This document discusses healthcare reforms in four nations - the UK, Netherlands, US, and Canada - from the 1980s to 2010. It analyzes how each country transitioned from an "ideal type" system in the 1980s to a hybrid system by 2010. The UK moved from a Beveridge-style hierarchical system to an internal market. The Netherlands shifted from Bismarck-style sickness funds to managed competition. The US changed from a residual system to a dual system. Canada maintained a single-payer system but with increased provincial variation. It argues that policy cycling is normal in healthcare systems as they seek to balance control between hierarchies, markets, and professionals over time.
This document provides a summary of the major provisions of the Affordable Care Act that impact employers and recommendations on how to prepare. It includes an overview of requirements that are already in place and future requirements. It also notes that Colonial Life's voluntary benefits are exempt from many of the health insurance reforms and discusses important considerations for voluntary benefits like the health insurance exchanges, employer reporting on W-2 forms, and the excise tax.
Stephen Frank - Role of Private Insurance for Prescription Drugs in CanadaPharmacare 2020
Private insurance plays an important role in supplementing Canada's public healthcare system by covering around 14% of total healthcare spending. While private insurers have to navigate a complex system with different provincial rules, they have adopted outsourcing and active plan management strategies to reduce costs and increase efficiency. Going forward, a mixed public-private system is optimal to ensure universal coverage while leveraging the strengths of both sectors in adapting to changes and controlling expenditures.
The Dutch health care system has struggled to control costs under universal health insurance. The introduction of regulated competition in 2006 through the Health Insurance Act aimed to increase incentives for efficiency. However, costs have continued to rise due to factors such as increased medicalization and supplier-induced demand from providers paid based on services rather than outcomes. Further reforms are needed such as reducing ex-post compensation for insurers, tying provider payments to health outcomes, and empowering purchasers and consumers to contain costs through more choice and transparency.
Jan-Kees Helderman on NHS reform - a Dutch perspective The King's Fund
Jan-Kees Helderman, assistant professor in Comparative Governance and Public Policy at Radbouyd University Nijmegan, outlines how the Dutch health care system operates and reflects on the English health reforms.
The document provides an overview of the Dutch healthcare system, including its financing, regulation, and introduction of competition in certain markets. Key points:
- The system relies on private health insurers and providers but with extensive government regulation focused on accessibility, affordability, and quality.
- A Dutch Healthcare Authority regulates insurers and providers to mitigate dominant market positions and initiate market reforms where possible.
- Competition was introduced for some elective hospital procedures, leading to price reductions in the competitive segment compared to the regulated segment.
- Long-term care is also being reformed, with ideas to introduce more private insurance or shift more to local government and consumer choice models.
There is broad consensus around the structure of national health reform proposals but disagreements remain around key details. Most proposals include subsidies for lower-income individuals, a health insurance exchange, a mandate for individuals to have coverage, new rules for insurers, and efforts to slow cost growth through payment reforms. However, important questions remain around issues like how much subsidies should cover, who will run the exchange, how affordability will be determined, and how the proposals will be financed without adding to the federal deficit.
Presentation made by Dr. Carolyn A. (Cindy) Watts on the 5th of November, 2012 during the live webinar hosted by VCU Department of Gerontology (discussion moderated by Dr E. Ayn Welleford) - review recording of webinar at http://www.alzpossible.org/wordpress-3.1.4/wordpress/alliedhealth/
The Dutch Health Care Reform 2006, a reflection
Having witnessed the movement of the Dutch Health Care Reform (see Wikipedia), it is inspiring to review it to evaluate what processes and forces have initiated the development and formed its course. In discussing possibilities for moving desired developments, we were reflecting on what processes or factors might be used to work along to stimulate innovation and change.
This document provides a summary of the major provisions of the Affordable Care Act that impact employers and recommendations on how to prepare. It includes an overview of requirements that are already in place and future requirements. It also notes that Colonial Life's voluntary benefits are exempt from many of the health insurance reforms and discusses important considerations for voluntary benefits like the health insurance exchanges, employer reporting on W-2 forms, and the excise tax.
Stephen Frank - Role of Private Insurance for Prescription Drugs in CanadaPharmacare 2020
Private insurance plays an important role in supplementing Canada's public healthcare system by covering around 14% of total healthcare spending. While private insurers have to navigate a complex system with different provincial rules, they have adopted outsourcing and active plan management strategies to reduce costs and increase efficiency. Going forward, a mixed public-private system is optimal to ensure universal coverage while leveraging the strengths of both sectors in adapting to changes and controlling expenditures.
The Dutch health care system has struggled to control costs under universal health insurance. The introduction of regulated competition in 2006 through the Health Insurance Act aimed to increase incentives for efficiency. However, costs have continued to rise due to factors such as increased medicalization and supplier-induced demand from providers paid based on services rather than outcomes. Further reforms are needed such as reducing ex-post compensation for insurers, tying provider payments to health outcomes, and empowering purchasers and consumers to contain costs through more choice and transparency.
Jan-Kees Helderman on NHS reform - a Dutch perspective The King's Fund
Jan-Kees Helderman, assistant professor in Comparative Governance and Public Policy at Radbouyd University Nijmegan, outlines how the Dutch health care system operates and reflects on the English health reforms.
The document provides an overview of the Dutch healthcare system, including its financing, regulation, and introduction of competition in certain markets. Key points:
- The system relies on private health insurers and providers but with extensive government regulation focused on accessibility, affordability, and quality.
- A Dutch Healthcare Authority regulates insurers and providers to mitigate dominant market positions and initiate market reforms where possible.
- Competition was introduced for some elective hospital procedures, leading to price reductions in the competitive segment compared to the regulated segment.
- Long-term care is also being reformed, with ideas to introduce more private insurance or shift more to local government and consumer choice models.
There is broad consensus around the structure of national health reform proposals but disagreements remain around key details. Most proposals include subsidies for lower-income individuals, a health insurance exchange, a mandate for individuals to have coverage, new rules for insurers, and efforts to slow cost growth through payment reforms. However, important questions remain around issues like how much subsidies should cover, who will run the exchange, how affordability will be determined, and how the proposals will be financed without adding to the federal deficit.
Presentation made by Dr. Carolyn A. (Cindy) Watts on the 5th of November, 2012 during the live webinar hosted by VCU Department of Gerontology (discussion moderated by Dr E. Ayn Welleford) - review recording of webinar at http://www.alzpossible.org/wordpress-3.1.4/wordpress/alliedhealth/
The Dutch Health Care Reform 2006, a reflection
Having witnessed the movement of the Dutch Health Care Reform (see Wikipedia), it is inspiring to review it to evaluate what processes and forces have initiated the development and formed its course. In discussing possibilities for moving desired developments, we were reflecting on what processes or factors might be used to work along to stimulate innovation and change.
