Israel and UK health care - What can we learn from each other?

Sciana Members visit Israel for study tour of country's health systems

A recent health care study trip to Israel took place at a significant time for both the UK and Israel. For each, the 70th anniversary of the post-war settlement that defines one of their key systems approaches: the State of Israel's formation and the founding of the NHS. Coincidentally, 70 is also the sum of the median ages of the populations in Israel (30.2) and the UK (40), highlighting the very different demographics that their systems provide care for.
 
Sciana: The Health Leaders Network kindly funded three of the UK Sciana members, Samantha Jones, Caroline Clarke and Paul Bate on a short study tour of Israel's health systems.

Our aim was also to discover the similarities and differences to the UK and any opportunities to transfer learnings to the NHS. Our main finding was that while integration is being pursued vigorously by both countries, the focus is very different. In this article, we explore two of these differences:

1. The uses of data.
2. The approach to joining up care across settings.

 
Key facts

• The total health care expenditure as a percentage of GDP (2016) is 7.6% for Israel compared to the OECD average of 8.9%.
• Israel has 3.1 hospital beds per 1,000 population compared to the OECD average of 4.8.
• In 2013, Israeli life expectancy at birth was 82.1 years, above the OECD average of 80.5 years.
• Complex inequalities between different socio-economic groups with respect to health care provision remain an issue in Israel.
• Israel has 3.3 practicing physicians per 1,000 population, slightly above the OECD average of 3.2. Israel has an insurance-based health care system, with contributions paid out of salaries at a progressive rate and supplemented by state funding. Employees earning up to 60% of the average wage contribute 3.1% of their salaries. Above that level, employees pay 5% of their salaries. The government is responsible for financing and ensuring some level of access, but non-governmental bodies are responsible for the provision of care. 

• Four competing non-profit health plans (Clalit, Maccabi, Leumit and Meuhedet) provide insurance to the Israeli population, covering the basic basket of health benefits guaranteed to Israelis under the National Health Insurance Law, 1995.
• The median age of the Israeli population is currently 30.2 years, which is ten years below the median UK age. We couldn’t find any international comparative data that took this difference into account when assessing relative spends on health and care.

Data-driven integration
The integrated electronic medical record (EMR) sits at the heart of the Israeli health system. In the two major health maintenance organisations that we visited, Clalit and Maccabi (which together cover over 75% of the country's population), the record of each individual can be accessed across all health organisations – from hospitals to primary care clinics, to telemedicine services. Such a rich set of individual-level data provides at least five major opportunities:

• Improved direct clinical care, as the treating clinician can see the full health information including test results, medications and allergies.
• Better research, comparing interventions on individuals' outcomes across matched populations.
• Focused interventions based on personalised medicine.
• More effective and efficient organisational and system management, as waste, variability and bottlenecks are exposed.
• Greater consumer empowerment, with comparable data and the ability for the individual to choose who sees their information.

 
Within the constraints of what can be seen, discussed and learned in two days, our view was that most energy had been directed into improvements in the first three of the categories listed above. Front-line clinicians clearly liked the access they had to the full EMR; and world-leading, envy-inducing research (Israel already invests more than 4% of its GDP in research and development) has resulted from systematic data-based studies. Coming from an NHS that prizes comparative data – on waiting lists, infection rates, consultant-level outcomes and much more – and which is hungry for information to improve care delivery models across health economies, we were interested to see where the Israeli focus currently appears to be.

Joining up the cracks in the care pathway
While significant focus has been on vertical integration across Israel and the development of strong primary care, there has, as yet, been little integration in areas that influence the wider determinants of health. We found the UK health system is more advanced in its thinking in this area. However, the Israeli system is focusing its attention in this area to build on the strength of the work to date and to address the rising challenges of an ageing demographic.

Conclusions
To draw definitive conclusions from a short and subjective study tour would be unwise at best. What is reasonably clear is that many of the same challenges face both health systems, however different their starting points of demography, system structure and policy intent may have been. The integrated EMR is an exciting, valuable and fundamental asset, and its value in action was helpful in confirming the importance of connecting data taken from all parts of the care journey.

Above all, the study tour helped in bringing perspective to our everyday work and created a network across the participants and our colleagues in Israel that we are committed to nurturing. We are grateful to our funders* for this opportunity and to KPMG for organising the visit for us.

* Declarations of funding

Samantha Jones, Caroline Clarke, Chief Finance Officer and Deputy Chief Executive, Royal Free London NHS Foundation Trust and Paul Bate, Director of NHS Services, Babylon Health were funded by Sciana: The Health Leaders Network, whose funding comes from the Health Foundation in the UK, the Robert Bosch Foundation in Germany and the Careum Foundation in Switzerland.