School of Medicine & Health The Changing National Context David Hunter Professor of Health Policy &...
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Transcript of School of Medicine & Health The Changing National Context David Hunter Professor of Health Policy &...
School of Medicine & Health
The Changing National Context
David Hunter
Professor of Health Policy & Management
School of Medicine & Health
Structure of Talk
Challenges facing health systems
Overview of government’s NHS changes
Problems with the proposals
An alternative approach to change in complex systems
School of Medicine & Health
Medicine is a social science, and politics nothing else but medicine on a large scale.
Rudolf Virchow (1821-1902)
School of Medicine & Health
Challenges/Pressures Facing Health Systems
Sustainable financing of the health sector, including efficiency, productivity, cost control
Confronting the non-communicable disease epidemic (constitutes over 85% of the disease burden in the WHO European Region)
Growing importance of lifestyle risk factors (e.g. alcohol misuse, obesity)
Widening health inequalities
School of Medicine & Health
Continuing Policy Churn and Uncertainty
Coalition government’s ideological drive to roll back the State shouldn’t be underestimated
Policy and organisational landscape is unstable, unclear, complicated
Ultimate fate of Health & Social Care Bill remains uncertain – opposition hardening
School of Medicine & Health
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)
School of Medicine & Health
Main Criticisms of Proposed Changes (1)
Unnecessary – NHS performs well and is highly rated by the public
Changes will increase bureaucracy and layers of management not reduce them
GPs cannot ‘do’ commissioning – most don’t want to in any case
School of Medicine & Health
Main Criticisms of Proposed Changes (2)
Case for more competition and private sector involvement in health care not proven
Concerns about more fragmentation, less collaboration remain
Increased patient choice is an illusion
School of Medicine & Health
Any Qualified Provider and Competition
ConcernsApplication of competition law: UK and EU
Role of Monitor remains uncertain
Care is complex and demands collaboration/pathways, not fragmentation
Is competition the answer?
School of Medicine & Health
The Case Against CompetitionEvidence concerning its virtues is limited and not convincing
Loss of control and accountability if services put at mercy of shareholders and owners
What happens if private companies fail or go bust as some will?
The central issue is not about efficiency and productivity but the public interest
School of Medicine & Health
Justice and the Common Good:the 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?
School of Medicine & Health
Towards an Alternative Approach
Governments mistake structural for cultural change
The result is dynamics without change
The structure doesn’t need major change
Focus on other levers for real change
School of Medicine & Health
The 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)
School of Medicine & Health
Symptoms of Failure in Health Systems (1)
Persistent financial, quality or safety problems
Management distracted by constant ‘redisorganisation’, changing policies, priorities
Low staff morale, including clinician disengagement
Weak implementation of policies and plans
School of Medicine & Health
Symptoms of Failure in Health Systems (2)
Policy incoherence – policies push and pull in different directions
Poor leadership in handling complexity and wicked issues
Lack of political will
Absence of cooperation across care pathway/total system
Inter-organisational relationships undeveloped
School of Medicine & Health
Potential Levers for ChangeLean management – a hospital’s operational effectiveness
Performance management – the creation and use of clinical quality and productivity targets in managing operations
Talent management – the recruitment, development, rewarding, retention of high-performing staff
Clinical leadership – the way the roles, skills, mind-sets of hospitals doctors contribute to the management of clinical services
McKinsey-LSE joint research (2008)
School of Medicine & Health
NHS Health and Wellbeing (The Boorman Report, 2009)
Relationship between staff health and wellbeing
improved quality and organisational performance
patient satisfaction
increased productivity
simple good management practices
School of Medicine & Health
North East Transformation System
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
School of Medicine & Health
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?