Jon Bigelow discussed 8 trends in medical communications that matter including: 1) physicians practicing in a 24/7 world, 2) the recession resetting healthcare, 3) pharma restructuring, 4) a focus on specialty markets and emerging nations, 5) a reinvigorated FDA, 6) reforming healthcare through regulation and legislation, 7) increasing pharmaskepticism, and 8) the need for a call to action to address challenges in medical communications. He emphasized the importance of proactively presenting the value and best practices of medical communicators to multiple stakeholders.
Jon Bigelow discussed 8 trends in medical communications that matter including: 1) physicians practicing in a 24/7 world, 2) the recession resetting healthcare, 3) pharma restructuring, 4) a focus on specialty markets and emerging nations, 5) a reinvigorated FDA, 6) reforming healthcare through regulation and legislation, 7) increasing pharmaskepticism, and 8) the need for a call to action to address challenges in medical communications. He emphasized the importance of proactively presenting the value and best practices of medical communicators to multiple stakeholders.
Carolyn Tuohy: The institutional entrepeneur – a new force in health policy Nuffield Trust
In this slideshow, Professor Carolyn Hughes Tuohy, School of Public Policy and Governance, University of Toronto, outlines the concept of the institutional entrepeneur, particularly in UK, Dutch and US contexts of health reform.
Professor Tuohy presented at the Nuffield Trust seminar: Sharing international experience: The institutional entrepeneur – a new force in health policy in July 2012.
The document discusses how market-based policies have been introduced into the English NHS due to the influence of neoliberal ideology over the past 30 years. It argues that New Labour abandoned social democracy and adopted a form of Thatcherism in order to appease global financial markets. This has led the NHS to open up to market forces and privatization despite evidence that markets fail in healthcare provision. The document supports the BMA's campaign against the increasing marketization of the NHS.
Presentatie Leers Augustus 2007 Tbv Chinese Delegation Jppcmarusjkalestrade
I. The Dutch healthcare system is facing challenges as healthcare expenditures rise and the population ages, resulting in a shift from acute to chronic conditions. Healthcare performance is poor due to the planning and financing system.
II. Government intervention in prices and quantities has led to insufficient cost and quality awareness, lack of innovation, and waiting lists.
III. Stimulation of the healthcare system is needed to improve performance. This includes introducing more market forces, countervailing power between insurers and providers, and less government involvement.
Single payer health care could provide universal coverage at lower costs than the current US system. Evidence from other countries shows that single payer systems lead to higher access to care, greater utilization of services, better health outcomes, and lower overall costs compared to the US multi-payer system. Administrative costs are much lower under a single payer system due to simplified billing and insurance processes. Taiwan's transition to a national single payer system improved health outcomes, especially for vulnerable groups, while keeping costs low.
The document discusses various topics related to health care economics and financing in the United States, including the legislative process for health reform, current issues, health care financing models, sources of health insurance coverage, national health expenditures, payment reform efforts, and principles of health economics.
Healthcare systems and market access Germany and Denmark Carsten FrankeCarsten_Franke
With >20 years international sales and marketing strategies Carsten Franke is an expert in helping companies to develop go-to-market strategies enter European healthcare markets.
As German he lived 8 years in Denmark and now 2 years in Finland he is an expert in the European healthcare systems, especially Denmark and Germany.
Our biggest problem in healthcare is efficiency (quality of care per dollar spent) and Obamacare doesn't solve it. Our spending is off the charts by any measure (growth over time, % of GDP, per capita) Consumerism as a force of change in Healthcare is just getting started, but there are many barriers in place that serve to protect existing stakeholders in the industry. Knocking down these barriers to competition is what the GOP should be focusing on, but it's not. "Repeal and replace" seems to be a slogan, not a plan. Do Republican lawmakers have the will to make changes that might upset entrenched players?
This document summarizes and compares the healthcare systems of several countries, including the US, Japan, Germany, France, the UK, and Canada. It discusses the organization, quality, choice, access and problems of each system. The main models of healthcare delivery are national health services (UK), entrepreneurial/private systems (US), and mandated universal insurance (Germany). While every system faces rising costs, countries providing universal coverage achieve comprehensive benefits and access to care for all citizens.
Intellectual Property Rights and Access to
Essential Medicines
Thomas Pogge
Professor of Political Science, Columbia University
Centre for Applied Philosophy and Public Ethics, Australian National University
Centre for the Study of Mind in Nature, University of Oslo
This document discusses the role of government intervention in healthcare markets. It outlines different types of government intervention including informing, regulating, financing, providing, and taxing/subsidizing goods. It also discusses types of goods like public goods and merit goods that are prone to market failures. The key reasons for government intervention are to address market failures from public goods, externalities, incomplete markets, and market power. However, the document also notes potential government failures from capture by special interests, bureaucracy, and lack of capacity. There is no consensus on the appropriate role of public versus private sectors in different countries.
The survey found that healthcare companies see major market changes driving innovation, especially those resulting from healthcare reform. Retail exchanges and accountable care organizations were the top issues cited by over 40% of respondents. Regional health plans were most concerned about exchanges due to their complex requirements. Accountable care organizations also present challenges around network management and contracting. Overall the impending reform deadlines and legal uncertainties are creating a competitive environment where agile companies focused on innovation will have advantages.
The document discusses public-private partnerships (PPPs) in healthcare systems and provides examples from Abu Dhabi and Denia, Spain. It describes DAMAN, Abu Dhabi's compulsory public health insurance program established through a PPP with Munich Re. It outlines DAMAN's structure, products, and growth over time. It also summarizes the Denia project, a 15-year PPP contract in Spain integrating public health services and facilities under private management. The document concludes that strong private partners with expertise are key to PPP success and that gradual introduction of competition improves access, quality and efficiency.
This document provides an overview of a presentation focused on reducing health inequalities and the effects of privatization and profit-seeking on patient care and inequalities. It discusses evidence that privatization can lead to less community orientation, less teaching/training, more implicit rationing, and risk selection practices like "skimming, dumping, and skimping." The presentation also examines the political context and forces pushing privatization in the UK/England, questioning whether it is due to conspiracy, spin, or delivering on election promises. It outlines some policy options and calls for action from professionals, political parties, and the public.
