The Changing National Context

1. The Changing National Context David Hunter Professor of Health Policy & Management

2. Structure of Talk • Challenges facing health systems • Overview of government’s NHS changes • Problems with the proposals • An alternative approach to change in complex systems

3. Medicine is a social science, and politics nothing else but medicine on a large scale. Rudolf Virchow (1821-1902)

4. 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

5. Welcome to the NEW

7. 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

8. Continuing Policy Churn and Uncertainty • Coalition government’s ideological drive to roll back the State shouldn’t 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

9. The coalition programme…involves a restructuring of…public 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-Gooby and Stoker, The Political Quarterly (2011)

10. 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

11. The NHS: From This…

12. …To This…

15. 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 don’t want to in any case

16. 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

17. 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?

18. 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

19. Justice and the Common Good:the 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 intrusion…[U]nless 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: What’s the right thing to do?

20. Towards an Alternative Approach • Governments mistake structural for cultural change • The result is dynamics without change • The structure doesn’t need major change • Focus on other levers for real change

21. The Nature of the Problem ...[T]he 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 doesn’t make sense. It drains energy and confidence from the workforce....[T]he 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)

22. Potential Levers for Change • Lean management – a hospital’s 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)

23. 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

24. 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

25. 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?

26. 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)