Table 1 Summary of health and IPC/AMR governance in the three included countries according to criteria defined by Smith et al [5]
England | France | Germany | ||
|---|---|---|---|---|
Governance model | • National Health Services (NHS): centrally planned health system • AMR: Hierarchical with authoritative pressure of DH | • Central-level governance model based on central government leading and setting directions for the health care system. • AMR: Hierarchical organization with authoritative pressure of the ministry of health and the Regional agency of health | • Federal government with corporate governance and the help of agencies • Wage-related contributions • 16 federal states (Länders) with their own administration • AMR: national and federal | |
How priorities are set for improving actions and standards? | Who is involved & what is the role? | • The DH & Care Quality Commission sets targets and puts in place the Outcomes Framework; Providing support, guidance, legislation, and Code of Practice. • NICE: provide clinical guidance. | • Ministry of Health via national agencies: Technical committee (High council of public health), policy group (Cosu Propias), the interministerial committee for health dedicated to AMR • Regional agency of Health: spell out criteria and targets for the provision of care. | • Bundesministerium für Gesundheit (BMG; Federal Ministry of Health) • The Commission of Hospital hygiene and Infection prevention (KRINKO) at the Robert Koch-Institute (RKI) • Possibility of local priority setting by federal states |
What is the evidence base for decision-making? | • Health technology assessment (rational arguments) | • Health technology assessment (rational arguments) | • Health technology assessment (rational arguments) | |
What are the main strengths | • Transparency of information to public | • Performance management approach: Emphasis on structural and infrastructural aspects. | • Relatively strong degree of delegated and autonomous decision making. | |
What are the main weaknesses? | • Difficulties to convert national goals into local practices • National targets led to local anomalies and unsustainable • Patient role not well defined. • Cost-effectiveness analysis studies not available | • Poor cost-effectiveness analysis | • Weak governmental powers. Decisions possibly blocked by nongovernmental and could delay the implementation of priorities • Risk of somewhat arbitrary goals by agencies. | |
How is performance monitored? | By whom? | • DH and PHE (NINSS): National surveillance. • NHS Improvement (formerly the Monitor): Intervene if concerns about performance of NHS foundation trusts. • Care Quality Commission: Inspections and assessments of NHS (foundation) trusts regarding national objectives. | • Ministry of Health: mandatory indicators with public reporting. • High Authority of Health (HAS): hospital certification. • Public Health of France and 5 interregional coordinating centres: Voluntary surveillance (RAISIN) for benchmarking. | • IQTIQ: Federal institute for quality management, quality report each year on federal level (formerly AQUA institute). • National Reference Centre for Surveillancce (Nationales Referenzzentrum für Surveillance von nosokomialen Infektionen, NRZ). Funded by the BMG, Its activities led to the creation of a national nosocomial infection surveillance system entitled Krankenhaus-Infektions-Surveillance System (KISS). |
How and what are the main strengths and weaknesses? | • Performance management approach: mandatory indicators with public reporting. Penalties and fines. • Empower patients. • Creation a culture of fearfulness and open up the possibilities of gaming. • Tunnel vision. | • Performance management approach: mandatory indicators with public reporting. • Tunnel vision. | • Mandatory for hospitals to survey nosocomial infections in high-risk areas (neonatal ICUs) and to record emerging multi-resistant nosocomial pathogens. • Nationwide surveillance of nosocomial infections, multi-resistant nosocomial pathogens and alcoholic hands rub consumption in Germany. | |
How is accountability for performance ensured? | How are the accountability mechanisms in place linked to the health system’s broader governance structures? | • Direct incentives through managerial control. • Financial pressure on contracts. • Public release of performance data, informed by goals and priorities, and serving a meaningful accountability process. | • Direct incentives through managerial control. • Public release of performance data, informed by goals and priorities, and serving a meaningful accountability process. • Financial penalties for not reporting data | • Statutory and voluntary accreditation schemes, at the organizational and practitioner level, and the freedom of patients to choose provider. • Confidential reporting of surveillance data |
Are the mechanisms effective? | • Increasing pressure for hospitals to produce and file plans for control activities with health authorities. • Increasing tendency for hospital and boards to be subject to audit. • Strong accountability structure in hospital trusts. | • No strong accountability structure. | • Weak governmental accountability. | |
To what extent are the three components aligned? | • Broad national goals must translate into achievable local targets. • Possible conflict between national and local priorities. | • Broad national goals must translate into achievable local targets. • Possible conflict between national and local priorities. | • Lack of capacity and coordination, technical difficulties. • Capture by powerful vested interests. | |