This document discusses concerns about increasing privatization and for-profit involvement in the UK's National Health Service (NHS). It focuses on evidence that privatization can lead to risk selection, fragmentation of care, less community orientation, and rising transaction costs. The presentation examines political factors driving privatization policy and questions whether privatization will truly increase efficiency as claimed, given evidence it may increase costs. It argues for more transparency and accountability in health policy decisions.
The document discusses key issues related to health reform implementation for safety net health systems. It provides an overview of the National Association of Public Hospitals and Health Systems (NAPH), which advocates for safety net hospitals. The document outlines provisions of the Affordable Care Act related to coverage expansion, exchanges, provider payments, and innovation opportunities. It identifies challenges and questions for safety net health systems to consider regarding health reform implementation.
Jon Bigelow discussed 8 trends in medical communications that matter including: 1) physicians practicing in a 24/7 world, 2) the recession resetting healthcare, 3) pharma restructuring, 4) a focus on specialty markets and emerging nations, 5) a reinvigorated FDA, 6) reforming healthcare through regulation and legislation, 7) increasing pharmaskepticism, and 8) the need for a call to action to address challenges in medical communications. He emphasized the importance of proactively presenting the value and best practices of medical communicators to multiple stakeholders.
Jon Bigelow discussed 8 trends in medical communications that matter including: 1) physicians practicing in a 24/7 world, 2) the recession resetting healthcare, 3) pharma restructuring, 4) a focus on specialty markets and emerging nations, 5) a reinvigorated FDA, 6) reforming healthcare through regulation and legislation, 7) increasing pharmaskepticism, and 8) the need for a call to action to address challenges in medical communications. He emphasized the importance of proactively presenting the value and best practices of medical communicators to multiple stakeholders.
Carolyn Tuohy: The institutional entrepeneur – a new force in health policy Nuffield Trust
In this slideshow, Professor Carolyn Hughes Tuohy, School of Public Policy and Governance, University of Toronto, outlines the concept of the institutional entrepeneur, particularly in UK, Dutch and US contexts of health reform.
Professor Tuohy presented at the Nuffield Trust seminar: Sharing international experience: The institutional entrepeneur – a new force in health policy in July 2012.
The document discusses how market-based policies have been introduced into the English NHS due to the influence of neoliberal ideology over the past 30 years. It argues that New Labour abandoned social democracy and adopted a form of Thatcherism in order to appease global financial markets. This has led the NHS to open up to market forces and privatization despite evidence that markets fail in healthcare provision. The document supports the BMA's campaign against the increasing marketization of the NHS.
Presentatie Leers Augustus 2007 Tbv Chinese Delegation Jppcmarusjkalestrade
I. The Dutch healthcare system is facing challenges as healthcare expenditures rise and the population ages, resulting in a shift from acute to chronic conditions. Healthcare performance is poor due to the planning and financing system.
II. Government intervention in prices and quantities has led to insufficient cost and quality awareness, lack of innovation, and waiting lists.
III. Stimulation of the healthcare system is needed to improve performance. This includes introducing more market forces, countervailing power between insurers and providers, and less government involvement.
Single payer health care could provide universal coverage at lower costs than the current US system. Evidence from other countries shows that single payer systems lead to higher access to care, greater utilization of services, better health outcomes, and lower overall costs compared to the US multi-payer system. Administrative costs are much lower under a single payer system due to simplified billing and insurance processes. Taiwan's transition to a national single payer system improved health outcomes, especially for vulnerable groups, while keeping costs low.
The document discusses various topics related to health care economics and financing in the United States, including the legislative process for health reform, current issues, health care financing models, sources of health insurance coverage, national health expenditures, payment reform efforts, and principles of health economics.
Healthcare systems and market access Germany and Denmark Carsten FrankeCarsten_Franke
With >20 years international sales and marketing strategies Carsten Franke is an expert in helping companies to develop go-to-market strategies enter European healthcare markets.
As German he lived 8 years in Denmark and now 2 years in Finland he is an expert in the European healthcare systems, especially Denmark and Germany.
Our biggest problem in healthcare is efficiency (quality of care per dollar spent) and Obamacare doesn't solve it. Our spending is off the charts by any measure (growth over time, % of GDP, per capita) Consumerism as a force of change in Healthcare is just getting started, but there are many barriers in place that serve to protect existing stakeholders in the industry. Knocking down these barriers to competition is what the GOP should be focusing on, but it's not. "Repeal and replace" seems to be a slogan, not a plan. Do Republican lawmakers have the will to make changes that might upset entrenched players?
This document summarizes and compares the healthcare systems of several countries, including the US, Japan, Germany, France, the UK, and Canada. It discusses the organization, quality, choice, access and problems of each system. The main models of healthcare delivery are national health services (UK), entrepreneurial/private systems (US), and mandated universal insurance (Germany). While every system faces rising costs, countries providing universal coverage achieve comprehensive benefits and access to care for all citizens.
Intellectual Property Rights and Access to
Essential Medicines
Thomas Pogge
Professor of Political Science, Columbia University
Centre for Applied Philosophy and Public Ethics, Australian National University
Centre for the Study of Mind in Nature, University of Oslo
This document discusses the role of government intervention in healthcare markets. It outlines different types of government intervention including informing, regulating, financing, providing, and taxing/subsidizing goods. It also discusses types of goods like public goods and merit goods that are prone to market failures. The key reasons for government intervention are to address market failures from public goods, externalities, incomplete markets, and market power. However, the document also notes potential government failures from capture by special interests, bureaucracy, and lack of capacity. There is no consensus on the appropriate role of public versus private sectors in different countries.
The survey found that healthcare companies see major market changes driving innovation, especially those resulting from healthcare reform. Retail exchanges and accountable care organizations were the top issues cited by over 40% of respondents. Regional health plans were most concerned about exchanges due to their complex requirements. Accountable care organizations also present challenges around network management and contracting. Overall the impending reform deadlines and legal uncertainties are creating a competitive environment where agile companies focused on innovation will have advantages.
The document discusses public-private partnerships (PPPs) in healthcare systems and provides examples from Abu Dhabi and Denia, Spain. It describes DAMAN, Abu Dhabi's compulsory public health insurance program established through a PPP with Munich Re. It outlines DAMAN's structure, products, and growth over time. It also summarizes the Denia project, a 15-year PPP contract in Spain integrating public health services and facilities under private management. The document concludes that strong private partners with expertise are key to PPP success and that gradual introduction of competition improves access, quality and efficiency.
