Can the English National Health Service learn from the Dutch reforms?
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Transcript of Can the English National Health Service learn from the Dutch reforms?
Can the English National Health Service learn from the Dutch reforms?
Meeting the medium term challenge of the financing of health & aged care in England
27 January 2011 The Royal Society, London
Gwyn BevanDepartment of Management, LSE
Objectives of health care reforms in OECD countries*
2. Cost control: rationing & expenditure caps
1. Equity: access by need not ability to pay
3. Performance: incentives & competition
* Cutler (2002) Equality, Efficiency, & Market Fundamentals: The Dynamics of International Medical-Care Reform. Journal of Economic Literature.
UK from 1990s
Law of requisite variety: 3 goals 3 instruments
Cost control
Equity
Performance
NHS 1980s: 3 goals & 2 instruments
Health authorities run providers
Above target income: cuts not ‘efficiency’ savings
Below target income: no ‘efficiency’ savings
‘Efficiency’ savings
Cost control: fixed total budget
Formula funding equitable allocations
From 1991: purchaser / provider3 goals & 3 instruments
Purchasers
Private providers
NHS providers
Efficiency by competition
Cost control: fixed total budget
Formula funding equitable allocations
Internal market (1989 -97): Design*
Purchaser / Provider Provider competition
‘money follows the patient’
Selective contracting health authorities GP fundholders (no patient choice)
*Working for Patients
Internal market (1989 -97): Impact
Le Grand (1999)* Little evidence of change Incentives too weak & constraints
too strong
Tuohy (1999)** NHS logic
Ministerial accountability Collegial decision making Poor information on prices & quality
* Le Grand (1999) Competition, cooperation, or control? Health Affairs** Tuohy (1999) Accidental Logics. Oxford University Press
Patient choice & competition (2006 - 10): Design*
Provider competition ‘money follows the patient’ (PbR) standard tariff: quality competition
Selective contracting Primary Care Trusts World Class Commissioning
Patient choice Provider diversity
Foundation Trusts & Independent Sector Treatment Centres
*Delivering the NHS Plan
Patient choice & competition (2006 - 10): Impact
Failure to create functioning market* political interference weak purchasers barriers to exit &
entry changing policies reorganisations
No
* Brereton & Vasoodaven (2010) http://www.civitas.org.uk/nhs/download/Civitas_LiteratureReview_NHS_market_Feb10.pdf
Impact both NHS markets? Overview of literature*
No good evidence reforms produced beneficial outcomes classical economic theory predicts of marketsprovider responsiveness to patients &
purchasers large-scale cost reduction innovation in service provision
NHS incurs transaction costs of market without benefits?
* Brereton & Vasoodaven (2010) http://www.civitas.org.uk/nhs/download/Civitas_LiteratureReview_NHS_market_Feb10.pdf
NHS from 2010?
We will stop the top--down reorganisations of the NHS that have got in the way of patient care
If reorganisation of purchasers is the answer …
0
100
200
300
400
500
91-94 94-97 97-01 01-05 05-11 11-13 13-?
GP Authority
Population ('000s)
Liberating the NHS: Objectives?*
NHS commissioning board Steering not rowing?
GP Consortia GPs involved in shaping services?
Independent providers Choice & managed competition?
Reorganisation Evolution not revolution?
* Equity and excellence: Liberating the NHS
Reflections: 20 years ofmarket reforms
The Netherlands
1 agreed policy Dutch procession of
Echternach
MHP competition as yet little selective
contracting
Model exported Germany &
Switzerland
England
5 blitzkriegs (SW1) army of occupation in
hostile territory?*
Provider competition limited impact
Model abandoned New Zealand,
Scotland & Wales*Shock (1994) Medicine at the centre of the nation’s affairs, BMJ
Going Dutch: Provider Purchaser competition?
Mutual Healthcare Purchasers (MHPs)
PCT clusters
Efficiency by purchaser competition &selective contracting /integration
Cost control: fixed total budget
Risk-adjusted funding equitable allocations
Mutual Healthcare Purchasers (MHPs)
Plurality PCTs / GP consortia Insurers? Foundation Trusts?
Define catchment areas Guarantee duty of care Selectively contract / integrate
Explicit insurance contract Choice of packages
Restrict choice? Charges?
NHS Commissioning Board: Regulation of MHPs
Entry key competences & duty of quality
Competition sufficient numbers & information
Equity funding & open enrolment
Insurance solvency & transparency
Can the English National Health Service learn from the Dutch reforms?*
Thank youGwyn Bevan
Department of Management, LSE [email protected]
* Bevan & van de Ven (2010). Choice of providers & Mutual Healthcare Purchasers: can the English NHS learn from the Dutch reforms? Health Economics, Policy & Law