Don’t imagine that a new model of healthcare will solve most problems of the population

Sir Malcolm Grant, Chairman of National Health Service (NHS), UK was in India in early February, leading a Healthcare Innovation Trade Mission, Createch 2018, to the country. He tells that India’s aspiration to move towards a model of universal health coverage (UHC), is the right one but cautions that it is the provider who wins the trust, expanding on the drawbacks of insurance-based UHC systems. Edited excerpts from the interaction

You started your address at the Healthcare Innovation Trade Mission to India by refuting US President Donald Trump’s tweet that the ‘NHS was broken and not working.’ India is taking baby steps towards its own brand of universal health coverage (UHC), through the National Health Protection Scheme announced in the Union Budget 2018. What are your comments on the amount of allocation, these measures?

For me, UHC is the ultimate desire and should be of any civilised nation. But we have to appreciate that the healthcare system of any nation is a product of its culture and history. In America, it is not a model of UHC but the federal government intervenes throughout the process to ensure that the provision of healthcare is regulated and gets extended. So, Obamacare is built on a model of insurance. Insurance models, sometimes called the Bismarck model, after Otto von Bismarck, is probably the more common model around the world, certainly in France, Germany and much of the rest of Europe.

The UK model, which is a very specific one, is almost entirely borne out of taxes. If you take the economic theory, we pool the risk across the whole population. We take from those who can afford, not from those who can’t because that’s the nature of a graduated tax system.

But it’s important to remember that not every nation can get to that. It was possible in the UK as a result of the social resettlement after the second World War which saw an enormous amount of government intervention in the economy. Which would have had to be the case through the war, so people saw this as a continuation, the redistribution of wealth and investment in the social fabric of the country. I would say that a huge advantage of a model of UHC under the British model is that nobody has to pay. People pay relatively small amounts on prescriptions, and for optical treatment and dentistry. But nobody is bankrupted by medical bills. I feel that that is effectively a very strong moral statement.

There is a small market of health insurance, it is probably less than 10 per cent of the population but many of those who have health insurance for many conditions would rather go to an NHS hospital rather than into a private one. Because the private one does not have the array of technology that a modern government NHS hospital would have.

That’s why I was very strongly resistant to President Trump’s characterisation of UHC system  being broken. It is just nonsense. He’s got a system in which there isn’t healthcare for some 22 million people in the US. I feel that his comments were ill informed and just wrong.

So, when we come to India, again, I think the aspiration to move towards a model of UHC is the right one. There are many variants within it so you could have a model of UHC which has a insurance basis to it which could probably be France or Germany. Or you could have a model which is a mixed economy in which some people fall onto to the states for healthcare and others opt for  private provision. Or you could have a model in which the state stands back and is not the sole payor but is the regulator of the system to ensure that through regulation of private, charitable and government operators you get uniformity of cover. That is more the German model where hospitals are one third private, one third state and one third charitable. So, it is a more mixed economy.

The UK is probably towards one extreme in which we the NHS are both the single payer and the single provider. It is a much more complex ecosystem than that suggests. The advantage is that it reduces overheads. If you insert an insurance model then there are quite a lot of costs in setting policies, taking premiums, paying or resisting claims. And also of course, in an insurance model, having to tell the patient that their cover is not sufficient for this particular condition. Or, there is a pre-existing condition which they are not willing to offer cover for. That I think again provides a quite discriminatory model of healthcare as opposed to a universal one where rich or poor get the same treatment.

So, from the Honourable Finance Minister’s statement. First, I would put great emphasis on the intent to move towards universal model of healthcare. Secondly, it will take a long time. Thirdly, it mustn’t be simply investment in shiny new hospitals. It has to continue to increase the investment into primary care and to the prevention of ill health, particularly into rural areas, bringing down infant mortality rates, etc to bring primary care into the most remote areas using new technologies, all of which are at the forefront of the government’s mind. We now know that with smart phones, we can do a great deal for healthcare that previously required a physical visit from a trained professional to the patient.

How can we apply the learnings from other countries in terms of health systems that the Indian government is trying to set up? Any particular country or model that you would suggest? Sri Lanka and Thailand are commonly cited examples. What are your views?

