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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?