This document provides an overview of a presentation focused on reducing health inequalities and the effects of privatization and profit-seeking on patient care and inequalities. It discusses evidence that privatization can lead to less community orientation, less teaching/training, more implicit rationing, and risk selection practices like "skimming, dumping, and skimping." The presentation also examines the political context and forces pushing privatization in the UK/England, questioning whether it is due to conspiracy, spin, or delivering on election promises. It outlines some policy options and calls for action from professionals, political parties, and the public.
This document discusses concerns about increasing privatization and for-profit involvement in the UK's National Health Service (NHS). It focuses on evidence that privatization can lead to risk selection, fragmentation of care, less community orientation, and rising transaction costs. The presentation examines political factors driving privatization policy and questions whether privatization will truly increase efficiency as claimed, given evidence it may increase costs. It argues for more transparency and accountability in health policy decisions.
The document discusses key issues related to health reform implementation for safety net health systems. It provides an overview of the National Association of Public Hospitals and Health Systems (NAPH), which advocates for safety net hospitals. The document outlines provisions of the Affordable Care Act related to coverage expansion, exchanges, provider payments, and innovation opportunities. It identifies challenges and questions for safety net health systems to consider regarding health reform implementation.
This document discusses the potential impacts of automation on healthcare employment and discusses alternative views beyond job loss. It notes that automation may lead to reconfiguring of healthcare work rather than outright job loss. Examples of existing technologies that have automated tasks in healthcare like pharmacy automation and emerging technologies like decision support systems and personal health tracking are provided. The document advocates that automation could lead to a virtuous cycle in healthcare if it allows workers to focus on tasks that require human skills and judgment.
Evaluation of the Integrated Care and Support Pioneers ProgrammeNuffield Trust
This document summarizes the findings of evaluations of the Integrated Care and Support Pioneers Programme in the UK. The evaluations found that while Pioneers aspired to comprehensive system change, their activities focused more narrowly on initiatives like risk stratification and care coordination teams. Progress was difficult to measure against indicators and Pioneers faced challenges from financial pressures and competing priorities. The evaluations concluded that further integration will be challenging under increasing demands on the health system.
The document discusses lessons learned from the Southwark and Lambeth Integrated Care (SLIC) program in London. Key points:
- SLIC aimed to reduce hospital admissions and care home placements for older adults through risk stratification, holistic assessments, and care management.
- Success required agreement on the problem, dedicated teams, funding shifts to support community care, and leadership development.
- Future programs need a strong business case, co-design with citizens, and a dedicated "engine room" team to drive local transformation.
Effectiveness of the current dominant approach to integrated care in the NHSNuffield Trust
Jonathan Stokes of the Greater Manchester Primary Care Patient Safety Translational Research Centre presents a systematic review of case management in integrated care.
Providing actionable healthcare analytics at scale: Understanding improvement...Nuffield Trust
This document discusses measurement for quality improvement. It explains that measurement in improvement aims to provide a basis for action to improve processes and outcomes, rather than just estimating parameters. Improvement measures should be simple, specific, and available in real-time. Statistical process control methods are important to separate normal variation from changes resulting from interventions. Examples are provided of run charts measuring improvements in recording BMI for mental health patients and compliance with care bundles. The document advocates making the theories behind improvement efforts more explicit.
Ramani Moonesinghe, Associate National Clinical Director for Elective Care at NHS England, discusses the use of data for monitoring care quality at various levels within the system.
This document discusses using statistical process control (CUSUM) charts to monitor mortality rates at the level of individual general practitioners and health authorities. It describes how CUSUM charts could potentially have detected Harold Shipman, a GP who murdered over 200 patients, by spotting outliers in the routine mortality data. The document also discusses challenges in risk adjusting outcomes to account for differences in patient characteristics and casemix between providers. Accurately adjusting for factors like age, comorbidities, and emergency status is important for fair comparisons but difficult using only administrative data.
Martin Utley, Director of the Clinical Operational Research Unit at University College London, reflects upon his involvement in the launch of specific tools to monitor care quality for paediatric cardiac surgery.
Evaluating new models of care: Improvement Analytics UnitNuffield Trust
Martin Caunt, Improvement Analytics Unit Project Director and NHS England and Adam Steventon, Director of Data Analytics at The Health Foundation share insights into how they have approached evaluating new models of care.
Lisa Annaly, Head of Provider Analytics at the Care Quality Commission, discusses lessons learned from the CQC as they have worked to monitor care quality over time.
- Real-time monitoring of healthcare services requires defining both a reporting window and data window to accurately capture demand, activity, and wait times.
- Using only a reporting window (e.g. a single month) to request data can result in invalid or misleading performance metrics, as it does not account for patients with long wait times.
- Defining a larger data window that includes all patients requested before the end of the reporting window and reported after the start avoids this problem, but requires a counterintuitive data request.
- Without properly defining both windows, real-time monitoring can provide an inaccurate picture of service performance and falsely suggest the need for more resources.
Monitoring quality of care: making the most of dataNuffield Trust
Chris Sherlaw-Johnson, Senior Research Analyst at the Nuffield Trust, introduced the Monitoring quality of care conference and gives an overview of some of the approaches that we've been using at the Trust to identify where care quality has been improving, especially for frail and older people.
Providing actionable healthcare analytics at scale: Insights from the Nationa...Nuffield Trust
Christopher Boulton, Falls and Fragility Fracture Audit Programme Manager at the Royal College of Physicians and Rob Wakeman, Clinical Lead for Orthopaedic Surgery at the National Hip Fracture Database talk about what they have learned by analysing the national hip fracture database.
Providing actionable healthcare analytics at scale: A perspective from stroke...Nuffield Trust
Benjamin Bray, Research Director and the Sentinel Stroke National Audit Programme, presents at the Monitoring quality of care conference about stroke care analytics.
New Models of General Practice: Practical and policy lessonsNuffield Trust
Nuffield Trust policy researchers Rebecca Rosen and Stephanie Kumpunen present findings from our upcoming report on large scale general practice models.
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
Histololgy of Female Reproductive System.pptxAyeshaZaid1
Dive into an in-depth exploration of the histological structure of female reproductive system with this comprehensive lecture. Presented by Dr. Ayesha Irfan, Assistant Professor of Anatomy, this presentation covers the Gross anatomy and functional histology of the female reproductive organs. Ideal for students, educators, and anyone interested in medical science, this lecture provides clear explanations, detailed diagrams, and valuable insights into female reproductive system. Enhance your knowledge and understanding of this essential aspect of human biology.