I think these are very good examples. But you can look universally. If you go to the Commonwealth, then that gives you 11 models of healthcare. You have to ask, what are you judging it by? And if you judge it by outcomes and the health of the population then you have to realise that the uniformity on healthcare has a relatively small part to play in that. It has to do with the genes, environment, where people were born, live, work, etc. So to promote the health of a nation requires quite different actions such as enhanced sanitation, clean water, clean air, clean dwellings, and those are the major determinants of health for a big section of the population.

So, we shouldn’t start by imagining that a new model of healthcare will solve most of the problems of the population. What it can do is give hope to those who suffer from a disease, and who are otherwise denied the right to means to have their proper treatment, I think we could look at any of the models around the world.

The critical thing is how is risk shared. Is it shared with the whole or a part of the population? So in the American model of insurance scheme for example, would cover just those people who work for a company or maybe their families as well. The effect of that is that when you move to another employer, you lose your benefits. You might move to another employer whose health scheme doesn’t cover pre-existing conditions. That is what I would warn those designing the Indian system of, if it is to be an insurance model. And I think as things are starting to go in India, I think that’s the likelihood. Then I think you need to move to an insurance to cover most of what is currently taken as out-of-pocket, which is around 68 per cent. Which is, going back to my original point, a huge burden on families. So there are 180 different health systems in the world, with a wealth of models.

What is the impact of Brexit on the NHS in terms of funding, etc?

At the moment, it is difficult to say because we currently have no idea of where Brexit is going to land. There are two extremes. Britain ends up in a very close relationship with the rest of the EU, which is possible at the moment through a single market. You might call that the  Norwegian, or actually Switzerland option. Or it comes out completely and starts out on its own. The consequences of that are quite different. The way in which it affects the NHS is first of all in terms of adequate funding. There was a great promise made at the time of Brexit that the UK government was sending off  350 million pounds a week to the EU, why wasn’t that being invested back into the NHS? That was the rhetoric. That actually creates quite a great expectation. People went in for it (Brexit) because of that. And so we would anticipate that, and a number of senior politicians are agreed, that the Brexit bonus must be to the NHS. So, that I think is important.  These are political promises, we wait to see its realisation.

I think the second issue is around employment. We have a number of staff who are from other EU countries and there is quite a lot of concern being expressed at the moment as to whether we will lose these staff. There have been people who have left the NHS, a falling away in the number of nurses seeking to be registered with the NHS. So, there is speculation on whether this just a short term blip, or will confidence return, as I suspect it will. This has been reinforced by statements made by the Prime Minister last week that the country is open still for people to come, work and live in the UK.

The third element is the cost of drugs and equipment. For us, as far as cost is concerned, one of the by products of Brexit was the deterioration in the value of the pound. So, we are already bearing surplus costs, as much of our medical equipment and drugs are brought in from abroad. How that will be absorbed, remains a matter of uncertainty.

Regulation likewise, the European Medicines Regulation Agency (Medicines and Healthcare products Regulatory Agency, MHRA), will move from London to Amsterdam. The question is, can the UK remain effectively a full member? Which is obviously desirable because then we have a single certification across Europe and we do not have to push pharma companies into different forms of accreditations. We and the government are all very sympathetic to the UK remaining in the EMEA (European Medicines Evaluation Agency) because for up to now, it has been the UK scientists who has been effectively running the EMEA.

What is the rationale behind the partnerships that the healthcare delegation seeks to cement during Createch 2018? And what are the next five years going to be like for the NHS, given the fact that you’ve completed 70 years?

70 years! Seems just like yesterday! But it is a serious point. It may be 70 years but its not been a static 70 years. It has been 70 years of innovation, change, development, churning through different institutions, different structures, different technologies. It is a very complex ecosystem. The partnerships that we hope to promote (during Createch 2018) are along the following lines. We’ve brought 14 institutions, three of them really good NHS Trusts. And, they were all chosen on the basis of their innovations. What are they doing that could help transform healthcare? Secondly, what could they do that could benefit them from coming to India, in terms of learning from India but also bringing products and ideas to India. Sometimes it is easier to get a product under development in the UK and manufacture here. What strikes me is that a number of them are so well suited to what is required in India.

They are here talking to a number of investors, CEOs of healthcare companies to try to marry up an interest on the British side with an interest on the Indian side.

You also talked about doctors and nurses from the NHS leaving possibly due to Brexit. The NHS has always had a very high percentage of healthcare professionals from India as well as other countries. Are they contributing to the development of healthcare manpower in India, as we have a dearth of doctors and nurses, both in terms of the capability as well as the numbers? How is the NHS collaborating either with the government or private institutions, on this aspect, given its strengths in education, training and research?

