Changes are ahead in how medicine is financed. Dr Natalie-Jane Macdonald talks to Paul Robertson about cancer top-ups, wellness programmes and the role of the NHS
At the end of interviews, when the interviewee is feeling a bit relaxed, it is often fun to ask: "So, is there any subject you are glad I didn't touch on?" Occasionally someone will answer: "Well, it's lucky you didn't ask about ..." While any PR people in attendance have a fit.
Doctor Natalie-Jane Macdonald, managing director of Bupa UK membership, is the first person to immediately reply: "Why would I tell you that?" In conversation, this level of focus is striking. She discusses issues succinctly, without deviation and obviously knows her onions.
Although she has been at Bupa for a decade, she actually began her working life as a doctor. However, she decided she was unhappy with medicine's career path. "When I was a young doctor, medicine was a traditional career and a bit predictable. There just weren't that many surprises and I lost my motivation. I liked being a doctor and relating to patients but I was in academic medicine and wanted a bit more variety," she says.
Well she certainly has variety now as the world of medicine, or more exactly, the funding of medicine is changing. Macdonald sees recent announcements on the funding of cancer top-ups as a harbinger of changes to come, while stressing that, unlike many other goods and services markets, healthcare moves quite slowly.
"What would happen in a year in retail sales can take 15 years in healthcare. A lot of changes are almost imperceptible. However, the reality is that this debate about top-ups for cancer boil down to two things.
"Firstly, in an area of healthcare important to people, it has been publicly suggested for the first time that the NHS may not always be there to help when really needed. A lot of customers with private medical insurance (PMI) say to me 'I love having PMI but I know if something really serious crops up, the NHS will be there for me'. We take that for granted in this country. So it is significant that it was in the issue of cancer that this arose. We have been aware of postcode rationing for many years but it has not forced the public to question if something they have contributed to will be there when they may need a life-saving treatment."
Role of the NHS
Macdonald's second point, which coincides with the launch of the NHS constitution, is there is no definition of what the NHS is actually for. She notes we have no explanation of what someone contributing to the NHS is entitled to.
"This makes it quite hard for someone working in the supplementary insurance industry to be able to articulate what and where the boundary is between the NHS and private sectors. My suspicion is that this is a continuation of an inevitable trajectory, started 12 years ago when the National Institute for Health and Clinical Excellence (Nice) was established, that we will inevitably get to a point where we will have to make decisions about whether drugs are going to get funded or not.
"The genie cannot be put back in the bottle. Over the next few years, very slowly, the pressure on Government, businesses and individuals, in terms of what we are all funding, will continue to grow while the demands of healthcare will grow even faster.
This begs the obvious question of whether someone will get around to defining the NHS. Macdonald makes the point that this would be an act of bravery on anyone's part as it is a political no-win situation.
She says: "The way that Mike Richards elegantly extricated himself from the top-up problem was to change the threshold for Nice's decision making so cancer drugs would become funded. The problem is that it is only possible to do that for a bit, fudging the issue is not the answer.
"Whether the answer ends up being some form of wholesale reform or whether there will be a series of incremental changes that affect the nature and the boundaries of the NHS is hard to say. I personally think it more likely to be the latter. While some, such as the Netherlands, have gone through a wholesales reform process, I think we would find that route a bit difficult."
One would think that this was an open ticket for the PMI sector to increase its customer base but it is not all going the insurers' way as the NHS has staged something of a fight back in recent years.
Macdonald says: "On one hand, we are seeing things leading people to question just how much they can rely on the NHS, but on the other, the NHS has improved immeasurably over the last 10 years - although it remains far from perfect. A lot of people have seen their medical experience improve and they have been able to forgo self pay or PMI as they have been able to get treated a lot more easily on the NHS than they would a few years ago.
"There are still challenges: a wait of 18 weeks can seem a substantial time to wait for something that can be pretty serious. Our members tend to complain if they have to wait more than a week or two. In addition, the thing frightening most people is the issue of cleanliness and picking up an nfection while in the hospital."
Essentially, Bupa sees cost as key. "People want to be able to know that they can keep on paying for the long term. They don't want to buy a benefit and then have to question its value. So one of the main challenges is not price per se but the sustainability, especially for older people," says Macdonald.
Another aspect has been the rise of non-medical technology - people consuming and interacting online - as people behave in a different way and become more willing to make their own choices. Many expect this to feed through to wellness programmes but Macdonald is wary of the difficulties of these schemes, while seeing opportunities in terms of traditional PMI.
Macdonald says: "Struggles we have had in providing traditional PMI, mirroring the NHS apart from chronic conditions and A&E, will become easier as people make choices rather than opting for traditional PMI. Arguably, some of the day-to-day limitations in healthcare are getting access to a GP, continuity of care and access to services. We are becoming more intolerant of what we are given and we will see that feed through to insurance. The overall traditional product will remain but we are going to have to become more flexible in what we offer the public."
Getting well soon
However she describes wellness programmes as a "difficult nut to crack".
"We all know that eating healthily and keeping a good weight is good for us but most people don't actually do it. So what are the points we can use to meet people and hook them? It requires very sophisticated marketing in order to have an effect. We also need to ally this to clinical intelligence. There needs to be a medically sound reason for what we do. There is a lot of nonsense in the wellness arena, such wacky tests with no sound basis, which are not very helpful. Wellness issues will be gradual but inexorable as, over the long term, you can keep down healthcare costs through improving people's risks."
So where are the growth areas for the adviser? Macdonald says small to medium-sized enterprises (SMEs) are significantly under penetrated in relation to the number of companies. She also sees a potential for crossover sales in this arena.
"The skill is to offer best value for money and to make the client workforce optimally productive. Arguably no single product is going to do that, it requires a combination. It is a combination of products and services, joined up in a sensible way that is of real value. This holds most true for SMEs as they are quite simple in their organisations, larger ones become fragmented and the people responsible for PMI are not responsible for income protection plans or occupational health, for example. However, we need to actually demonstrate that we can make a difference, and there is quite a lot of work to do in that area."
Bupa increasingly sees employers wanting to offer healthcare but not to offer everything: looking at plans to provide cover to keep people at work, but at the same time, which can be administered fairly. This approach has its problems.
"We know employers are looking to cover cancer for a year, but if someone is in the middle of chemotherapy, withdrawing the treatment is difficult. There are logical break points in treatment where people could be handed back into the NHS once it is obvious they will not be returning to work. However, it needs to be understood not only in terms of the benefit but in healthcare as well.
"The worst thing would be to invent something clever, sell it to employers and end up with distressed unhappy employees having added something more to worry about. Essentially, employers want sustainability of affordability and the ability to cap the costs and financial risk," says Macdonald.
So busy times ahead in PMI markets. As a new appointee to the post, Macdonald is well placed to see these changes through: "I have been at Bupa for just over 10 years and believe in the organisation. I have the potential to influence the future in ways good for the organisation, our customers and, hopefully, our potential customers."
CV: DR NATALIE-JANE MACDONALD
Natalie-Jane Macdonald obtained her medical degree from Glasgow University in 1984. She also has an MBA from London Business School. Previously head of ethics and international affairs at the British Medical Association, she joined Bupa in 1994. Macdonald has worked in the company's insurance business for the past nine years, most recently as medical director of UK Membership and managing director of Bupa Commissioning.
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