Implementing Change in Health Systems: Market Reforms in the United Kingdom, Sweden, and the Netherlands

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Michael I. Harrison

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    Preface

    Do health systems become more efficient, less subject to cost escalation, and more responsive to patient needs when there is competition among insurers and providers and these organizations adopt modern business practices? During the 1990s in Europe and elsewhere, many policymakers and analysts enthusiastically cited the examples of the United States, the United Kingdom, Sweden, and the Netherlands as evidence that markets could deliver these benefits. I began my research in reaction to this wave of enthusiasm. I wanted to know what had actually happened in the nations that were so often mentioned as leaders in market reform. I also wanted to know whether other countries could reasonably follow the example of these prominent nations. I decided to concentrate on European leaders in market reform, since the United States differed from most advanced industrial nations in its level of health expenditure, its reliance on forprofit insurers and providers, and its lack of national health insurance. This book reports how I recast the deceptively simple questions that motivated my study, what I learned about market reforms, and how I came to understand the processes of policy implementation and health system change.

    I could not have carried out this research without the help and cooperation of many health researchers, managers, and practitioners. Chief among them were the people who gave generously of their time in interviews. Unfortunately, most must remain anonymous. I particularly appreciate the hospitality and assistance of the professional and administrative staff of the Swedish hospital that is called Brookside in this book. Listing the many other people who helped me in my work does not do justice to the full extent of their logistical support, sharing of valuable information, encouragement, collegiality, and international friendship. For help in Sweden I owe thanks to Lennart Kohler, Johan Calltorp, John Ovretveit, Rose Wesley-Lindahl and other members of the staff of the Nordic School of Public Health; Tobjorn Malm and the staff of the Western Stockholm Medical Services District; Sven-Eric Bergman, Leif Borgert, Per Olof Brogren, and Olle Saemond. For help in the Netherlands, thanks to Eirk Konen and the staff of the National Hospital Institute; Bert Hermans, Harm Lieverdink, Aad de Roo, and Rafael Smit. In the United Kingdom, thanks are due to Stephen Harrison, David Hunter and the staff of the Nuffield Institute for Health at the University of Leeds; Chris Ham and Jonathan Shapiro at the Health Services Management Centre of the University of Birmingham; John Appleby and Neil Goodwin.

    Other colleagues to whom I am grateful for help and encouragement on one or more phases of the project include Jeorg Althammer, Christa Altenstetter, Mats Brommels, Reinhard Busse, David Chinitz, Brad Kirkman-Liff, Denis Kodner, Donald Light, Anita Pfaff, Martin Pfaff, Bruce Rosen, Friedrich Wilhelm Schwartz, Mordechai Shani, Richard Saltman, Arie Shirom, and Andrew Twaddle. Special mention is due to the people who commented on draft chapters and earlier, related papers and reports: Sven-Eric Bergman, David Hunter, Stephen Harrison, Johan Calltorp, Erik Konnen, Hava Etzioni-Halevi, Harm Lieverdink, Nicholas Mays, Debra Stone, and Ilan Talmud.

    I wrote portions of this study during a stay as a Visiting Scholar at the Institute for Health Policy at Brandeis University. Thanks to Stanley Wallack, Stuart Altman, Christine Bishop, Grant Ritter, and other institute members for their cooperation and help. I also worked on the study while I was a Visiting Scholar at Georgetown University's Graduate Institute for Public Policy and its Institute for Health Care Research and Policy. Thanks to Judy Feder and the institute staff for their hospitality and support. Thanks also to Irene Fraser and the staff of the Center for Delivery, Organization, and Markets at the Agency for Healthcare Research and Quality for supporting my work on the final stages of manuscript preparation. I appreciate the help of the following people who provided research assistance on various stages of the project: Aviv Barhom, Jane Cohen, Joseph Elias, Tracy Hartman, Shirly Hering, Merav Kinan, Edna Mirziof, Ednah Smolin, and Ronit Yitshaki Hagai.

    The research was supported by grants from the Israel National Institute for Health Policy, the Schnitzer Fund of Bar-Ilan University, and the Medical Research and Development Fund for Health Services (Sheba Medical Center, Tel Ha Shomer, Israel), which provided a publication grant. Support for travel and sabbatical leave came from Bar-Ilan University. The book's contents do not represent the views of the funding organizations. Nor do they represent the views of the Agency for Healthcare Research and Policy in Washington, DC, where I am currently a Senior Research Scientist.