Rasamanikya is a excellent preparation in the field of Rasashastra, it is used in various Kushtha Roga, Shwasa, Vicharchika, Bhagandara, Vatarakta, and Phiranga Roga. In this article Preparation& Comparative analytical profile for both Formulationon i.e Rasamanikya prepared by Kushmanda swarasa & Churnodhaka Shodita Haratala. The study aims to provide insights into the comparative efficacy and analytical aspects of these formulations for enhanced therapeutic outcomes.
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
Does Over-Masturbation Contribute to Chronic Prostatitis.pptxwalterHu5
In some case, your chronic prostatitis may be related to over-masturbation. Generally, natural medicine Diuretic and Anti-inflammatory Pill can help mee get a cure.
- Video recording of this lecture in English language: https://youtu.be/Pt1nA32sdHQ
- Video recording of this lecture in Arabic language: https://youtu.be/uFdc9F0rlP0
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Integrating Ayurveda into Parkinson’s Management: A Holistic ApproachAyurveda ForAll
Explore the benefits of combining Ayurveda with conventional Parkinson's treatments. Learn how a holistic approach can manage symptoms, enhance well-being, and balance body energies. Discover the steps to safely integrate Ayurvedic practices into your Parkinson’s care plan, including expert guidance on diet, herbal remedies, and lifestyle modifications.
Promoting Wellbeing - Applied Social Psychology - Psychology SuperNotesPsychoTech Services
A proprietary approach developed by bringing together the best of learning theories from Psychology, design principles from the world of visualization, and pedagogical methods from over a decade of training experience, that enables you to: Learn better, faster!
Promoting Wellbeing - Applied Social Psychology - Psychology SuperNotes
Carolyn Hughs Tuohy: A tale of three healthcare reforms
1. A Tale of Three Healthcare Reforms – and a Short Story:
the scale and pace of change in four advanced nations
…….and implications for England in the future
Carolyn Hughes Tuohy
Presentation for the London School of Hygiene and
Tropical Medicine and the Nuffield Trust
September 27, 2010
1
3. National Pre-Reform Ideal Type Post-Reform Hybrid
Example (1980s) (2010)
UK Beveridge:
(Big-bang)
Rule-based state hierarchy
Professional influence
Netherlands Bismarck
(Blueprint)
Sickness funds
Private insurance
Coordination through
intermediary associations
US Residual
(Mosaic)
Employer-based private
insurance as norm
Public programs for elderly
and poor
Canada Single-payer (SP) + mixed
(Incremental) market (MM)
SP for physician & hospital
services
MM for all other services
4. National Pre-Reform Ideal Type Post-Reform Hybrid
Example (1980s) (2010)
UK Beveridge: Internal market (England)
(Big-bang)
Rule-based state hierarchy Purchaser-provider split
Professional influence Hierarchical control through monitoring, evaluation
Netherlands Bismarck
(Blueprint)
Sickness funds
Private insurance
Coordination through
intermediary associations
US Residual
(Mosaic)
Employer-based private
insurance as norm
Public programs for elderly
and poor
Canada Single-payer (SP) + mixed
(Incremental) market (MM)
SP for physician & hospital
services
MM for all other services
5. National Pre-Reform Ideal Type Post-Reform Hybrid
Example (1980s) (2010)
UK Beveridge: Internal market
(Big-bang)
Rule-based state hierarchy Purchaser-provider split
Professional influence Hierarchical control through monitoring, evaluation
Netherlands Bismarck Managed competition
(Blueprint)
Sickness funds Universal mandatory insurance
Private insurance Comprehensive regulation of all insurers
Coordination through
intermediary associations
US Residual
(Mosaic)
Employer-based private
insurance as norm
Public programs for elderly
and poor
Canada Single-payer (SP) + mixed
(Incremental) market (MM)
SP for physician & hospital
services
MM for all other services
6. National Pre-Reform Ideal Type Post-Reform Hybrid
Example (1980s) (2010)
UK Beveridge: Internal market
(Big-bang)
Rule-based state hierarchy Purchaser-provider split
Professional influence Hierarchical control through monitoring, evaluation
Netherlands Bismarck Managed competition
(Blueprint)
Sickness funds Universal mandatory insurance
Private insurance Comprehensive regulation of all insurers
Coordination through
intermediary associations
US Residual Dual
(Mosaic)
Employer-based private Universal mandatory insurance
insurance as norm Employer-based private insurance as norm
Public programs for elderly Managed competition in individual and small-group
and poor market
Canada Single-payer (SP) + mixed
(Incremental) market (MM)
SP for physician & hospital
services
MM for all other services
7. National Pre-Reform Ideal Type Post-Reform Hybrid
Example (1980s) (2010)
UK Beveridge: Internal market
(Big-bang)
Rule-based state hierarchy Purchaser-provider split
Professional influence Hierarchical control through monitoring, evaluation
Netherlands Bismarck Managed competition
(Blueprint)
Sickness funds Universal mandatory insurance
Private insurance Comprehensive regulation of all insurers
Coordination through
intermediary associations
US Residual Dual
(Mosaic)
Employer-based private Universal mandatory insurance
insurance as norm Employer-based private insurance as norm
Public programs for elderly Managed competition in individual and small-group
and poor market
Canada Single-payer (SP) + mixed Single-payer (SP) + mixed market (MM)
(Incremental) market (MM)
Increased cross-provincial variation
SP for physician & hospital SP for physician & hospital services – some changes
services in organization & remuneration
MM for all other services MM for all other services: some changes in eligibility
esp. re drugs
8. Understanding Policy Change: Overview
• Policy cycling is the norm in advanced health care states
• Periodically, but rarely, external forces open a window of opportunity to
establish a new framework
• In those windows, different strategies of change are possible - large vs.
small scale; rapid vs slow pace – depending on political and institutional
conditions
• Britain, the Netherlands and the US provide examples of different strategic
decisions and their aftermath
• Canada provides the “short story” – the default case of continuous policy
cycling
• Particular attention to be paid to the English case
• Final speculations about Liberating the NHS
10. • A fundamental tension inherent to health care:
– how to control the agency relationship between providers and recipients of care.
“It all comes down to what happens in the operating room [office, surgery]”
– Essential to achieving all other goals: access, cost, quality
• Policy frameworks vary
– in the weights assigned to hierarchy, market and peer control mechanisms of
control
– In the balance of power across the state, private finance and providers
• These frameworks establish powerful and self-reinforcing logics
– lines of accountability: to whom do decision-makers feel responsible, and for
what – senior civil servants and politicians? managers of large pools of private
capital? medical professionals?
