The Changing National Context

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The Changing National Context

• David Hunter
• Professor of Health Policy Management

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Structure of Talk

• Challenges facing health systems
• Overview of governments NHS changes
• Problems with the proposals
• An alternative approach to change in complex
  systems

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Medicine is a social science, and politics
nothing else but medicine on a large
scale. Rudolf Virchow (1821-1902)
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Challenges/Pressures Facing Health Systems

• Sustainable financing of the health sector,
  including efficiency, productivity, cost control
• Confronting the non-communicable disease epidemic
  (constitutes over 85 of the disease burden in
  the WHO European Region)
• Growing importance of lifestyle risk factors
  (e.g. alcohol misuse, obesity)
• Widening health inequalities

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Welcome to the
NEW
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The Health and Social Care Act (2012)

• Devolve power to front-line doctors and nurses
• Drive up quality
• Ensure a focus on integration
• Strengthen public health
• Give patients more information and choice
• Strengthen local democratic involvement
• Reduce bureaucracy

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Continuing Policy Churn and Uncertainty

• Coalition governments ideological drive to roll
  back the State shouldnt be underestimated
• Policy and organisational landscape is unstable,
  unclear, complicated
• Considerable anger and resistance
• The government may have won the battle, but has
  it won the war?
• Considerable risks lie ahead

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The coalition programmeinvolves a restructuring
ofpublic services that takes the country in a
new direction, rolling back the state to a level
of intervention below that in the United States
something which is unprecedented. Britain will
abandon the goal of attaining a European level of
public provision. The policies include
substantial privatisation and a shift of
responsibility from state to individual. Taylor-G
ooby and Stoker, The Political Quarterly (2011)
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Transition Risk Register (September 2010)

• Loss of financial control
• Loss of staff morale
• Loss of clinical time by GPs due to CCG
  management responsibilities
• GP leaders are not sufficiently developed
• Inability to reduce running costs because of
  consortia numbers
• Postcode commissioning
• QIPP failure

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The NHS From This
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To This
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Main Criticisms of Proposed Changes (1)

• Unnecessary NHS performs well and is highly
  rated by the public
• Changes will increase bureaucracy and layers of
  management not reduce them
• GPs cannot do commissioning most dont want
  to in any case

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Main Criticisms of Proposed Changes (2)

• Case for more competition and private sector
  involvement in health care not proven
• Concerns about more fragmentation, less
  collaboration remain
• Increased patient choice is an illusion

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Any Qualified Provider and Competition

• Concerns
• Application of competition law UK and EU
• Role of Monitor remains uncertain
• Care is complex and demands collaboration/pathways
  , not fragmentation
• Is competition the answer?

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The Case Against Competition

• Evidence concerning its virtues is limited and
  not convincing
• Loss of control and accountability if services
  put at mercy of shareholders and owners
• What happens if private companies fail or go bust
  as some will?
• The central issue is not about efficiency and
  productivity but the public interest

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Justice and the Common Goodthe moral limits of
markets
Since marketising social practices may corrupt or
degrade the norms that define them, we need to
ask what non-market norms we want to protect from
market intrusionUnless we want to let the
market rewrite the norms that govern social
institutions, we need a public debate about the
moral limits of markets.

Michael Sandel (2010) Justice
Whats the right thing to do?
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Towards an Alternative Approach

• Governments mistake structural for cultural
  change
• The result is dynamics without change
• The structure doesnt need major change
• Focus on other levers for real change

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The Nature of the Problem
...The leaders of the NHS and government have
sorted and resorted local, regional and national
structures into a continual parade of new
aggregates and agencies. Each change made sense,
but the parade doesnt make sense. It drains
energy and confidence from the workforce....The
time has come for stability, on the basis of
which, paradoxically, productive change becomes
easier and faster for the good, smart, committed
people of the NHS.
Don Berwick
(2008)
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Potential Levers for Change

• Lean management a hospitals operational
  effectiveness
• Performance management the creation and use of
  clinical quality and productivity targets in
  managing operations
• Talent management the recruitment, development,
  rewarding, retention of high-performing staff
• Clinical leadership the way the roles, skills,
  mind-sets of hospitals doctors contribute to the
  management of clinical services
• 
  McKinsey-LSE joint research (2008)

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NHS Health and Wellbeing (The Boorman Report,
2009)

• Relationship between staff health and wellbeing
• improved quality and organisational performance
• patient satisfaction
• increased productivity
• simple good management practices

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North East Transformation System
No barriers to health well being No avoidable
deaths, injury or illness No avoidable pain or
suffering No helplessness No unnecessary waiting
or delays No Waste No inequality
Vision
Method
Compact
Psychological contract Gives, gets, new
imperatives
Toyota Production System / Virginia Mason Medical
Centre
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Why do we need NETS?
The NHS delivers service which incorporates real
excellence which it should be proud.
But. Pockets of excellence and poor practice in
a sea of mediocrity We have Unexplained
variation? Difficulty spreading best practice
universally? Change that does not sustain? Non
value added activity and waste?
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Back to the Future?
The NHS is a triumphant example of the
superiority of collective action and public
initiative applied to a segment of society where
commercial principles are seen at their
worst. Aneurin Bevan, In Place of Fear (1952)