Inaugural lecture
Centre for Public Services Organisations annual lecture
21 February 2013
WHAT IS THE FUTURE OF THE NHS?
Professor Mark Exworthy
Professor of Health Policy and Management
From the east end to the west coast:
`a victim of geography’?
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•
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•
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Loughborough University
Queen Mary & Westfield
Southampton University
London School of
Economics
University College London
University of California, San
Francisco
Oxford Brookes University
Royal Holloway, University
of London
Two faces of
primary
health care:
east London
& west coast,
USA
Health policy and management - “a victim of geography”?
Geography
Health
services
research
Social
policy
Management
Centre for Public Services Organisations
Annual Lectures
• Sir Derek Wanless (former CEO NatWest & adviser to Gordon Brown)
– Securing Good Health for the Whole Population - What should the
Government do?
• Prof. Angela Coulter (Picker Institute & Oxford University)
– Choice in Healthcare: who wants it and why?
• Prof. Sue Richards (National School of Government)
– Public Service Reform – Continuity and Change
• David Walker (Audit Commission & Guardian journalist)
– The performance of public services: how much does the public really
want to know?
• Lord Nigel Crisp (former CEO of NHS & Permanent Secretary,
Department of Health)
– The search for global health in the 21st century
What is the future of the NHS?
• The NHS in a changing world
• Recent policy developments
• Three fault-lines in NHS policy and management
• The NHS in the wider world
• Which way for the NHS?
National Health Service
• Treats 1 million patients every 36 hours
• Employs 1.4 million people (2012)
• Budget:
– £137.4 billion (2010/11 at 2012/13 prices)
• £2.642 billion per week / £376.4 million per day
• £1,875 per person in England (2011)
• 8.2% of GDP → possibly 16% by 2061
• 23% of English public service spending (2012)
• Compare:
– M&S annual revenue £9.9 billion (2012)
– NHS budget similar to national income of New Zealand (2010)
Health system challenges in a changing world
Access
Cost
Quality
Health system challenges in a changing world
Patterns of disease
Clinical advances
Lifestyles & behaviour
Demography
Cost
Access
Info technology
Quality
Recent NHS policy developments
1. Funding
– Feast and now famine*
2. Markets and competition
– Commissioning
– Patient choice
– Private sector (including Private Finance Initiative)
3. Delegation of management
– Organisational autonomy via Foundation Trusts
4. Performance management
– Centralised “targets and terror”
• ...and 12 Secretaries of State (since 1989 White Paper)
Annual % change in NHS expenditure in England,
1974/75 to 2014-15
Parliament, 2012
Recent NHS policy developments
1. Funding
– Feast and now famine*
2. Markets and competition
– Commissioning
– Patient choice
– Private sector (including Private Finance Initiative; PFI)
3. Delegation of management
– Organisational autonomy via Foundation Trusts
4. Performance management
– Centralised “targets and terror”
• ...and 12 Secretaries of State (since 1989 White Paper)
Three fault-lines in NHS policy and management
Health
Central
Profession
Local
Management
Health-care
Adapted from Exworthy & Freeman (2009)
Fault-line 1: Central - Local
1. NHS traditionally highly centralised
a. Bevan: "the sound of a bedpan falling in Tredegar
Hospital should resound in the Palace of Westminster"
2. Post-1991, increasing fragmentation through:
a. Decentralisation
•
•
Self-governing Trusts & Foundation Trusts
But centralisation persists
b. Markets & competition
a. Local commissioners
b. `Any qualified provider’
c. Patient Choice
Fault-line 1: Central - Local
1. The `Local NHS’
a. Public support for `local’ hospital despite `national’ title
b. NHS spending remains high localised*
2. Central role remains vital
a. Accountability for public spending
b. Equity - the `N’ in NHS
3. Central-local tensions remain; currently:
a. Post-code lottery and national guidelines co-exist
b. `Top-down re-organisation’ of secondary care
c. Clinical Commissioning Groups and National Commissioning Board
% of PCT budget allocated to NHS local providers, 2011-12
Percentage PCT budget to local
providers
1.2
1
0.8
Mean=0.70
0.6
0.4
0.2
0
PCTs
Exworthy, Frosini & Thompson (2012)
% of PCT
budget
allocated to
NHS local
providers,
2011-12
Exworthy, Frosini & Thompson (2012)
Fault-line 1: Central - Local
1. The `Local NHS’
a. Public support for `local’ hospital despite `national’ title
b. NHS spending remains high localised*
2. Central role remains vital
a. Accountability for public spending
b. Equity - the `N’ in NHS
3. Central-local tensions remain; currently:
a. Post-code lottery and national guidelines co-exist
b. `Top-down re-organisation’ of secondary care
c. Clinical Commissioning Groups and National Commissioning Board
Fault-line 2: Profession - Management
1. NHS had always been subject to:
– Provider-capture / shroud-waving → inertia?
