Richard Smith: A week in a schloss

Richard SmithAs I arrived in Salzburg at Schloss Leopoldskron, globally prominent because of is role in the “Sound of Music,” I wondered if it would be possible for people from 29 countries, ranging from Uganda to the USA, to hold mutually useful conversations on health system reform. In particular, would a hard boiled, cynical, globe trotting old timer like me learn something? Well, I did.

I learnt in particular from two exercises we conducted—preparing a memo for our health ministers and scenario planning. I was classed as “faculty,” which seemed to be just a euphemism for “old,” and so didn’t have to produce a memo, but I had the chance to scan the three proposals that each of the 30 or so young folk had to produce for their ministers.

Some of the words I saw commonly didn’t surprise me—words like prevention, community, and primary care.  What is perhaps surprising—or rather disappointing—is that these are not the words that denominate debates on health reform in most countries. Usually the debate is dominated by talk of hospitals and costs, and I was interested to learn that the first health objective of governments in Singapore and Japan is to contain costs. Singapore spends some 4% of its gross domestic product on health care and recognises that it will inevitably go higher as the population ages, but the government wants to avoid the 9% or 10% that is common in Europe let alone the 16% of the US.

If these young, well informed people, many of them working in government in their countries, recognise the importance of prevention, community, and primary care will these become the issues that dominate future debates on health reform? Will that be the very practical benefit of locking people up in a magnificent, baroque schloss for a week and force feeding them health reform? I hope so.

I was pleased as well to see the words “universal coverage.” This is the aspiration of most countries, and we heard how Colombia and Mexico have come close to achieving it by beginning their debates on health reform not with technicalities but with broad, national debates on whether health should be a human right. Both countries decided it should and so wrote the health as a human right into their constitutions. People from the US wondered if they should do the same.

The word that did surprise me from the memos was “insurance.” In most low income countries most health care is paid for “out of pocket,” and serious health problems can bankrupt families.  Few if any countries try to counter this by funding universal coverage from income tax. All seem to opt for insurance—often a mix of social and private—despite the transaction costs of raising insurance and the problems of insuring those at high risk. Indeed, one thing that Britons learn at these meetings, often to their surprise, is that the British model of state funded, provided, and regulated health care is as much an outlier as the US system. So, old dog that I am, I shouldn’t have been surprised by insurance being a commonly used word.

Among the people writing the memos there was spirited discussion around the role of traditional healers. Are they part of the problem or part of the solution? They might be seen as part of the problem in that some offer remedies that are far from evidence based with some being indistinguishable from those offered by the three witches in Macbeth. But they have the great advantage of being where the people are and of having their trust. (Another theme of the week was the general distrust of public sector services in low and middle income countries.) Uganda has something like one doctor for every 100 000 people (and most of them are in cities) but one traditional healer for every 40 people. And there are examples of health professionals working effectively with traditional healers. We need more debate on this topic, and maybe some traditional healers should be invited to the next meeting in the schloss.

In our scenario exercise we had to select two “key drivers” of the future, one directly related to health and one more social, and describe four scenarios that result from the two drivers being either positive or negative. My group selected attitudes to death (either denial or acceptance) and concern about the environment (high or low). We sketched the four scenarios, which we called Sterile Water, Hemlock Tea, Botox Martini, and Sex on the Beach, and then thought hard about Sterile Water, a world of death denial but great concern about the environment.

This turned out to be a world with lots of regulation, a nurse as president, a big spend on green healthcare, great support for biodiversity, few cars, no meat, and lots of “the living dead.” We plan to explore the scenarios further, but we should all think seriously about such a world because death is being increasingly denied and concern about the environment will surely grow as the consequences of climate change.

As with most meetings, my biggest learning came not from the meeting itself but from a side conversation, when a Dutch woman described having been a few days earlier to the euthanasia of a friend. It was, she said, “beautiful.” The people around the patient cried as she very calmly said goodbye and how she loved all those present. Also fascinating was how the British GP beside me—as smart, agreeable, rational, and level headed person as you could hope to meet—was almost overcome by emotion as he heard the story. He wasn’t sure why.

But what is clear to me is that we must think much more about death, and where better to do it than in a schloss in Salzburg where the heart of the Archbishop who built it is buried in a box in the chapel.

The meeting was funded by the Salzburg Global Seminar, the Nuffield Trust, and the Health Foundation, and the BMJ was a media partner. There are podcasts and videos on the Salzburg Global Seminar website, including a video, which is also on YouTube, of me doing a 90 second rant on the unsustainability of the US health system. Videos and podcasts will also be placed on the BMJ website.

Competing interest: RS had his fare paid to Salzburg and was put up in the schloss, fed, and given wine and a tie for free, but he wasn’t paid for his “work” as a member of the faculty (and who would have paid him anyway?).

Richard Smith was the editor of the BMJ until 2004.