IPHA Annual Meeting Innovation in a New Economic Reality. Charles Normand Edward Kennedy Professor of Health Policy & Management University of Dublin Trinity College

Plan of presentation A crisis and an opportunity Changing how we deliver care Changing how we pay for care Changing skills and professions Changing the roles of service users Better services at lower cost.

A crisis and an opportunity Status quo is not an option Needs are increasing Demands are increasing Opportunities are increasing Resources are declining Costs are high, efficiency relatively low Government is committed to improvement There is a widespread acceptance that there must be changes in what is delivered and how.

A crisis and an opportunity 2 The action is in chronic disease and (generally) care outside hospital Demands on hospital system are growing more slowly than for primary and LTC Structures and processes still treat the continuous as episodic and surprising The challenge is increasing chronic disease and especially multi-morbidity.

Changing how we deliver care 1 From discreet events to continuous processes From referral to pathways From random events to planned events As centralised as necessary, as local as possible Likely that the changes will shift activity from (what is currently called) hospital care to (what is currently called) primary and community services The changes are less about structures and more about processes.

Changing how we deliver care 2 More use of guidelines and protocols and decision support More team work More support needed for navigation of the system More saying yes, and more saying no.

Changing how we pay for care 1 Tax versus UHI is less important than budgets versus MFTP Money can follow patients in lots of ways, and time and care is needed to design a suitable system MFTP can be designed to ensure incentives for the right service at the right time in the right place The current system of private health insurance provides limited additional services at high additional cost (including to the Government).

Changing how we pay for care 2 In times of very limited resources it is wise to attempt to minimise costs and maximise incentives for efficiency. It is possible that the Government plans will be simplified for this reason In designing any system of finance and payments we need to look carefully at incentives to patients and providers.

Changing skills and professions 1 There is no formal profession of optometry in France Dentistry has only been separated from surgery in Italy in recent times The present professional boundaries are no longer fully fit for purpose New professions and skill sets are emerging (dental hygienists, ANP etc) Evidence shows that in some chronic care the best managers are specially trained nurses.

Changing skills and professions 2 Optometrists now carry out some work formerly done by ophthalmologists The challenge is not just to encourage this trend, but to manage it so that we get safe and effective care.

Changing the roles of service users Service users want more choice (but it is really the fruits of choice that seem to be important) Users often can only participate if they are assisted and supported. This is seldom effectively done. Ageing brings more need for care and more carers. Statutory services will need to learn to work more in partnership.

Better services at lower cost. It’s simple – more demands and less resource requires lower cost services Lower costs come from doing less, doing more efficiently or lower pay We do not want doing less There are many versions of paying less – some involving changes in skill mix It may be easier to change the cost base of services when needs are growing and resources falling.

Thank you for your attention End Thank you for your attention