Reforming the English NHS Stephen P. Dunn, PhD, MA Senior Policy Advisor, Department of Health CMWF...
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Transcript of Reforming the English NHS Stephen P. Dunn, PhD, MA Senior Policy Advisor, Department of Health CMWF...
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?