1. School of Medicine & Health The Changing National Context David Hunter Professor of Health Policy & Management

2. 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

3. School of Medicine & Health Medicine is a social science, and politics nothing else but medicine on a large scale. Rudolf Virchow (1821-1902)

4. 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

5. School of Medicine & Health Welcome to the

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7. 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

8. 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 )

9. School of Medicine & Health The NHS: From This…

10. School of Medicine & Health …To This…

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14. 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

15. 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

16. School of Medicine & Health Any Qualified Provider and Competition Concerns Application of competition law: UK and EU Role of Monitor remains uncertain Care is complex and demands collaboration/pathways, not fragmentation Is competition the answer?

17. School of Medicine & Health The Case Against Competition Evidence 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

18. 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?

19. 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

20. 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)

21. 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

22. 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

23. School of Medicine & Health Potential Levers for Change Lean 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) McKinsey-LSE joint research (2008)

24. 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

25. School of Medicine & Health North East Transformation System Vision MethodCompact No barriers to health & well being No avoidable deaths, injury or illness No avoidable pain or suffering No helplessness No unnecessary waiting or delays No Waste No inequality Toyota Production System / Virginia Mason Medical Centre Psychological contract ‘Gives’, ‘gets’, new imperatives

26. 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 mediocrity We have… Unexplained variation? Difficulty spreading best practice universally? Change that does not sustain? Non value added activity and waste?

27. School of Medicine & Health Back to the Future? [The NHS is] a triumphant example of the superiority of collective action and public initiative applied to a segment of society where commercial principles are seen at their worst. Aneurin Bevan, In Place of Fear (1952)