1. Funding & Performance of UK Countries Healthcare Systems Before & After Devolution Gwyn Bevan Professor of Policy Analysis Department of Management London School of Economics & Political Science R.G.Bevan@lse.ac.uk January 2012

2. 2 Models of governance in principle Altruism Low cost & popular Variation & perverse incentives reward failure Hierarchy & (central) targets (H&T) Powerful in short run Gaming: dysfunctional in long run? Choice & competition (C&C) Responsive & high performance? Problems in design & implementation entry & exit Reputation Powerful Gaming Individual Organisational

3. Models of governance since 1991: England 1991-97 1997- 2000 2000-052005-102013? England Altruism H&T C&C Reputation & Wales Wales Altruism C&C

4. C&C: Internal market (1989-97) Design* Purchaser / Provider Provider competition money follows the patient Selective contracting (no patient choice) health authorities GP fundholders *Working for Patients

5. C&C: Internal market (1989-97) Impact? Le Grand (1999)* Little evidence of change Incentives too weak & constraints too strong Tuohy (1999)** NHS logic Ministerial accountability Collegial decision making Poor information on prices & quality * Le Grand (1999) Competition, cooperation, or control? Health Affairs ** Tuohy (1999) Accidental Logics. Oxford University Press

6. C&C Altruism (1997) New Labour manifesto We will save NHS End Tory internal market & waiting for cancer surgery NHS manifesto pledge: 100,000 waiting list the New NHS 3rd way (Altruism)

7. 17 January 2000: Lord Winstons verdict gave categorical promises would abolish internal market... not done that want NHS steadily deteriorate rationed & inferior for heart disease & cancer? NHS much the worst in Europe medical expert & Labour peer Source: The New Statesman, interview, 17 January 2000

8. 20 January 2000: Most expensive breakfast in British history 4% 2% Weve decided to NHS spend to European average (% GDP) NHS spend (% GDP)

9. Altruism H&T & Reputation Star ratings (2000-05) 9 Key targets balanced scorecard patient surveys clinical outcomes capability & capacity Zero Clinical Governance Clinical Governance

10. Star rating: naming & shaming of zero stars devastating …hit right down to the workforce – whereas bad reports usually hit senior management upwards …nurses demanding changing rooms.. because being accosted in streets Source: Mannion et al (2005) 2001:the dirty dozen

11. England: Altruism (3 rd way) Numbers waiting elective admissions (England) (000s)

12. England: Altruism (3 rd way) Reputation (s tar rating) Numbers waiting elective admissions (England) (000s) Star ratings published

13. Source: Bevan (2009) Star ratings published No/000 waiting > 6 months elective hospital admission England: Altruism Reputation Wales: Altruism

14. Source: Bevan (2009) Star ratings published No/000 waiting > 3 months GP 1st outpatient appointment

15. Natural experiment: Altruism & H&T & Reputation Source: Connolly et al (2010) % waiting list > 13 weeks for hospital admission (March 2008)

16. Natural experiment: Altruism & H&T & Reputation Star ratings published Target Source: Bevan & Hamblin (2009) % Ambulance response times to life-threatening emergencies < 8 minutes

17. Barber (2007) Instruction to Deliver Awful adequate Command & control public not satisfied have to keep flogging the system Adequate good / great quasi market & consumer choice innovation from self- sustaining systems

18. C& C: Patient choice (2006 - 10): Design* Provider competition money follows the patient (PbR) standard tariff: quality competition Selective contracting Primary Care Trusts (World Class Commissioning) Patient choice Provider diversity Foundation Trusts & Independent Sector Treatment Centres *Delivering the NHS Plan

19. C& C:Patient choice (2006-10) Impact? Failure to create functioning market* political interference weak purchasers barriers to exit & entry changing policies reorganisations No * Brereton & Vasoodaven (2010) http://www.civitas.org.uk/nhs/download/Civitas_LiteratureRe view_NHS_market_Feb10.pdf

20. Publications Connolly S, Bevan G, Mays N. Funding and Performance of Healthcare Systems in the Four Countries of the UK before and after Devolution. London: the Nuffield Trust, 2011 (revised). Bevan, G. Approaches and impacts of different systems of assessing hospital performance. Journal of Comparative Policy Analysis, 2010, 12(1 & 2): 33 - 56. Bevan, G. Have targets done more harm than good in the English NHS? No. BMJ 2009; 338: a3129 Bevan G, Hamblin R. Hitting and missing targets by ambulance services for emergency calls: impacts of different systems of performance measurement within the UK. Journal of the Royal Statistical Society (A), 2009, 172(1):1-30.

21. Publications Bevan G. Is choice working for patients in the English NHS? BMJ 2008; 337: a935. Bevan G. Setting Targets for Health Care Performance: lessons from a case study of the English NHS. National Institute Economic Review 2006, 197: 67-79. Bevan G, Hood C. Whats Measured is What Matters: Targets and Gaming in the English Public Health Care System. Public Administration 2006, 84(3): 517-38. Bevan G, Hood C. Have targets improved performance in the English NHS? British Medical Journal 2006, 332: 419-422.