Rebecca Rosen: Tipping the balance
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Rebecca Rosen: Tipping the balance






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Rebecca Rosen: Tipping the balance Rebecca Rosen: Tipping the balance Presentation Transcript

  • Tipping the balance:quality and values versus money and power Dr Rebecca Rosen, Senior Fellow The Nuffield Trust 1
  • The context for change FinancialTechnology and Patient & Public innovation Slow progress to more efficient service design and delivery Policy & Regulation Professional 2
  • What have we tried to date? NHS commissioning cycle 1: Commissioning Commissioning reform agenda • Clinician engagement - PBC • Building commissioning capacity • External support for commissioning • World class commissioning • New incentives and tools • Payment by results • Demand Mx & service redesign • Competitive tendering2008 Audit commission review:• Limited clinician engagement in PBC with main focus on provision• Mixed picture regarding commissioning capacity and effective use of new commissioning tools.• Mis-aligned incentives restricting progress.• Early signs of competitive tendering used to change provider landscape• Power imbalance with providers a continuing problem. 3
  • What have we tried to date?2: Targets• Wide range of targets• Some clear wins • waiting times • access • QOF • Cancer careWell described un-desiredeffects• Tensions between managerialand clinical goals"The waiting time targets for new outpatient appointments at the Bristol Eye Hospital have beenachieved at the expense of cancellation and delay of follow-up appointments. At present we cancelover 1,000 appointments per month. Some patients have waited 20 months longer than the planneddate for their appointment."Harrad R. Evidence Submitted On Behalf Of Bristol Eye Hospital To The Health Select Committee,2004Risk of distorted organisational and clinical priorities 4
  • What have we tried to date?3: Regulation• Financial - Monitor • Assessment • Regulation • Development support• Quality HCC – CQC • Annual reviews • Special reviews/studies • Special investigations• Clarity about who does what• Nature and timing of investigation and intervention• Regulation as an improvement process 5
  • What have we tried to date?4: Models of care• NSFs and other nationalmodels• Evidence based qualityimprovement for highprevalence conditions andkey care groups• Single diseases & all longterm conditions• Regionalisation via Darziwork streams Balancing top down and bottom up initiatives to improve quality of care 6
  • What have we tried to date?5: Quality and values•Multiple NHS initiatives : NHS Institute IHI Pursuing perfection Collaboratives• Locally driven through clinicalchampions• Built on professional engagement By helping to develop and promote a culture of competency, the NHS Institute is seeking to help alland values NHS organisations achieve the same levels of quality and efficiency as top performing organisations. 2009Often project based small scale andhard to replicate 7
  • What have we tried to date?6: Money and powerNHS Turn around•Purely financial focus•Brute force change at high speed•? Impact on quality• ‘Hair-cutting’ with no attempt tore-align incentives for the longterm 8
  • What are we aiming for? Elective care Aligned incentives supporting different types of carePrimary care Long term conditions Integration of: • Patient care • Prof practice • Information • Strategic planning 9
  • Current challengesCrowded policy and regulatory landscape isconstraining ability to innovate • Payment by results • Financial regimes • Regulatory requirements • Choice and competition • Information governance 10
  • Getting the physiology right:Policy, regulation Professional Patient and publicfinance and targets• Quality: Post-Darzi • Quality: re-balancing • Quality: access,quality improvement ‘clinical ‘quality with outcome and other dimensions relationships•Move away fromblanket approach • Pace – a thirst for •Choice and voice inacross all care sectors change different settings• Balanced range of • Engagement > • Multiple ways tonational and local resistance interact with NHSpolicy levers 11
  • What will give us some oomph– Mixed model of organisational and financial regimes • Differentiation between episodic intervention and chronic care • Freedom to develop new organisational forms • Mixed basket of macro and micro incentives– Within different models, local discretion and redefined roles and relationships– Renegotiation of objectives re quality– More sophisticated patient influence– Data and IT to support targeted innovation– Air cover • regulation light, IT innovation, reduced levels of choice etc 12