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

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

3. School of Medicine & Health Where are we Now? Health & Social Care Bill halted – pause and listen But has the horse bolted? Case for reform not made: what is the problem to which the Bill is the solution? NHS performs well and is highly rated by the public Blair’s legacy: pace of change Various scenarios, including Health Committee’s report on commissioning

4. School of Medicine & Health Challenges to the Reforms Extension of competition GP commissioning consortia Accountability Risks in transition

5. School of Medicine & Health Challenges/Pressures Facing Health Systems (1) 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 (eg alcohol misuse, obesity) Widening health inequalities

6. School of Medicine & Health Challenges/Pressures Facing Health Systems (2) Consumerism and patient choice Priority-setting and rationing Public-private mix in health systems Harnessing new technologies to deliver improved health and health care

7. School of Medicine & Health New Challenges The age of austerity and financial cuts Doing more with less Doing less with less The Holy Grail – improving quality at less cost

8. School of Medicine & Health A strategy for chronic care severity age Life threat Symptoms emerge diagnosis salvage treatment Life Threat Symptoms emerge Management / Risk modification Predictions From thisTo this

9. School of Medicine & Health Capacity v Whole Systems Model Capacity v Whole Systems Model Capacity model Whole systems Acute Intermediate P.C. Centre Acute intermediate P.C Centre Long Stay Long Stay Individual service shifts are ‘negotiated’ across firewalls Portfolio / Integrated investment

10. School of Medicine & Health Any Willing/Qualified Provider and Competition Concerns Application of competition law: UK and EU Negative impact of price competition Role of Monitor The right sort of competition? What does the evidence say? Care is complex and demands collaboration/pathways, not fragmentation

11. School of Medicine & Health Does Competition Work? Competition under fixed prices appears to have beneficial results while competition where hospitals bargain over price and quality does not. Carol Propper (2010)

12. School of Medicine & Health Are Other Factors Important? 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)

13. 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

14. 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

15. 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?

16. School of Medicine & Health Last Word [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)