Reforming the English NHS Stephen P. Dunn, PhD, MA Senior Policy Advisor, Department of Health CMWF Harkness Fellow,

The NHS today treats 1 million people a day spends over £5 million ($8.5m) an hour polls show that 7/10 are happy with treatment polls show that majority of the British public –are proud of the NHS –4/5 think NHS is critical to British Society –must be maintained

= effective cost containment? Source: OECD (2002)

… but at what price? Source: Coleman (1999) Five year cancer survival rates

a legacy of under-funding! history of under-investment –cumulative £220bn underspend compared to EU ave too few doctors, nurses & other professionals too many old, inappropriate buildings late & slow adoption of medical technologies gap between system performance & public expectation growing = make or break for NHS

= funding controversies Q1: how much should the country be spending? –publicly (and privately) on healthcare? A1: 9.4% Q2: what is the optimal speed of catch up? –given capacity constraints? A2: 5 years Q3: how should the extra revenue be raised? –what is the fairest and most efficient route?

A3: stick with taxation ensure equitable, universal coverage minimise risk selection, gaming & cost-shifting harness monopsony power minimise administrative costs

Investment largest ever sustained increase in funding 50% increase in NHS funding –reaching c£90bn (c$160bn) in ! by 2008 total health spending will amount to 9.4% of national income –on a par with European levels

+ Reform = +expanding capacity +establishing national systems –standards –audit –inspection +improving choice & responsiveness –diversity –contestability

+ expanding capacity growing the number of health professionals –50,000 extra nurses, 5,000 more consultants & 1,500 GPs since 1997 modernising infrastructure –29 major new hospitals > 1,200 more general & acute beds in 2001/02 –1200 GP premises refurbished or replaced –200 new one stop-centres provided … major IT investment...

modernising IT infrastructure 3yr £2.3bn ($4bn) IT investment –country wide Electronic Health Record –Electronic prescribing and scheduling aims –reduce medical errors, lost records, delays & duplication –efficiency & promote active case management –provide certainty of appointment times –underpin patient choice of providers

+ expanding capacity growing the number of health professionals –50,000 extra nurses, 5,000 more consultants & 1,500 GPs since 1997 modernising infrastructure –29 major new hospitals > 1,200 more general & acute beds in 2001/02 –1200 GP premises refurbished or replaced –200 new one stop-centres provided –3yr £2.3bn ($4bn) IT investment supported learning and development –Modernisation Agency & NHSU

+ national systems national standards and targets –National Service Frameworks (NSFs) –National Institute for Clinical Effectiveness (NICE) inspection and regulation –Health Commission published performance information –Star ratings direct intervention for failing providers

… setting, delivering and monitoring standards NICE (guidelines & HTA) National Service Frameworks National Patient Safety Agency Health Commission Star Ratings NHS Modernisation Agency National Patient Survey Clear standards of service Monitored standards Professional Self-regulation Clinical governance Relicensing NCAA NHSU Patient & public involvement Dependable local delivery

… and national targets, e.g. cutting cancer death rates by 20% in people <75 by 2010 cutting heart disease death rates by 40% in people <75 by 2010 reducing death rates from suicide by 20% by 2010 reducing inequalities in health by 10% by 2010 –measured by infant mortality & life expectancy at birth, reducing the <18 conception rate by 50% by 2010 guaranteeing access to primary care physicians to 2 days by 2004 completing treatment (or admitting to hospital) all accident & emergency cases within four hours by 2004 cutting the wait for NHS-funded surgery to 12 weeks by 2008 improving patients experiences, as measured by national surveys improving the value for money of NHS care by at least 2% per year

… and national targets, e.g. cutting cancer death rates by 20% in people <75 by 2010 cutting heart disease death rates by 40% in people <75 by 2010 reducing death rates from suicide by 20% by 2010 reducing inequalities in health by 10% by 2010 –measured by infant mortality & life expectancy at birth, reducing the <18 conception rate by 50% by 2010 guaranteeing access to primary care physicians to 2 days by 2004 completing treatment (or admitting to hospital) all accident & emergency cases within four hours by 2004 cutting the wait for NHS-funded surgery to 12 weeks by 2008 improving patients experiences, as measured by national surveys improving the value for money of NHS care by at least 2% per year guaranteeing access to primary care physicians to 2 days by 2004 completing treatment (or admitting to hospital) all accident & emergency cases within four hours by 2004 cutting the wait for NHS-funded surgery to 12 weeks by 2008 guaranteeing access to primary care physicians to 2 days by 2004 completing treatment (or admitting to hospital) all accident & emergency cases within four hours by 2004 cutting the wait for NHS-funded surgery to 12 weeks by 2008

+ single payer, not single provider active single payer, primary care led purchasing introducing greater patient choice aligning provider incentives –DRG type reforms –new primary care contract new entrants & physician plural supply –international providers, e.g. United Kaiser? VHA? devolving control = >choice, responsiveness, diversity & contestability

new primary care contract new PCP contract –simpler rules, fairer capitation extra £1.9 bn for primary care –33% over 3yrs 18% increases in PCP income on quality –based on 146 indicators covering clinical (weighted by disease prevalence) organisational standards patient experience additional services

= major reform of the NHS redefining the model a National Health System? = a national set of values = care point of delivery based on need monolithic provision NHS as a national insurer –a mixed economy of provision –a Bismark / Beveridge hybrid

NHS which is a monopoly provider of health services & centrally accountable A greater diversity & plurality of services, more responsive to patients, inspected & regulated against transparent, common standards by an independent body that reports nationally & locally Move fromTo = major reform of the NHS

= new vision

= Tony Blairs reform principles Public Sector high national standards & clear accountability devolution of responsibility more flexibility for front line workers choice & diversity of provision

= major risk ?!?!?! the stakes are high –can the system deliver? the next election is a key threshold will enough have been achieved? … to earn Tony Blair another term? … and to give the NHS the time it needs?