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

2. 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.

3. 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.

4. 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.

5. 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.

6. 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.

7. 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).

8. 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.

9. 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.

10. 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.

11. 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.

12. 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.

13. Thank you for your attention
End
Thank you for your attention