Building world-class health services in a global economic downturn

By Howard Lyons, International Healthcare Partner with PA Consulting Group

What is World Class Healthcare? It’s a term that was used a lot during the recent Arab Health Congress and Exhibition held in Dubai at the end of January. Despite the global economic downturn - described by the Deputy Governor of the Bank of England as possibly the largest financial crisis of its kind in human history – around 50,000 people from over 65 countries visited Arab Health to discover just how one of the fastest growing healthcare markets in the world (16% per annum) is seeking to achieve parity with the best healthcare in North America and Europe.

Over the past 25 years, certain Middle East countries have used their vast oil revenues to build superbly-equipped, state-of-the-art hospitals, install the latest information systems and staff their facilities with healthcare professionals from around the world. They have sought international recognition from leading Western accreditation commissions and formed alliances with major brand names in healthcare delivery. Well-known institutions like Cleveland Clinic, Johns Hopkins, Moorfields, Harvard and Imperial College have not only given their names to be associated with hospitals in the Gulf but they have also, in some cases, provided management teams and top clinicians to work full-time in the region

These are recognised short-cuts to world class healthcare but they are invariably expensive solutions and, in the current financial climate, may not be sustainable. World class healthcare is not something that can be achieved overnight like buying a world class Rolls Royce or a fleet of Boeing Dreamliners or building a seven star hotel like Burj Al Arab. 

Clinicians and Patients are the Best Judges of World Class Healthcare

So despite the pronouncements of rulers, governments and private providers, those who are best placed to judge whether healthcare services are world class are the clinicians who deliver services and the patients who are on the receiving end.

Clinicians in North America and Western Europe have clear criteria for determining the quality of healthcare provision in any institution. Having state-of-the-art technology and information systems is just one of those criteria and is perhaps the easiest to fulfil through substantial financial resources but other criteria take years of perseverance, rigour and application to achieve. These include:

• Proven track record in treating complex, rare conditions
• Excellence in health outcomes against key specialty indicators (eg cancer)
• High number of citations in peer-reviewed medical journals
• International reputations of named clinicians and their teams
• High profile in clinically-applied research and development
• Rapid application of effective new treatments in clinical settings
• High throughput of simple cases with large volume of operating hours

Very few, if any, hospitals in the Middle East fulfil all these criteria.

Then there is the patient perception which in these days of increasing consumer power may actually be more important, especially with the widespread availability of comparative data available on the internet. Indeed, in April 2009, the UK will become the first country in the world to collect, as a matter of routine, patient-reported outcome measures (PROMs) on clinical quality performance for hip, knee, hernia and varicose vein operations.

Patients will be able to judge not just on whether the hospital provides a clean, comfortable, safe environment but also how mobile they are three months after a hip operation, their mental state before and after treatment, their general well-being and so forth. Their anonymised responses will be published online and future patients can then decide on where they are most likely to get the best treatment outcomes.

Findings of Patient Survey on Quality of Healthcare in Dubai

PA Consulting recently conducted a survey of 500 patients who had sought treatment at a healthcare facility in Dubai in the past two years to find out what their views were on the quality of care they received. 73% of all respondents said they were satisfied or very satisfied with the overall quality of care they received. When a similar finding was published following a survey in London, patient groups and the media were up in arms at the low score and remedial action was taken forthwith. In Dubai, the reaction was a pleasant surprise that the score was so high so clearly there is a difference in perception and expectations in the Gulf compared with Europe.

In the PA survey, Westerners who attended mainly private hospitals were much more satisfied than nationals who mainly attended public hospitals. Westerners also cited highly-trained clinical staff as the most important requirement for ensuring superior quality of care whilst local nationals tended to rate the standard of equipment and physical facilities as more important.

Attaining World Class Standards will take a Generation in the Middle East

In future, all patients should increasingly be able to judge the quality of care based on agreed outcome measures which will inevitably reflect both the quality of the clinical staff and the level of equipment. But the goal of achieving patient outcomes in the Gulf to compare with the best in the world will require a generation and a massive investment of human and financial capital. Clinicians who have the best training, the best equipment and the best facilities who build a reputation for themselves and their institutions through rigorous peer review, dedicated research work, regular publications in the best-regarded medical journals will gradually and visibly start to produce the best outcomes. But it won't happen overnight.

So, in the meantime, and in the current financial climate, what can be done to improve the quality of care and move closer to the best international standards? Here are four suggestions based on PA's experience.

1. Better Use of Current Resources through Performance Improvement
Although the health sector is continuing to expand in the Middle East, financial pressures will require existing public and private sector providers to deliver more for less. This will need a sharper and more intensive focus on effective and efficient healthcare delivery. The health sector has learned many lessons from techniques applied in other sectors, notably manufacturing with the application of LEAN principles which is based on respect for people and society rather than headcount reductions. Through analysing current workflows and practices, identifying bottlenecks and better ways of organising services, clinical services can often be re-designed to deliver more effective care with fewer staff.

PA has demonstrated this for clients around the world helping to improve quality and safety (fewer medication errors, untoward incidents etc); delivery (better quality work is done more quickly); throughput (more patients diagnosed with same equipment and same staff); and accelerated momentum where clear procedures in a stable environment create the basis for continuous improvement.

