Who should provide Health Care?
Summary of an Address to the Hispanic Development Foundation inc.

By Dr James Appleyard, President of the World Medical Association
(in association with the Corinthian Medical I.P.A.)
at the New School University, New York, February 28th 2004

Health care systems must be founded on meeting the needs of individual patients as well as respect for the professionalism of physicians who serve them. No one system will cover all in shape size or scale. Their design should depend on local communities and on the diverse environments

The World Medical association has struggled with these issues for over forty years since the Association laid down twelve principles at the World Medical Assembly held in New York in 1963. Key to the discussion are the questions of quality choice, equity and efficiency

There are important lessons to be learnt from international comparisons – not only on how much the governments of individual nations are prepared to invest in the health of their citizens – but on the part that various factors play in health outcomes. True the share of public spending on health has a positive effect on prolonging life span, but there is a much stronger correlation with the number of physicians practicing in each country (see slide).

Doctors play the core role in any successful health system. However the response to the escalating costs has seen increasing cost control systems being introduced in the belief that the micromanagement of patients by lay administrators is more efficiently carried out than by physicians. In some health systems decisions that were once taken by physicians in partnership witheir patients are being second guessed by lay clerical officers in call centres.

Research by Dr Magee, a senior fellow at the WMA, has revealed that extremely important relationship between the patient and physician is second only to family relationships. Patients surveyed in six countries – US, UK, Canada, Japan, Germany and South Africa still go to their doctor as the primary source of health information and place trust in their physician for the action to take on their health in up to 98% far more than the internet, the media or indeed government.

These high ratings of physicians were consistent across the differing health systems.

Health systems will fail to deliver effective care unless the professional role of the physician is understood and respected.

Indeed some health systems have a serious negative effect on the behaviour of physician and undermine this trust. Dr Magee’s interesting study surveyed the humanistic rating of ‘compassion’ from both the patients and physician point of view. He found a very significant perception gap between how patients in the NHS perceived their relationship with their NHS doctor a value of 35 whereas in the US with the choice of a multiplicity of programs the perception ‘gap’ was much less at 11. Equally worrying was the similar difference between the perception of patients and doctors in the NHS about ‘access’ to their services with a value of 31 whereas ther was no significant difference between patients and their physicians in the US. It is as though physicians in the UK have accepted poorer access and on this issue side with management.

In the US there is a choice of Health Maintenance Organisations with differing models of provision. Those directly employing doctors are more closely aligned to the NHS. The alternative and in many ways professionally more attractive model are the Independent Practice Associations. This model allows physicians and their patients to retain their individuality, yet by combining with others be able to negotiate with providers on behalf of the local community. They are disadvantaged by having to operate in a very uneven playing field. Cartels of ‘management’ are not subject to the same anti-trust legislation.

Many vested interests might view such arrangements as untidy and lacking in cost control. It takes a determined group of physicians able to tolerate and overcome the pressures of the market place.

It is however reassuring to hear of groups of physicians who are prepared to work hard on behalf of their patients and the local community, thereby rolling back the increasing cost burden of over management that is dehumanizing health care systems.