Prof David Hunter - Meeting the Challenge - Does the new NHS promote or hinder cooperation and integration?

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School of Medicine Pharmacy & Health

Meeting the Challenge of Long
Term Conditions:
Does the new NHS promote or hinder cooperation
and integration?
Presented by David Hunter
Professor of Health Policy and Management
28th March 2014

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Medicine is a social science, and politics nothing
else but medicine on a large scale.
Rudolf Virchow (1821-1902)

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The English Patient
The new NHS one year on
 Policy and organisational landscape: unstable,
confused, complicated
 Case for change unproven
 NHS performs well: highly
rated by the public and
internationally
 Extending choice and
competition: on what grounds?
Where’s the evidence?

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2012 Olympic Games Tribute to NHS

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Note: * Estimate. Expenditures shown in $US PPP (purchasing power parity).
Source: Calculated by The Commonwealth Fund based on 2007 International Health Policy Survey; 2008 International Health Policy Survey of Sicker
Adults; 2009 International Health Policy Survey of Primary Care Physicians; Commonwealth Fund Commission on a High Performance Health System
National Scorecard; and Organization for Economic Cooperation and Development, OECD Health Data, 2009 (Paris: OECD, Nov. 2009).
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
Access 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
Health Expenditures/Capita, 2007 $3,357 $3,895 $3,588 $3,837* $2,454 $2,992 $7,290
Country Rankings
1.00–2.33
2.34–4.66
4.67–7.00
Exhibit ES-1. Overall Ranking

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Confused?
You should be

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The NHS: From This…

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…To This

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…Or This

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…Or This
Communication links
Painted by Jackson
Pollock
…this must be
Pollock’s!

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Main Criticisms of Changes
 Changes have increased bureaucracy and
layers of management, not reduced them
 GPs (with a few honourable exceptions)
cannot ‘do’ commissioning – most don’t
want to
 Upshot is fragmentation, not collaboration

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A Dog’s Breakfast

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Justice and the Common Good:
the moral limits of markets
Since marketising social practices may corrupt or
degrade the norms that define them, we need to
ask what non-market norms we want to protect
from market intrusion…[U]nless we want to let
the market rewrite the norms that govern social
institutions, we need a public debate about the
moral limits of markets.
Michael Sandel (2010) Justice: What’s the right thing to do?

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The coalition programme…involves a restructuring
of…public services that takes the country in a new
direction, rolling back the state to a level of intervention
below that in the United States – something which is
unprecedented. Britain will abandon the goal of attaining
a European level of public provision. The policies include
substantial privatisation and a shift of responsibility from
state to individual.
P Taylor-Gooby, G Stoker (2011) The Political Quarterly
Triumph of Ideology over Evidence

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Comparethemeerkat.com

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Last Words from Outgoing NHS
Chief Executive
 Competition rules and regulations made 'it very difficult [for
health providers] to make decisions' and was preventing
service change
 'It's not clear now who makes the decisions...'
 Commissioners are not driving change
 New system required 'mutual trust and working across
organisations' but 'a lot of experienced people had left the
service' and 'a lot of those relationships have been fractured'.
Sir David Nicholson speaking to HSJ,
March 2014

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Challenges/Pressures Facing Health
Systems
 Sustainable financing of the health sector, including
efficiency, productivity, cost control
 Confronting the non-communicable disease epidemic
(constitutes over 85% of the
disease burden in the WHO Europe
an Region)
 Growing importance of lifestyle risk
factors (e.g. alcohol misuse, obesity)
 Disease burden partly reflects
growing inequalities

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The Obesity System

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Source: The Economist, 12 November 2003.
Evolutionary Trends: How far
have we really come?

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New Challenges
The age of austerity and financial cuts
 Doing more with less
 Doing less with less
 The Holy Grail – improving
quality at less cost

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A Strategy for Long Term Conditions
From this To this
severity severity
age age
Life threat
Symptoms emerge
diagnosis
salvage
treatment
Life threat
Symptoms emerge
Management /
Risk modification
Predictions

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Capacity v Whole Systems Model
Capacity
model
Whole
systems
Acute Community
Primary
Care
Acute Community Primary
Care
Social
Care
Social
Care
Individual
service shifts
are ‘negotiated’
across firewalls
Portfolio /
Integrated
investment

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Symptoms of Failure Health
Systems (1)
 Persistent financial, quality or safety problems
 Management distracted by constant ‘redisorganisation’,
changing policies, fads and fashions, priorities
 Low staff morale, including clinician disengagement
(e.g. Mid Staffs)
 Weak implementation of policies and plans because of
all of the above

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Symptoms of Failure Health
Systems (2)
 Policy incoherence – policies push and pull in
different directions
 Poor leadership in handling complexity and ‘wicked
issues’
 Lack of political will
 Absence of cooperation across care
pathways/whole system
 Inter-organisational relationships undeveloped

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What is NETS?

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Why do we need NETS?
The NHS delivers service
which incorporates real
excellence which it should
be proud.
But….
Pockets of excellence and
poor practice in a sea of
mediocrity
We have…
Unexplained variation?
Difficulty spreading best
practice universally?
Change that does not
sustain?
Non value added activity
and waste?

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Real Reform
 Patient-centred
 Service redesign
 Work collaboratively across boundaries
 Nurture high trust relationships with local
partners
 Importance of collaborative leadership

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The Challenge
The needs of one person addressed
by people acting as one team, from
organisations behaving as one
system.
Oldham report (2014)
Independent Commission on Whole Person Care

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Health System Access Pyramid
Regional
Centres
Acute
Hospitals
Primary Care
Services
Social Care
Health Improvement &
Wellbeing

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Health System Access Pyramid
Health Improvement &
Wellbeing
Social Care
Primary Care
Services
Acute
Hospitals
Regional
Centres

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!

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