– flows of information: filtered up hierarchical channels? generated and
disseminated through signals from multiple independent actors? telegraphed
through professional networks?
11. • All of the mechanisms for controlling the agency relationship are flawed:
– Hierarchies may distort information through filtering; fail or delay in response to
local conditions
– Markets may lead to inequities, depending on initial endowments
– Both markets and hierarchies require a sophisticated and legitimate purchasing
function
– Peer control may reproduce the conflicts of interest that give rise to the need to
control the agency relationship in the first place
• Policy-makers therefore cycle through the repertoire established by the
prevailing framework
– Cycling reflects political, institutional and fiscal contexts: shifts in ideological
complexion of government; ad hoc coalitions; economic climate
– Centralization/decentralization; regulation/competition; collegiality vs autonomy
– Budgetary constraint/largesse
12. Policy Cycling In Britain 1970s-1980s
• Context: health-care agenda defined not by the growing cost pressures of
health as in other nations, but by mounting criticisms of the effects of cost
constraint.
• Policy cycles involved re-organization of the NHS hierarchy, and altering the
balance of influence between managers and professionals.
• Two cycles of organizational reforms in regional hierarchy: 1974 and 1982
– centralized then decentralized the regional hierarchy, altered the boundaries and
functions of regional authorities
– These changes reflected the respective ideological tilts of the governments that
instituted them.
– Labour (1970s) more favourable to central state action, consolidated and
rationalized the formerly tripartite structure of the NHS
– Conservatives (1980s), more favourable to local discretion, abolished one
regional layer and re-organized boundaries to allow for more localized entities.
13. • Another pattern of cycling re organization at the centre: the degree
of autonomy of NHS headquarters within the Department of Health.
– Conservatives (1980s and 1990s): NHS given progressively greater
institutional autonomy, epitomized by physical move to Leeds (Jarman
and Greer 2010).
– Labour after 1997: new cycle: re-integration of functions, epitomized by
combining the roles of the NHS Chief Executive and departmental
Permanent Secretary
– 2006: roles were split apart again and a debate about greater NHS
independence was rekindled
14. Policy cycling in the Netherlands, 1970s-1980s
• Context: ongoing tension between solidarity and subsidiarity in Dutch
political culture; fiscal pressures of health cost increases
• Dutch healthcare policy has sought to balance strong roles for intermediary
associations, notably insurers, vs. the state as regulator and subsidizer of
the system.
• In 1970s -1980s, solidarity was threatened as private insurers abandoned
voluntary community-rating under pressure of cost increases
• Produced cycles of price and supply constraint; increased/decreased state
weight within corporatist structures; stop-gap measures e.g. high-risk pool
15. Policy cycling in the US, 1970s-2000s
• Context: “veto-ridden” institutional structure and highly adversarial politics;
persistent strain of distrust of government, especially federal
• 1970s-1980s: Cycles of regulation/deregulation: HMOs, PSROs/PROs,
HSAs
• 1980s-1990s: Cycles of tightening and relaxing constraints on payments to
providers under Medicare
• 1990s-2000s: incremental increases/decreases in eligibility for coverage:
welfare reform; SCHIP; Medicare prescription drug coverage
• State-level experimentation and variety, largely in insurance regulation and
Medicaid
• Reactive to developments in private market and practicalities of ad hoc
coalition-building, largely within budgetary process
16. Policy cycling in Canada, 1970s-2000s
• Context: federal system with strong provinces; single-payer system for
physician and hospital services; tight accommodation between medical
profession and state at provincial level
• 1970s-1990s: progressive reduction of federal transfers to provinces
– Provincial cycles of horizontal reorganization in hospital sector: numerous
changes in numbers/boundaries of regional bodies; election/appointment of
directors
– Real reduction (~8%) in per capita public spending on health 1992-1996
– Budget caps and supply constraints
• 2000s: progressive increases in federal transfers to provinces
– Continuing reorganization in hospital sector
– Increases in physician pay, both FFS pot and targeted at new forms of
organization and remuneration
18. • Embedded investments in existing system (acquisition of resources,
establishment of information channels) make it extremely unlikely that
change will be generated from within the health care system
• Change requires intersection of two factors in the broader political system
– Mobilizing of authority
• Depends on political institutions: more difficult (but not impossible) as veto
points increase – e.g. congressional systems, federalism
– Political will to address health care as central to broader agenda
• Depends on political and partisan climate
• Strategic options:
– Scale of change: extent of change in institutional mix or structural balance or
both
– Pace of change: simultaneous vs gradual
• Major change means large scale or rapid pace or both
• Three cases of major change (GBR, NLD, USA) and one default case
(CAN)
19. Strategies of Change – Four Domains
BLUEPRINT BIG-BANG
•consensus on an overall framework within •large-scale change in a single
which each element is to be enacted over comprehensive sweep.
Large
time
•new institutions supplant previous
•new institutions supplant previous institutions
institutions
•typical where actors have consolidated
•typical where at least some parties can authority but face competitive pressure – e.g.