2. `New Public Management’ (1980s onwards)
supposed to break `institutional stalemate’
– Managers became `agents of the centre’
3. Led to clinician-managerial conflict
– Managers became `stakeholders’ in their own right
• Sometimes the solution; often the problem
– Subsequently, collaboration and compromise
(Exworthy & Halford, 1999)
Fault-line 2: Profession - Management
1. Some clinicians (including doctors) have internalised
managerialism
– Being a `good’ doctor involves engaging with
managerialism
2. Some doctors take on managerial roles (hybrids)
– Danger that hybrids lose identity with and authority over
medical peers (Causer and Exworthy, 1999)
• Can they be `good’ doctors and `effective’ managers?
– Danger that managerialism fractures the profession
Fault-line 2: Profession - Management
Example: Public reporting and transparency
“The more we are watched, the better we behave” (Bentham)
• Study: Assessing impact of published mortality rates
associated with named surgeons
– Although patients rarely use the data, how do doctors respond to
increasing surveillance?
– What is the impact of more transparency upon clinical performance?
• Impact:
– Demonstrating competence to peer groups
– Resistance to performance but some internalisation
– Balancing tacit knowledge with explicit awareness
Exworthy et al, 2010; Gabe et al, 2012
Fault-line 3: Health – Health-care
1. NHS = national `sickness’ service
a. Overwhelming focus on NHS
b. Shift on public health to local government (April 2013)
c. Health-care may only contribute 15% to better health (McGinnis et al,
2002)
2. NHS ill-equipped to tackle “wicked problems” (Rittell & Webber, 1973)
a.
b.
c.
d.
e.
No definitive formulation
No stopping rule
Solutions are not true/false, & no ultimate test of a solution
No definitive list of solutions
Every problem is a symptom of another problem
Fault-line 3: Health – Health-care
Example: Health inequalities
a. Health outcomes - systematic gradient*
• “…in the wealthiest part of London, one ward in Kensington and
Chelsea, a man can expect to live to 88 years, while a few
kilometers away in Tottenham Green, one of the capital’s poorer
wards, male life expectancy is 71.” (Marmot, 2009, p.35)
b. Health-care inequalities - Inverse care law*
• “The availability of good medical care tends to vary inversely
with the need for it in the population served” (Hart, 1971)
Fault-line 3: Health – Health-care
Age standardised mortality rate by social class,
men, aged 25-64, 2011-2003
Marmot Review, 2010, p.49
Fault-line 3: Health – Health-care
Mortality of men in England, 1981-1992
Marmot Review, 2010, p.69
Life expectancy (in years) at birth of those living around
London Underground stations, 2012 http://life.mappinglondon.co.uk/#
Fault-line 3: Health – Health-care
Example: Health inequalities
a. Health outcomes - systematic gradient*
• “…in the wealthiest part of London, one ward in Kensington and
Chelsea, a man can expect to live to 88 years, while a few
kilometers away in Tottenham Green, one of the capital’s poorer
wards, male life expectancy is 71.” (Marmot, 2009, p.35)
b. Health-care inequalities - Inverse care law*
• “The availability of good medical care tends to vary inversely
with the need for it in the population served” (Hart, 1971)
Fault-line 3: Health – Health-care
Number of f.t.e. GPs per 100,000 weighted population by
area deprivation. DH, 2008, p.46
Fault-line 3: Health – Health-care
• “What is striking is that there has been much
written often covering similar ground . . . but
rigorous implementation of identified solutions has
often been sadly lacking.” Wanless 2004, p.3
• “What we know about equity and inequity in health
may in the end be less significant than how we
think, both about health and about government”
Freeman, 2006, p.66
Fault-line 3: Health – Health-care
Example: Wicked issues of health inequalities
• Challenges for NHS decision-makers
– Equivocal evidence
– Competing priorities
– Contested solutions
• Governance:
– Limited control over those able to
contribute to amelioration
– Low willingness to tackle the issues
The NHS in the wider world
• How does the NHS compare with other health systems?
• Is the NHS still the envy of the world?
How well does the NHS perform?
1. Equity (access)
– Progressive taxation
– Universal access but inequalities persist
2. Efficiency (cost)
– Spending now above OECD average*
– Central control of funding remains and low transaction costs
3. Effectiveness (quality)
– Moderate quality; variations in care persist
– User responsiveness and experience remain patchy
– Life expectancy similar to OECD average
Total health expenditure (% of GDP) among OECD
countries (2011)
How well does the NHS perform?