    I want to acknowledge the encouragement of my son Natan and my late father, Milton Harrison. My deepest debt is to my wife Jo-Ann, who saw me through a decade of research on Europe with the same combination of encouragement, guidance, and generous tolerance that she has offered ever since our days together in graduate school, when we first began to learn how to live and work together.

    Dedication

    In memory of my parents, Milton and Joan Harrison.

  • Appendix A: Abbreviations

    AWBZExceptional Medical Expenses Act (6–7)
    BMABritish Medical Association (2–3)
    CCCounty Council (4–5)
    CHICommission for Health Improvement
    DOHDepartment of Health (2–3)
    DRGdiagnosis related group (4–7)
    FCEfinished consultant episode (2–3)
    Federation of CCsFederation of Swedish County Councils (4–5)
    GDPgross domestic product (1–7)
    GPgeneral practitioner (2–7)
    GPFHgeneral practitioner fundholder (2–3)
    HAhealth authority (2–3)
    HMOhealth maintenance organization (1)
    Int./Ints.Interview/s (1–8)
    LOSlength of stay (1–8)
    LSVNational Association of Medical Specialists (7)
    NHSNational Health Service (1–3)
    OECDOrganization for Economic Cooperation and Development (1–8)
    PCGPrimary Care Group (3)
    PCTPrimary Care Trust
    PPPPurchasing Power Parity (1–8)
    SMASwedish Medical Association (4–5)
    WHOWorld Health Authority (1–8)

    The numbers in brackets refer to the chapters to which the abbreviation is relevant.

    Appendix B: Research Methods

    Interviews

    I conducted all the interviews face to face, except for three phone interviews. A small group of interviews took place in 1994, while most were conducted in 1996 and 1997. All interviews were held in English, except for one in Swedish, where a translator was used. The interviews usually took place in the respondent's office or in a meeting room and typically lasted from 45 minutes to an hour. Following conventional fieldwork procedures, I made notes during the interviews (usually totaling five or more pages), edited them subsequently, and then analyzed them.

    I used an interview guide tailored to the person's role and organizational affiliation. The questions focused on the nature of recent reforms, mandated changes in regulations and work arrangements, implementation within the organization where the person worked, developments at other levels about which he or she was knowledgeable, and effects of reforms on physicians and other health professionals. I also encouraged the people interviewed to raise other issues that they thought would help me understand recent developments.

    Except where paraphrased, statements from the interviews appear in the text of this book as recorded during the interview. Occasionally I have added or changed a word or two to render the statements more idiomatic. Any changes or additions that might affect the original meaning are enclosed in square brackets. I cite an anonymous interview as a source (e.g., ‘Int.’) when the interview provides the chief source of support for a statement in the text. The plural, ‘Ints.’ shows that two or more interviews support a statement.

    The interviews are not cited as sources on topics about which there was widespread knowledge and agreement (e.g., the contents of a government proposal for reform). Unattributed quotations are from interviews except for jargon and terms that were in wide usage, such as ‘value for money’ (UK) and ‘buy-sell system’ (Sweden). Such terms are only enclosed in quotations when first used. Where it is appropriate to refer to specific interviews or organizations, I provide fictitious names and initials. There are occasional bibliographic references to people who made ‘on the record’ statements as experts or spokespersons.

    Documentary materials included many unpublished materials and local press coverage, some of which were translated from the original language. These documents were suggested by people interviewed, by colleagues in each country, and located through library and web searches. In addition, I examined national statistical data on the country's health services, along with the data published by the OECD (2001, 2002).

    Validity

    Many opportunities arose for triangulation among interviews, documents, and statistics (Jick, 1979), which helped compensate for some of the limitations in the three types of data. In addition I was often able to check for consistency and plausibility through comparisons within data types and within individual sources of data (e.g., a single statistical report or a single interview).

    I checked the validity of my country analyses by soliciting comments from local experts on the chapters in my earlier monograph (Harrison, 1995a) and in this book. Collaboration with local scholars (Harrison and Calltorp, 2000; Harrison and Lieverdink, 2000) also contributed to the validity of my findings and interpretations. I also received helpful feedback and suggestions from many local scholars, all of whom are listed in the references, footnotes, or Preface.

    Appendix C: Health Expenditures, Resources, and Utilization, 19981

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