School of Medicine & Health The Changing National Context David Hunter Professor of Health Policy & Management

School of Medicine & Health

The Changing National Context

David Hunter

Professor of Health Policy & Management


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


Medicine is a social science, and politics nothing else but medicine on a large scale.

Rudolf Virchow (1821-1902)


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


Welcome to the

NEW



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

Ultimate fate of Health & Social Care Bill remains uncertain – opposition hardening


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)


The NHS: From This…


…To This…





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


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


Any Qualified Provider and Competition

ConcernsApplication of competition law: UK and EU

Role of Monitor remains uncertain

Care is complex and demands collaboration/pathways, not fragmentation

Is competition the answer?


The Case Against CompetitionEvidence 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


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?


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


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)


Symptoms of Failure in Health Systems (1)

Persistent financial, quality or safety problems

Management distracted by constant ‘redisorganisation’, changing policies, priorities

Low staff morale, including clinician disengagement

Weak implementation of policies and plans


Symptoms of Failure in Health Systems (2)

Policy incoherence – policies push and pull in different directions

Poor leadership in handling complexity and wicked issues

Lack of political will

Absence of cooperation across care pathway/total system

Inter-organisational relationships undeveloped


Potential Levers for ChangeLean 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)


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


North East Transformation System

Vision

Method Compact

No barriers to health & well beingNo avoidable deaths, injury or illnessNo avoidable pain or sufferingNo helplessnessNo unnecessary waiting or delaysNo WasteNo inequality

Toyota Production System /Virginia Mason Medical Centre

Psychological contract‘Gives’, ‘gets’, new imperatives


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 mediocrityWe have…Unexplained variation? Difficulty spreading best practice universally?Change that does not sustain?Non value added activity and waste?


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)

Documents

School of Medicine & Health The Changing National Context David Hunter Professor of Health Policy & Management