1. Equity (access)
– Progressive taxation
– Universal access but inequalities persist
2. Efficiency (cost)
– Spending now above OECD average*
– Central control of funding remains and low transaction costs
3. Effectiveness (quality)
– Moderate quality; variations in care persist
– User responsiveness and experience remain patchy
– Life expectancy similar to OECD average
AUS
CAN
GER
NETH
NZ
UK
US
OVERALL RANKING (2010)
3
6
4
1
5
2
7
Quality Care
4
7
5
2
1
3
6
Effective Care
2
7
6
3
5
1
4
Safe Care
6
5
3
1
4
2
7
Coordinated Care
4
5
7
2
1
3
6
Patient-Centered Care
2
5
3
6
1
7
4
6.5
5
3
1
4
2
6.5
Cost-Related Problem
6
3.5
3.5
2
5
1
7
Timeliness of Care
6
7
2
1
3
4
5
Efficiency
2
6
5
3
4
1
7
Equity
4
5
3
1
6
2
7
Long, Healthy, Productive
Lives
1
2
3
4
5
6
7
$3,357
$3,895
$3,588
$3,837*
$2,454
$2,992
$7,290
Access
Health spending/capita, 2007
Commonwealth Fund of New York (2010) “Mirror, mirror on the wall.”
So, which way for the NHS?
Scenarios for the future NHS
(1) "Slow uptake"
• People did little to improve their lifestyles
• Productivity grows <1.75%
• NHS spending rises to £184bn by 2022/23
(2) "Solid progress"
• More modest progress on improving public health
• NHS spending rises to £161bn by 2022/23
(3) "Fully engaged"
Wanless, 2002
• People adopted healthier lifestyles
• Rising productivity by <3% pa.
• NHS spending rises to £154bn by 2022/23
Questions for the future of the NHS?
1. Will the public retain faith in the NHS?
– NHS is no longer thought to be the top issue of public
concern1
– 44% not confident that a model of health care 'funded
by taxation and free to all' will survive2
•
1
36% expect NHS care to get worse over the next 5 years2
Ipsos-Mori, 2012; 2BSA, 2012;
– Transparency and quality
•
How will the NHS respond greater transparency of quality?
– Health-care scandals versus support for local hospital
– “Friends and family” test
Questions for the future of the NHS?
2. Will the public take on greater responsibility for their
health?
– Where should the NHS stop?
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•
88% agree that government should be mainly responsible for
paying for the cost of health-care. (82% in 1998). (BSA, 2012)
Health systems tend to exclude few services
– Who rations? Local commissioners, public consultation?
– Example: obesity
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Prevalence: 24% women, 22% men (2009; OECD)
What role for government, business, NHS & public?
Questions for the future of the NHS?
3. Can NHS balance rising demand within marginal
increases in funding?
– Increased funding in early 2000s did not lead to greater
productivity
• Approx.5% increase in funding needed to cope with demography
and technological advances
– But future funding rises likely to be limited for some time:
• Expected £20 billion NHS savings by 2015
• PFI adds further constraint*
– How will services be rationed in future and by whom?
• What role for local managers, clinicians and public?
£ billion
Annual payment schedule for all NHS PFI schemes over
contracts’ lifetimes
2012-2013
Parliament, 2012
Questions for the future of the NHS?
3. Can NHS balance rising demand within marginal
increases in funding?
– Increased funding in early 2000s did not lead to greater
productivity
• Approx.5% increase in funding needed to cope with demography
and technological advances
– But future funding rises likely to be limited for some time:
• Expected £20 billion NHS savings by 2015
• PFI adds further constraint*
– How will services be rationed in future and by whom?
• What role for local managers, clinicians and public?
Questions for the future of the NHS?
4. Can a new settlement be found between the public,
government, clinical professions and management?
– Re-set the policy direction:
•
•
•
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Integration should replace competition
England needs to learn lessons from Scotland, Wales & NI
Support for managers and leadership
Research evidence must inform but cannot dictate policy
– Overcome `reform fatigue’ within NHS:
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Constant organisational change without coherent narrative
Loss of organisational memory
Balance research evidence and social values
Questions for the future of the NHS?
4. Can a new settlement be found between the public,
government, clinical professions and management?
...Continued
– Re-discover `public service’ and `professionalism’
•
•
`Responsible professionalism’
– Balance power (autonomy) with responsibility
(accountability)
Co-production:
– Providers and public jointly define problems and devise
solutions
What is the future of the NHS? Final thoughts
• NHS has adapted over the past 65 years
– Its performance compares well to other countries
– But further change is imminent and on-going
• Fault-lines of NHS will shape its future
– Central-local / Profession-management / Health – health-care
• Answers to the questions will determine whether NHS can
remain central to British life for another 65 years
1.
2.
3.
4.
Keeping faith with the NHS
Taking responsibility for health
Paying for growing demands
Balancing public, government, professions & management
Inaugural lecture
Centre for Public Services Organisations annual lecture
21 February 2013
WHAT IS THE FUTURE OF THE NHS?
Professor Mark Exworthy
Professor of Health Policy and Management