SCALE
reasonably expect to be in a position of Westminster system with competitive parties
influence over time – e.g. systems with
established traditions of coalition government
Gradual PACE Simultaneous
•multiple simultaneous adjustments to existing
•gradual piecemeal adjustments to existing institutional arrangements
institutional arrangements
•new institutions may co-exist with established; may
•new institutions may co-exist with established or may not introduce new organizing principles
•default category: where neither condition for •typical where one party is well-enough positioned to
major change is met – i.e. “ordinary” times in all build a minimum winning coalition within a relatively
systems and typical in veto-ridden systems brief window of time - e.g. supermajorities in veto-
Small
ridden systems
INCREMENTAL MOSAIC
20. Large
BLUEPRINT BIG-BANG
UK
1989-91
SCALE
PACE Simultaneous
Gradual
UK
1991-2010
INCREMENTAL MOSAIC
Small
21. Large
BLUEPRINT BIG-BANG
UK
1989-91
Netherlands
1987-2006
SCALE
PACE Simultaneous
Gradual
UK
1991-2010
INCREMENTAL MOSAIC
Small
22. Large
BLUEPRINT BIG-BANG
UK
1989-91
Netherlands
1987-2006
SCALE
US
1993-94
(failed)
PACE Simultaneous
Gradual
UK
1991-2010
US
2009-10
US
1994-2008
INCREMENTAL MOSAIC
Small
23. Large
BLUEPRINT BIG-BANG
UK
1989-91
Netherlands
1987-2006
SCALE
US
1993-94
(failed)
PACE Simultaneous
Gradual
UK
1991-2010
US
2009-10
US
1994-2004
Canada
1987-2010
INCREMENTAL MOSAIC
Small
24. Political Conditions: Four Domains
Strategy Type National Example Political Conditions
Big Bang UK (1990)
US (1993-94)
Blueprint Netherlands (1987-
2006)
Mosaic US (2009-10)
Incremental Canada (1987-2010)
25. Political Conditions: Four Domains
Strategy Type National Example Political Conditions
Big Bang UK (1990) Unitary parliamentary government structure
Majority government in third successive mandate
US (1993-94)
Blueprint Netherlands (1987-
2006)
Mosaic US (2009-10)
Incremental Canada (1987-2010)
26. Political Conditions: Four Domains
Strategy Type National Example Political Conditions
Big Bang UK (1990) Unitary parliamentary government structure
Majority government in third successive mandate
US (1993-94) Bicameral congressional government structure
Presidency and both Houses of Congress controlled by same
party by narrow margins
Blueprint Netherlands (1987-
2006)
Mosaic US (2009-10)
Incremental Canada (1987-2010)
27. Political Conditions: Four Domains
Strategy Type National Example Political Conditions
Big Bang UK (1990) Unitary parliamentary government structure
Majority government in third successive mandate
US (1993-94) Bicameral congressional government structure
Presidency and both Houses of Congress controlled by same
party by narrow margins
Blueprint Netherlands (1987- Unitary parliamentary government structure
2006)
Coalition government
Mosaic US (2009-10)
Incremental Canada (1987-2010)
28. Political Conditions: Four Domains
Strategy Type National Example Political Conditions
Big Bang UK (1990) Unitary parliamentary government structure
Majority government in third successive mandate
US (1993-94) Bicameral congressional government structure
Presidency and both Houses of Congress controlled by same
party by narrow margins
Blueprint Netherlands (1987- Unitary parliamentary government structure
2006)
Coalition government
Mosaic US (2009-10) Bicameral congressional government structure
Presidency and both Houses of Congress controlled by same
party by clear margins – supermajority in Senate
Incremental Canada (1987-2010)
29. Political Conditions: Four Domains
Strategy Type National Example Political Conditions
Big Bang UK (1990) Unitary parliamentary government structure
Majority government in third successive mandate
US (1993-94) Bicameral congressional government structure
Presidency and both Houses of Congress controlled by same
party by narrow margins
Blueprint Netherlands (1987- Unitary parliamentary government structure
2006)
Coalition government
Mosaic US (2009-10) Bicameral congressional government structure
Presidency and both Houses of Congress controlled by same
party by clear margins – supermajority in Senate
Incremental Canada (1987-2010) Federal parliamentary government structure – poor climate of
federal-provincial relations through 1990s
Majority governments at national and provincial levels until 2006;
minority government at federal level and briefly in Quebec
thereafter
30. Strategic Vulnerabilities
BLUEPRINT BIG-BANG
Large
•Each step in enactment process needs to •Conditions for successful use are especially
be as balanced as overall framework rare
SCALE
Gradual PACE Simultaneous
•Stickiness in response to changing •Complexity makes gaining popular support and
circumstances overcoming implementation vetoes particularly
difficult
Small
INCREMENTAL MOSAIC
31. Implementation: the Role of Strategic Allies
National Post-Reform Hybrid Entrepreneurial Allies in
Example (2010) Implementation
UK Internal market
(Big-bang)
Purchaser-provider split
Hierarchical control through monitoring, evaluation
Netherlands Managed competition
(Blueprint)
Universal mandatory insurance
Comprehensive regulation of all insurers
US Dual
(Mosaic)
Universal mandatory insurance
Employer-based private insurance as norm
Managed competition in individual and small-group
market
Canada Single-payer (SP) + mixed market (MM)
(Incremental)
Increased cross-provincial variation
SP for physician & hospital services – some changes
in organization & remuneration
MM for all other services: some changes in eligibility
esp. re drugs
32. Implementation: the Role of Strategic Allies
National Post-Reform Hybrid Entrepreneurial Allies in
Example (2010) Implementation
UK Internal market
(Big-bang) GP fundholders; executives
Purchaser-provider split of hospital trusts; purchasing
Hierarchical control through monitoring, evaluation experts
Netherlands Managed competition
(Blueprint)
Universal mandatory insurance
Comprehensive regulation of all insurers
US Dual
(Mosaic)
Universal mandatory insurance
Employer-based private insurance as norm
Managed competition in individual and small-group
market
Canada Single-payer (SP) + mixed market (MM)
(Incremental)
Increased cross-provincial variation
SP for physician & hospital services – some changes
in organization & remuneration
MM for all other services: some changes in eligibility
esp. re drugs
33. Implementation: the Role of Strategic Allies
National Post-Reform Hybrid Entrepreneurial Allies in
Example (2010) Implementation
UK Internal market
(Big-bang) GP fundholders; executives
Purchaser-provider split of hospital trusts; purchasing
Hierarchical control through monitoring, evaluation experts
Netherlands Managed competition
(Blueprint) Executives in sickness funds
Universal mandatory insurance and provider organizations
Comprehensive regulation of all insurers
US Dual
(Mosaic)
Universal mandatory insurance
Employer-based private insurance as norm
Managed competition in individual and small-group
market
Canada Single-payer (SP) + mixed market (MM)
(Incremental)
Increased cross-provincial variation
SP for physician & hospital services – some changes
in organization & remuneration
MM for all other services: some changes in eligibility
esp. re drugs
34. Implementation: the Role of Strategic Allies
National Post-Reform Hybrid Entrepreneurial Allies in
Example (2010) Implementation
UK Internal market
(Big-bang) GP fundholders; executives
Purchaser-provider split of hospital trusts; purchasing
Hierarchical control through monitoring, evaluation experts
Netherlands Managed competition
(Blueprint) Executives in sickness funds
Universal mandatory insurance and provider organizations
Comprehensive regulation of all insurers
US Dual Management of exchanges
(Mosaic) ???
Universal mandatory insurance Participants in pilot projects
Employer-based private insurance as norm ????
Managed competition in individual and small-group Meso-level and arm’s-length
market organizations ????
