the changing national context

School of Medicine & Health

The Changing National The Changing National ContextContext

David HunterDavid Hunter

Professor of Health Policy & Professor of Health Policy & ManagementManagement


Structure of TalkStructure of Talk

Challenges facing health systemsChallenges facing health systems

Overview of government’s NHS changesOverview of government’s NHS changes

Problems with the proposalsProblems with the proposals

An alternative approach to change in An alternative approach to change in complex systemscomplex systems


Medicine is a social science, and politics nothing else but medicine on a large scale.

Rudolf Virchow (1821-1902)


Challenges/Pressures Facing Challenges/Pressures Facing Health SystemsHealth Systems

Sustainable financing of the health sector, Sustainable financing of the health sector, including efficiency, productivity, cost controlincluding efficiency, productivity, cost control

Confronting the non-communicable disease Confronting the non-communicable disease epidemic (constitutes over 85% of the disease epidemic (constitutes over 85% of the disease burden in the WHO European Region)burden in the WHO European Region)

Growing importance of lifestyle risk factors Growing importance of lifestyle risk factors (e.g. alcohol misuse, obesity)(e.g. alcohol misuse, obesity)

Widening health inequalitiesWidening health inequalities


Welcome to the


The Health and Social Care Act The Health and Social Care Act (2012)(2012)

Devolve power to front-line doctors and Devolve power to front-line doctors and nursesnurses

Drive up qualityDrive up quality

Ensure a focus on integrationEnsure a focus on integration

Strengthen public healthStrengthen public health

Give patients more information and choiceGive patients more information and choice

Strengthen local democratic involvementStrengthen local democratic involvement

Reduce bureaucracyReduce bureaucracy


Continuing Policy Churn and Continuing Policy Churn and UncertaintyUncertainty

Coalition government’s ideological drive to Coalition government’s ideological drive to roll back the State shouldn’t be roll back the State shouldn’t be underestimatedunderestimated

Policy and organisational landscape is Policy and organisational landscape is unstable, unclear, complicatedunstable, unclear, complicated

Considerable anger and resistance Considerable anger and resistance

The government may have won the battle, The government may have won the battle, but has it won the war?but has it won the war?

Considerable risks lie ahead Considerable risks lie ahead


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.

Taylor-Gooby and Stoker, The Political Quarterly (2011)


Transition Risk Register Transition Risk Register (September 2010)(September 2010)

Loss of financial controlLoss of financial control

Loss of staff moraleLoss of staff morale

Loss of clinical time by GPs due to CCG Loss of clinical time by GPs due to CCG management responsibilitiesmanagement responsibilities

GP leaders are not sufficiently developedGP leaders are not sufficiently developed

Inability to reduce running costs because Inability to reduce running costs because of consortia numbersof consortia numbers

Postcode commissioningPostcode commissioning

QIPP failureQIPP failure


The NHS: From This…


…To This…


Main Criticisms of Proposed Main Criticisms of Proposed Changes (1)Changes (1)

Unnecessary – NHS performs well and is Unnecessary – NHS performs well and is highly rated by the publichighly rated by the public

Changes will increase bureaucracy and Changes will increase bureaucracy and layers of management not reduce themlayers of management not reduce them

GPs cannot ‘do’ commissioning – most GPs cannot ‘do’ commissioning – most don’t want to in any casedon’t want to in any case


Main Criticisms of Proposed Main Criticisms of Proposed Changes (2)Changes (2)

Case for more competition and private Case for more competition and private sector involvement in health care not sector involvement in health care not provenproven

Concerns about more fragmentation, less Concerns about more fragmentation, less collaboration remaincollaboration remain

Increased patient choice is an illusionIncreased patient choice is an illusion


Any Qualified Provider and Any Qualified Provider and CompetitionCompetition

ConcernsConcerns

Application of competition law: UK and EU Application of competition law: UK and EU

Role of Monitor remains uncertainRole of Monitor remains uncertain

Care is complex and demands Care is complex and demands collaboration/pathways, not fragmentationcollaboration/pathways, not fragmentation

Is competition the answer?Is competition the answer?


The Case Against CompetitionThe Case Against CompetitionEvidence concerning its virtues is limited Evidence concerning its virtues is limited and not convincingand not convincing

Loss of control and accountability if Loss of control and accountability if services put at mercy of shareholders and services put at mercy of shareholders and owners owners

What happens if private companies fail or What happens if private companies fail or go bust as some will?go bust as some will?

The central issue is not about efficiency The central issue is not about efficiency and productivity but the public interestand productivity but the public interest


Justice and the Common Good:Justice and the Common Good:the moral limits of marketsthe 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?


Towards an Alternative Towards an Alternative ApproachApproach

Governments mistake structural for Governments mistake structural for cultural changecultural change

The result is dynamics without changeThe result is dynamics without change

The structure doesn’t need major changeThe structure doesn’t need major change

Focus on other levers for real changeFocus on other levers for real change


The Nature of the ProblemThe Nature of the Problem...[T]he leaders of the NHS and government have sorted and resorted local, regional and national structures into a continual parade of new aggregates and agencies. Each change made sense, but the parade doesn’t make sense. It drains energy and confidence from the workforce....[T]he time has come for stability, on the basis of which, paradoxically, productive change becomes easier and faster for the good, smart, committed people of the NHS.

Don Berwick (2008)


Potential Levers for ChangePotential Levers for ChangeLean management – Lean management – a hospital’s operational a hospital’s operational effectivenesseffectiveness

Performance management – Performance management – the creation and use the creation and use of clinical quality and productivity targets in of clinical quality and productivity targets in managing operationsmanaging operations

Talent management Talent management – the recruitment, – the recruitment, development, rewarding, retention of high-development, rewarding, retention of high-performing staffperforming staff

Clinical leadership – Clinical leadership – the way the roles, skills, mind-the way the roles, skills, mind-sets of hospitals doctors contribute to the sets of hospitals doctors contribute to the management of clinical servicesmanagement of clinical services

McKinsey-LSE joint research (2008)McKinsey-LSE joint research (2008)


NHS Health and Wellbeing (The NHS Health and Wellbeing (The Boorman Report, 2009)Boorman Report, 2009)

Relationship between staff health and Relationship between staff health and wellbeingwellbeing

improved quality and organisational improved quality and organisational performanceperformance

patient satisfaction patient satisfaction

increased productivityincreased productivity

simple good management practicessimple good management practices


North East Transformation North East Transformation SystemSystem

Vision

Method Compact

No barriers to health & well beingNo avoidable deaths, injury or illnessNo avoidable pain or sufferingNo helplessnessNo unnecessary waiting or delaysNo WasteNo inequality

Toyota Production System /Virginia Mason Medical Centre

Psychological contract‘Gives’, ‘gets’, new imperatives


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 mediocrityWe have…Unexplained variation? Difficulty spreading best practice universally?Change that does not sustain?Non value added activity and waste?


Back to the Future?Back to the Future?

[The NHS is] a triumphant example of the superiority of collective action and public initiative applied to a segment of society where commercial principles are seen at their worst.

Aneurin Bevan, In Place of Fear (1952)

the changing national context

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thethe health

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