For example, by undertaking high-level value-stream mapping exercises of patient pathways, clinicians and managers can quickly assess where time, effort and resources are wasted which can then be used to add new value. The end-to-end processes can be improved when obstacles are exposed and dealt with or when responsibilities are made clear through detailed standardised procedures.

Allied to process improvement is performance management which starts with an understanding and standardisation of patient pathways and the definition of key operational metrics to assess and drive performance. Once targets are agreed and defined, they can be used to measure the application of funds to improve services as well as monitor the success of service level agreements.

Performance Improvement and Management techniques can be powerful tools in improving quality towards international standards for individual public and private sector hospitals as well as for whole health systems.

2. Better Use of Future Resources through Effective Capacity Planning
The haphazard way in which new hospitals are being built throughout the Middle East can only lead to lower standards if patient needs are not closely matched to healthcare supply. A city like Dubai had just under 3000 beds in 2007 but is expected to have over 5,400 by 2010 if current building projects are completed. During this time, the population has seen rapid growth up to the end of 2008 but may now see some decline during the economic downturn. An oversupply of hospital beds inevitably leads to unnecessary in-patient admissions which is not only costly but dangerous to a patient's health. And with a preponderance of "Worried Well" in the local populations, inappropriate treatments will rise to the detriment of the reputation of clinicians and institutions.

PA's use of Capacity Planning in different parts of the world focuses first and foremost on Health Need, analysing the following critical components:

• Population and demographics
• Epidemiological rates and projections
• Unmet and latent demand
• Patterns of referral
• Resource throughput, utilisation and availability
• Scope of service levels and patient contracts
• Healthcare delivery system and incentives
• Technology developments
• Relationship between public and private sector

Whilst Health Need looks at the population's requirement for health services, the next stage involves looking at Health Demand and the activities which are required to meet this demand. From this analysis, options are developed to assess the Capacity Requirement to undertake these activities and comparison is made with the Actual Capacity to determine what additional capacity is required.

In undertaking this exercise in Ireland, PA discovered that despite the widespread perception that the country had insufficient beds to meet demand, the actual number of beds required was far less than the current provision if different but proven ways of delivering services could be adopted.

In Capacity Planning for the private sector, more emphasis is placed on researching the needs of a segment of the population and then developing services which health insurers will re-imburse or patients would be willing to pay from their own pockets.

Either way, the initial data analysis is critical to building a model which will enable various scenarios to be considered and flexible options developed. And usually the most important resource component is not the availability of facilities but the availability of appropriately-skilled and competent healthcare professionals. In the more prosperous Middle East countries, governments have become accustomed to making up for their Workforce Planning deficiencies by recruiting internationally for healthcare professionals on fixed-term contracts. In the less well-off countries, governments have to plan in great detail to ensure the right number of nurses, doctors and paramedics are available to meet the needs of the population only to find they are then recruited by neighbouring countries.

Nevertheless, detailed Workforce Planning is probably the most critical of all the factors which help a country to develop world class health services.

3. Better  Patient Care through Improved Clinical Leadership
Lord Darzi who undertook the review of London's health services following the survey mentioned earlier said "The quality of healthcare is best improved by empowering patients and empowering professionals." We have already seen how PROMs can empower patients. Empowering clinicians to play an effective role in delivering strategic responsibilities in the context of continuous service re-design and improvement is more of a challenge. PA has been involved in a three phase approach to developing clinical leadership programmes in the UK which can be applied in many different countries. This involves Diagnosis and Design; Delivery; followed by Sustain, Embed and Evaluate using the concept of 3 E's - Education, Exposure and Experience.

Results to date have led to a much deeper appreciation of the complimentary roles of managers and clinicians and closer collaboration in delivering better patient care.

4. Better Patient Care through Long-Term Public Private Partnerships
The availability of capital to fund major hospital building projects is likely to be scarce for the foreseeable future but during the last major recession in the early 1990s when capital was also scarce, the British Government came up with the idea of Public Private Partnerships whereby the private sector financed, built and maintained large public hospitals over 30 year terms whilst the government effectively paid a monthly rental for the use of the facility.

This idea has started to gain enormous interest in the Middle East and could be a means of locking in steady progress towards world class standards over a 25-30 year period. This would particularly apply to new hospitals where service agreements with leading institutions like Johns Hopkins could be secured from the outset to embed their renowned clinical practices in the way the hospital is designed and then operated.

Already, some Middle East governments are going down the path of corporatising their hospitals, bringing in external management companies and exposing them to market competition with other hospitals in both the public and private sector. Setting standards for the improvement of care over the duration of the management contract enables companies to plan their investment to meet the government's requirements in a progressive manner.

Conclusion

By taking specific initiatives, those responsible for healthcare provision in the Middle East can achieve world class services in less than a generation, despite the economic downturn. But it will require realism, perseverance and focus.

What has been achieved in healthcare in the Middle East in the past 25 years has been nothing short of remarkable. There is no reason not to think that, by 2030, the Gulf region will host some of the best healthcare services in the world.

Contact details:
John O'Neill, Marketing Manager, Healthcare
T: +44 1763 267133, E: john.o'neill@paconsulting.com