge and using simple pedometers and fresh in-house marketing and PR, individuals get fitter while helping their team towards the ‘global challenge’. This is a great way to include the less fit and engenders a healthy team spirit. http://www.gettheworldmoving.com/

Another ‘benefit’ that caught my eye was Workplace Giving UK. Their exhibition stand looked like a cross between Wizard of Oz and Desperate Housewives – all primary colours, wicker fence and gingham aprons. For exhibition attendees only, each company that signed up for the ‘give as you earn’ scheme were given an additional £5 donation voucher for each member of staff who joins the scheme. (http://www.workplacegiving-uk.co.uk/)

Maybe when it comes to employee benefits – giving is the new receiving…

Who should be responsible for employee healthcare?

The new Healthcare Reform Act in the US places some of the burden squarely on the shoulders of the employer. In the UK, we have the NHS to take care of our daily healthcare needs. The employer collects National Insurance Contributions from staff on behalf of the government and this in turn funds our state healthcare system.

Private Medical Insurance (PMI) can provide the additional benefits of greater patient choice, speedier and often more convenient appointment and surgery times, and often a more comfortable hospital environment.

One point significantly different from the US, is that UK PMI schemes tend not to cover maternity and chronic conditions such as diabetes which can be managed by the NHS.

In the early 1980’s company funded PMI was viewed as a perk for higher management. In our more egalitarian period of the 90’s these benefits were offered to the wider employed population, although still mainly ‘white collar workers’, and currently a healthcare trust for a major corporate can cost upwards of £20 million ($30m) annually. Companies have talked about dropping this expensive benefit but it is seen as a ‘must have’ for senior employees and would be very difficult to remove despite rising premiums year on year.

There are currently 4.1 million PMI policies held in the UK and just over 3 million of these policies are company funded for employees, (only 5% of the UK population) often with no personal contribution required. Do these schemes keep people healthy or are they just a recruitment tool? In a large corporate funded health scheme it is not unusual for only half the members to claim each year (and it is often the dependants and not the policy holder who claim)

And what about health and wellbeing solutions too? Does company funded healthcare keep staff healthy? How do you measure ROI on health screening and wellbeing programmes? Should an employer bear the cost of keeping their staff healthy? Or are the key benefits the ‘feel good factor’ – that an individual believes that their employer cares for their wellbeing? Should an employer incentivise an overweight employee to lose weight and maybe directly reduce their healthcare costs?

Comments please….

Healthcare Reform Conference in LA

After an uninspiring first day at the Corporate Wellness Conference I jumped ship and attended the Healthcare Reform Conference instead. What a revelation! Professional, knowledgeable and eloquent speakers talked about the subject that appears to fill every employer in the US with dread.

I was stunned at the depth of feeling and concern that the Patient Protection and Affordable Care Act (PPACA) will create a huge economic burden on employers. I won’t go into detail on the Act here – not least because it runs to 2000 pages and there appears to be very few people who truly understand it. Michael Bertaut of Blue Cross Shield of Louisiana ran an excellent workshop at the conference. He has spent a year researching this subject and believes that there are still many aspects of this document that need clarification.

In the UK the impression (and I accept that this is a vast generalisation) is that President Obama has created a healthcare reform that will provide healthcare cover to an additional 32 million people. What we didn’t understand is that a large proportion of this cost is to be borne by employers. The majority of speakers and delegates voiced the opinion that this was a poorly thought out piece of legislation that will have consequences far beyond the original brief. ‘This is a mess’, ‘We have to undo it before it inflicts permanent economic damage’ and ‘This could bankrupt America’ were all comments that I recorded verbatim in my notes. Strong stuff.

I was interested to note that there were many delegates from major corporations, attending the conference to try to understand the implications for their organisations leading up to full implementation of the Act in 2014. As one said to me – ‘how can we accurately complete our financial modelling for the next 5 years if we can’t be clear on the costs related to these reforms?’

This Act and the repercussions for business absolutely enthrals me and I shall no doubt return to it many times over the coming months. I shall also attempt to summarise the NHS reforms in the UK and the challenges facing UK Health Insurers.

On a personal note - I had a great time in LA and met some fascinating people. I realised that I already know a lot about Corporate Wellness but that I have a great deal to learn about PPACA. And I note that I am in very good company on both counts!

The Corporate Wellness Conference in LA - view from a British Commentator

I attended the 2^nd Corporate Wellness Conference in LA last week and I have to say

that it didn’t start well as the organisation of the event left much to be desired. One of the attractions of this conference was that three other related events were run concurrently. The downside of this was that we all felt a bit like it was our first day at junior school. Lots of different rooms and strange people milling about with none of us really knowing where we were supposed to be.

The welcome speech for the Corporate Wellness Conference was so downbeat that you could be excused for thinking you had stumbled into a wake. The keynote speaker couldn’t attend so the ‘highlight’ of the day was presented by a stand-in who simply read from a script and was unable to answer questions. Three other speakers followed – all describing in painful detail their corporate wellness programmes. Two of these speakers were last minute replacements (note to organisers – if you don’t pay your speakers or at very least fund their visit – they tend not to turn up…) . By the end of the first day and several more self indulgent trips down corporate wellness lane I was beginning to lose the will to live.

I would like to comment that two of the speakers did impress me though. Blanche Eden-Gnann from Bradley/Dixie Companies was refreshingly honest about the huge challenges in motivating an unhealthy workforce and Jackie Jones from ConocoPhillips spoke endearingly about how to create a wellness programme ‘with no money’. I loved the idea of voluntary health ambassadors for each worksite and will encourage my clients to consider this option.

My second day at the conference was much more interesting – check out my next blog…