Stephen P. Dunn, PhD, MA
Senior Policy Advisor,
Department of Health
CMWF Harkness Fellow, 2003- 4
• 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
5000
4000
3000
2000
1000
0
U
K
A u st ri al ia
F ra n ce
C an ad a
G er m an y
U
S
A
$ public ppp-adjusted per capita health spending
$ total ppp-adjusted per capita health spending
Source: OECD (2002)
England & Wales
Scotland
Europe
US
6
6
10
13
Five year cancer survival rates
Men lung cancer
Women breast cancer
England & Wales
Scotland
Europe
US
68
66
73
84
0 10 20 30 40 50 60 70 80 90 100
Percentage
Source: Coleman (1999)
• 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
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?
1

• ensure equitable, universal coverage
• minimise risk selection, gaming & cost- shifting
• harness monopsony power
• minimise administrative costs
• 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
+ expanding capacity
+ establishing national systems
– standards
– audit
– inspection
+ improving choice & responsiveness
– diversity
– contestability
• 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 ...
• 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
• 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
2

• 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
Patient & public involvement
NICE (guidelines & HTA)
National Service Frameworks
National Patient Safety Agency
Clear standards of service
Patient & public involvement
Professional
Self-regulation
Clinical governance
Relicensing
NCAA
NHSU
Dependable local delivery
Patient & public involvement
Health Commission
Star Ratings
NHS Modernisation Agency
National Patient Survey
Monitored standards
• 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
• 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 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
• 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
• new PCP contract
– simpler rules, fairer capitation
• extra £1.9 bn for primary care
– 33% over 3yrs
• 18% increases in PCP income on quality
– based on 146 indicators covering
• clinical (weighted by disease prevalence)
• organisational standards
• patient experience
• additional services
3

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
Move from
NHS which is a monopoly provider of health services
& centrally accountable
To
A greater diversity & plurality of services, more responsive to patients, inspected & regulated against transparent, common standards by an independent body that reports nationally & locally
Values
Spending
National standards
Providers
Staff
1948 model free at point of need annual lottery none monopoly rigid professional demarcations
Patients
System handed down treatment 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
high national standards & clear accountability devolution of responsibility more flexibility for front line workers choice & diversity of provision
• 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?
4