Canada Single-payer (SP) + mixed market (MM)
(Incremental)
Increased cross-provincial variation
SP for physician & hospital services – some changes
in organization & remuneration
MM for all other services: some changes in eligibility
esp. re drugs
35. Implementation: the Role of Strategic Allies
National Post-Reform Hybrid Entrepreneurial Allies in
Example (2010) Implementation
UK Internal market
(Big-bang) GP fundholders; executives
Purchaser-provider split of hospital trusts; purchasing
Hierarchical control through monitoring, evaluation experts
Netherlands Managed competition
(Blueprint) Executives in sickness funds
Universal mandatory insurance and provider organizations
Comprehensive regulation of all insurers
US Dual Management of exchanges
(Mosaic) ???
Universal mandatory insurance Participants in pilot projects
Employer-based private insurance as norm ????
Managed competition in individual and small-group Meso-level organizations
market ????
Canada Single-payer (SP) + mixed market (MM)
(Incremental) •Strategic alliances
Increased cross-provincial variation constrained by bilateral
SP for physician & hospital services – some changes monopoly, consolidated under
in organization & remuneration retrenchment
MM for all other services: some changes in eligibility
esp. re drugs
37. The Legacy of the Internal Market
• Internal market reforms were rare example of a major shift in mix of control
mechanisms
– from hierarchy and professional networks to contractual arrangements
among independent entities
– Implied significant change in types and flows of information
• Little change in balance of power across state, private finance and
providers, but shifts within these categories
• Reforms had a lasting impact on the system, but not before being absorbed
and mediated by the logic of the existing system.
• Relationships were re-styled as “contractual,” rather than “command-and-
control,” but established networks persisted, due to:
– Information costs
– Local health care political economies
38. The Legacy of the Internal Market (cont’d)
• Professional networks were reshaped with:
– Emergence of GP fund-holding
– Exercise of increased decision-making latitude by some hospital trusts
• i.e. certain key strategic actors saw the reforms as to their advantage and
began to drive them forward in particular ways
• Neither of these developments involved much “competition”
39. Blair Cycle 1, 1997-2000: “Third Way”
• Ambiguity and increasing central direction
• Elements of future directions signaled in December 1997 White Paper:
– PCT commissioning: cash-limited budgets, including prescribing
– National standards, not variation driven by competition in local markets: NICE,
CHI
– Clinical governance
– Patient voice through surveys
• Spending increased by ~4% annually, with focus on reducing obvious
failures to deliver:
– Waiting times
– Mortality from cancer, heart & stroke
40. Blair Cycle 2, 2000-2002:
Spending, centralization, targets
• Increased expenditure: Blair commitment to European Union average, 2001
Budget, Wanless reports
• Star-rating system under CHI
• Re-design of services under Modernization Agency
• Patient voice through forums in each Trust
• i.e. recovery of hierarchy, but (in theory) not central prescription of rules of
behaviour
– Rather, focus on ends, leaving means to discretion of local agents
– Trusts “compete” only with themselves – reward/punishment is related to
performance against targets, not performance against competitors
– In practice, much detailed central guidance
41. Blair-Brown Cycle 3, 2002-2010:
Return to markets and competition
• Delivering the NHS Plan:
– Devolution within a strategic framework
– Strategic Health Authorities replace HAs and NHS regional offices
– Foundation Trusts (FTs) – NHS providers with greater independence under
Independent regulator: Monitor
– Independent Sector Treatment Centres (ISTCs)
– Primary Care Trusts – strategic purchasers
• Later: practice-based commissioning
• The “Consumerist Wish:” patient choice through payment-by-results:
– Patient is offered choice at point of referral
– Money follows patient
– fixed tariff: therefore non-price competition on quality and access (vs internal
market)
• Self-report and publicity vs targets
– “Annual Health Check” replaces star-rating in 2005/2006
42. Ongoing centralization/decentralization tension
• Proliferation and reorganization of central bodies, e.g:
– CHI Healthcare Commission Care Quality Commission
– Modernization Agency NHS Institute for Innovation and Improvement
– NICE, Monitor
– Various patient involvement mechanisms
• Reorganization of regional structures, e.g:
– 2006: PCTs reduced from 303 152
43. Ambivalence re Clinician Involvement
• Abolition of “fund-holding” • PCGs PCTs PCTs+PBC:
continuing thread of GP centrality
• NICE clinical guidelines • Increased remuneration
• Reorganization of graduate • Sir Ara Darzi report: clinician-led,
education clinician endorsed (but BMA
skeptical)
• Increased lay control of GMC
45. How to read?
• “bold new vision?” “One of the biggest shake-ups in [NHS] history?”
• Or Cycle 4 of internal market framework?
46. • Historic election opened window of opportunity:
– unique (in peacetime) period of coalition government in the UK.
– aftermath of a synchronous global recession opened up agenda
• Neither a big-bang nor a blueprint strategy was likely:
– coalition governments do not lend themselves to big-bang strategies,
require multiple compromises
– blueprint approach was not feasible in a precarious coalition
• But a mosaic strategy of multiple novel adjustments and additions
might have been expected
– need to find support not only from both parties but across the left, right
and centre components of each party
– need for rapid action: one-term commitment
• In fact, however, the proposed reforms are best understood as a
fourth cycle of the internal market reforms, with a renewed emphasis
on
– clinical discretion and provider networks in the field
– increased NHS independence at the centre.
47. Liberating the NHS as Cycle 4
• fundamental logic of the purchaser-provider split was entirely consistent
with the broad agenda of “deconcentration” around which the Conservatives
and Liberal Democrats, could coalesce.
– “state-funded but self-run ‘foundation’ hospitals and ‘academy’ schools appeal to
an ancient Tory reverence for the local, the small and the independent” (The
Economist 2010:20).
– The decentralization motif also appealed to the Liberal Democrat leadership,
representing the “centre-right, small-state liberalism [that] for much of the history
of the Liberal Party, and then the Liberal Democrats, … has been able to coexist
happily with centre-left social liberalism” (Grayson in New Statesman 2010).
• All that was needed was to
– redress the tilt toward the centre through monitoring and performance
measurement under Labour (even in its most decentralist phases)
– accelerate the emphasis on “choice” of the last cycle of Labour policy
– resurrect and expand the role of GPs as key purchasers.
48. How will these changes now be absorbed by the logic
of the established framework?
• This will depend very much on the entrepreneurial allies of reform that
emerge
– Among GPs?
– Among “experts” in purchasing/commissioning?
– Among managements of Foundation Trusts?
– Within central agencies?