Historically, the NHS has employed quite a lot of Indian physicians. We think we’ve got around 50000 physicians of Indian origin working in the NHS. Not all of them were born in India, many were born in the UK but they are very proud of their Indian origins. Secondly, I’ve been surprised, since I’ve been here, of the number of people who have done their training in the NHS and are now physicians working in India. So, there has always been almost a pilgrimage to come and work in the NHS. If you are a good physician, the NHS can give you some really good specialist training which is in high demand back in India. As for nurses, again, there are quite a few nurses from India in the NHS. We also recruit quite heavily from the Philippines and else where. I think that will continue but I think there is a very strong moral case for recruiting professionals from a lower income country and then keeping them there. The visa system will continue to ensure that nurses can continue to come work in the UK but will then return to India. So, I think we need to do that in order to maintain supply here.

The NHS has played a very pivotal role in keeping down the prices of medicines. Pharmaceutical companies don’t like the NHS for doing that. And the Indian government is also taking steps towards this goal, with their decisions to cap the prices of medicines, including more medicines in the national list of essential medicines and also capping the prices of medical devices like heart stents. Is there any advising the NHS does for India’s Ministry of Health & Family Welfare, on a government to government basis. Are you looking at any collaborations within the government?

Yes I think so. I had a meeting yesterday with the Additional Secretary, Ministry of Health & Family Welfare. We talked about an array of things but the critical thing is that NICE (National Institute for Health and Care Excellence) in the UK is a phenomenon. To have been able to set up an organisation which will give price regulation on the basis of cost effectiveness is quite extraordinary. A number of the pharma companies don’t like that but actually most of them understand the rationale for it and are quite keen to have their drug accepted onto the NHS.

So, what often happens is that if they are not regarded as cost effective, then they reduce the cost, There have been a number of instances where we have been able to complete an agreement with a drug company under completely confidential arrangements. We don’t disclose the cost but we are able to bring benefit to NHS compared to what patients pay in unregulated markets. Particularly when its cancer medicines, which are very expensive and there are always claims that patients need a particular drug. We’ve turned the former cancer drugs fund into an experimental medicines fund, allowed medicines to come into it and have a trial for a couple of years whilst we measure its effectiveness in the clinic before we take a decision whether to include it or not into our formulary.

I think the NICE model is one that many countries have wanted to emulate. India would be in an ideal position to emulate it but I don’t know whether there is such a mechanism in place.

Trust is very important, especially in the healthcare sector because the patient is in a very vulnerable state. Whether it is trust in the pill that you take or in the hospital that you go to, or in the system itself. The NHS is a very trusted healthcare brand. Other systems in the world, be it Obamacare, Trumpcare have not been trusted as much. And now as we start to put Modicare into place, it is going to take a long time to trust the system. What have been the key facets to build up trust? A couple of years back, the argument against the NHS was there was a long queue to get an appointment. Many countries built their medical tourism around the fact that people could not get an appointment at an NHS facility.

First on the long queues. Certainly, 10 years ago that was a huge problem. People were waiting 18 months for elective surgery. Today, it is 18 weeks. We are mandated to start elective surgery within 18 weeks of the patient’s first appointment.

How did you move from 18 months to 18 weeks?

Several billion pounds! This was during Tony Blair’s premiership and he was challenged on TV on the UK’s healthcare versus the rest of the EU and he said, I’ll fix that. So, we in the NHS were told, (this was before my time), here is the additional money, this is what you’ve got to do with it. So 85 per cent of our patients will have their elective care within 18 weeks and that globally is a really impressive figure. It’s much faster for cancer, and depending on the type of cancer it could be as little as two weeks. In the emergency room, we are the only country in the world which says you have to have a 95 per cent standard, not just of seeing patients, but treating and discharging them or admitting them in four hours. That is really amazing. Canada has six hours, other countries have eight hours. A lot of the government funding came on condition that we met those targets. The NHS does what it does and gets trust for being able to perform on this basis of being a very safe system.

I would draw a distinction between Modicare and Obamacare on the one hand and the NHS on the other. The former are sort of funding streams, they are not provider streams. NHS is the provider. It is the provider who wins the trust. Nobody cares about the Obamacare model.  What they really care about is will they get safe and effective healthcare from a good provider.

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