Reforming the English NHS
Stephen P. Dunn, PhD, MA
Senior 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?
5000
4000
3000
2000
1000
US
A
Fr
an
ce
Ca
na
da
G
er
m
an
y
al
ia
Au
st
ri
UK
0
$ public ppp-adjusted per capita health spending
$ total ppp-adjusted per capita health spending
Source: OECD (2002)
… but at what price?
England & Wales
6
Scotland
6
Europe
Five year cancer survival rates
Men lung cancer
10
Women breast cancer
13
US
England & Wales
68
Scotland
66
Europe
73
US
84
0
10
20
30
40 50 60
Percentage
70
80
90 100
Source: Coleman (1999)
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
• guaranteeing
to primary
– measured
by infant mortality access
& life expectancy
at birth,
care
• reducingphysicians
the <18 conception
by by
50%2004
by 2010
to 2 rate
days
• guaranteeing
access to primary
care physicians
to 2 days by to
2004
• completing
treatment
(or admitting
• completing treatment (or admitting to hospital) all accident &
hospital) all accident & emergency cases
emergency cases within four hours by 2004
within
four
hours surgery
by 2004
• cutting the
wait for
NHS-funded
to 12 weeks by 2008
• cutting
the wait as
formeasured
NHS-funded
surgery
• improving
patients’ experiences,
by national
surveys
• improving
for money
of NHS care by at least 2% per year
tothe
12value
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
= new vision
Values
Spending
National
standards
Providers
1948 model
free at point of need
annual lottery
none
monopoly
Staff
rigid professional
demarcations
Patients
handed down treatment
System
top down
Appointments long waits
New model
free at point of need
planned for 3/5 years
NICE, NSFs and single quality
inspectorate/regulator
Plurality –
state/private/voluntary
modernised flexible
professions benefiting
patients
choice of where and when
get treatment
led by frontline – devolved to
primary care
short waits, booked
appointments
= 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?