Reforming the English NHS

Stephen P. Dunn, PhD, MASenior Policy Advisor,Department of Health

CMWF Harkness Fellow, 2003-4

The NHS today

• treats 1 million people a day• spends over £5 million ($8.5m) an hour• polls show that 7/10 are happy with

treatment • polls show that majority of the British

public– are proud of the NHS– 4/5 think NHS is critical to British Society – must be maintained

= effective cost containment?

0

1000

2000

3000

4000

5000

$ public ppp-adjusted per capita health spending

$ total ppp-adjusted per capita health spending

Source: OECD (2002)

… but at what price?

13

6

10

6

66

68

73

84

0 10 20 30 40 50 60 70 80 90 100

US

Europe

Scotland

England & Wales

US

Europe

Scotland

England & Wales

Percentage

Men lung cancer

Women breast cancer

Source: Coleman (1999)

Five year cancer survival rates

a legacy of under-funding!

• history of under-investment– cumulative £220bn underspend compared to EU ave

• too few doctors, nurses & other professionals• too many old, inappropriate buildings• late & slow adoption of medical technologies• gap between system performance & public

expectation growing

= make or break for NHS

= funding controversies

Q1: how much should the country be spending?– publicly (and privately) on healthcare?A1: 9.4%

Q2: what is the optimal speed of catch up?– given capacity constraints?A2: 5 years

Q3: how should the extra revenue be raised?– what is the fairest and most efficient route?

A3: stick with taxation

• ensure equitable, universal coverage

• minimise risk selection, gaming & cost-shifting

• harness monopsony power

• minimise administrative costs

Investment

• largest ever sustained increase in funding

• 50% increase in NHS funding 2002-7 – reaching c£90bn (c$160bn) in 2007-08!

• by 2008 total health spending will amount to 9.4% of national income– on a par with European levels

+ Reform =

+expanding capacity+establishing national systems

– standards– audit– inspection

+improving choice & responsiveness– diversity– contestability

+ expanding capacity

• growing the number of health professionals – 50,000 extra nurses, 5,000 more consultants &

1,500 GPs since 1997

• modernising infrastructure– 29 major new hospitals

> 1,200 more general & acute beds in 2001/02

– 1200 GP premises refurbished or replaced – 200 new one stop-centres provided

… major IT investment ...

modernising IT infrastructure

• 3yr £2.3bn ($4bn) IT investment – country wide Electronic Health Record– Electronic prescribing and scheduling

• aims– reduce medical errors, lost records, delays &

duplication – efficiency & promote active case

management– provide certainty of appointment times – underpin patient choice of providers

+ expanding capacity

• growing the number of health professionals – 50,000 extra nurses, 5,000 more consultants &

1,500 GPs since 1997

• modernising infrastructure– 29 major new hospitals

> 1,200 more general & acute beds in 2001/02

– 1200 GP premises refurbished or replaced – 200 new one stop-centres provided– 3yr £2.3bn ($4bn) IT investment

• supported learning and development – Modernisation Agency & NHSU

+ national systems

• national standards and targets– National Service Frameworks (NSFs)– National Institute for Clinical Effectiveness

(NICE)

• inspection and regulation– Health Commission

• published performance information– Star ratings

• direct intervention for failing providers

… and national targets, e.g.

• cutting cancer death rates by 20% in people <75 by 2010• cutting heart disease death rates by 40% in people <75 by 2010• reducing death rates from suicide by 20% by 2010• reducing inequalities in health by 10% by 2010

– measured by infant mortality & life expectancy at birth,

• reducing the <18 conception rate by 50% by 2010• guaranteeing access to primary care physicians to 2 days by 2004• completing treatment (or admitting to hospital) all accident &

emergency cases within four hours by 2004• cutting the wait for NHS-funded surgery to 12 weeks by 2008• improving patients’ experiences, as measured by national surveys• improving the value for money of NHS care by at least 2% per year

… and national targets, e.g.

• cutting cancer death rates by 20% in people <75 by 2010• cutting heart disease death rates by 40% in people <75 by 2010• reducing death rates from suicide by 20% by 2010• reducing inequalities in health by 10% by 2010

– measured by infant mortality & life expectancy at birth,

• reducing the <18 conception rate by 50% by 2010• guaranteeing access to primary care physicians to 2 days by 2004• completing treatment (or admitting to hospital) all accident &

emergency cases within four hours by 2004• cutting the wait for NHS-funded surgery to 12 weeks by 2008• improving patients’ experiences, as measured by national surveys• improving the value for money of NHS care by at least 2% per year

• guaranteeing access to primary care physicians to 2 days by 2004• completing treatment (or admitting to hospital) all accident & emergency cases within four hours by 2004• cutting the wait for NHS-funded surgery to 12 weeks by 2008

• guaranteeing access to primary care physicians to 2 days by 2004• completing treatment (or admitting to hospital) all accident & emergency cases within four hours by 2004• cutting the wait for NHS-funded surgery to 12 weeks by 2008

+ single payer, not single provider

• active single payer, primary care led purchasing• introducing greater patient choice• aligning provider incentives

– DRG type reforms– new primary care contract

• new entrants & physician plural supply– international providers, e.g. United Kaiser? VHA?

• devolving control

= >choice, responsiveness, diversity & contestability

= major reform of the NHS

redefining the model

• a National Health System?= a national set of values= care free @ point of delivery based on need monolithic provision

• NHS as a national insurer– a mixed economy of provision– a Bismark / Beveridge hybrid

1948 model New modelValues free at point of need free at point of needSpending annual lottery planned for 3/5 yearsNationalstandards

none NICE, NSFs and single qualityinspectorate/regulator

Providers monopoly Plurality –state/private/voluntary

Staff rigid professionaldemarcations

modernised flexibleprofessions benefitingpatients

Patients handed down treatment choice of where and whenget treatment

System top down led by frontline – devolved toprimary care

Appointments long waits short waits, bookedappointments

= new vision

= major risk ?!?!?!

• the stakes are high– can the system deliver?

• the next election is a key threshold

• will enough have been achieved?… to earn Tony Blair another term?… and to give the NHS the time it needs?