1. Economic Issues in the NHS John Appleby Chief Economist King’s Fund

2. What issues? Spending Waiting lists Choice Efficiency, competition and incentives

3. Determining NHS spending £0£1,000 bn Full range of spending options Realistic spending range? Current spend

4. How much should we spend? xy Health care (£y-x) Education (£x) Total resources available Cost Benefit A B z Fast cars (£z-y) C

5. …and now with real data.. Total resources available Cost Benefit ?

6. Pledge/promise…er..aspiration

7. Will we get there?

8. Spend what we can afford?

9. Wanless Review of NHS funding Defined a ‘vision’ of the NHS in 2022 Costed vision (ie, reductions in waiting times, increased quality, better infrastructure etc) Crude sensitivity analysis produced three possible spending pathway scenarios Cost by 2022 (today’s prices) –‘Fully engaged’: £154 bn (10.5% GDP) –‘Solid progress’: £161 bn (11.1% GDP) –‘Slow uptake’: £184 bn (12.5% GDP)

10. Wanless recommends….

11. ...Brown accepts

12. Issues for Wanless II Cause and effect Health  health care spending Improving health is the objective Better sensitivity analysis Evidence base for assumptions More of the same? Patient/public satisfaction

13. Cause and effect Wanless assumed relationships between variables that were: –Fixed (constant over time) –Linear (A determines B) –Bivariate (only A determines B) But, relationships change over time, have ‘feedback’ loops and tend to be multivariate: eg Technological advance influences supply and demand Reduced waiting times creates more demand...

14. Health  health care spending Differences in assumptions about population’s future health generates the three ‘scenarios. Level of health assumed rather than generated by Wanless Increased spending > improved health: not part of Wanless’ approach Health influences demand (and hence spending levels) but is also a desired outcome of higher spending

15. Improving health is the objective Is the ‘vision’ for the NHS in 2022 the best (eg most effective and cost effective) way to achieve actual goal: ie improving population health?

16. Better sensitivity analysis Most important cost drivers: delivering high quality services and meeting rising expectations (common to all three scenarios). But how sensitive are predictions about changing quality and expectations?

17. Evidence base for assumptions Need for systematic review of the evidence supporting Wanless Review recommendations

18. More of the same? Wanless had a tendency to assume the NHS in 2022 would look similar to the NHS in 2002 - but bigger. Different structures, different ways of working?

19. Patient/public satisfaction What are the determinants of satisfaction? How do these change over time? Patient/public involvement in determining spending levels?

20. Why do we wait? Not enough resources? Demand > supply? Poor management? Private practice? Clinical variations? No prices?

22. Targets, Targets, Targets Numbers Maximum waiting time Average waiting time Variations in waiting list/maximum/average time …a fair waiting list process?

23. Reduce total waiting

24. How was it achieved?

25. Reduce maximum wait

26. Reduce average wait

27. Reduce variations in waiting

28. ...a fair process? Clinical need (urgent, soon…er…never?) Scoring system?

29. Choice Economics: study of behaviour of people with choices Sociology: study of behaviour of people with none

30. Choice: current policy New policy objective for the NHS? National cardiac care choice scheme London patients choice project How did we get here? Implications for financial flows

31. Choice in the NHS: some issues Choice vs other system goals (eg equity, efficiency) Choice of what? Limits to choice? Information (eg asymmetry and knowledge) Relationship between principle and agent

32. Efficiency, competition, incentives Target to reduce waiting times......Patient choice......Financial flows…. = Fixed price contract market!?

33. Fixed (HRG) price market Implementation? –What tariff? –What period? –Rules of engagement?

34. Fixed (HRG) price market Benefits –Incentive to increase volume –Reduce private sector prices –Cut costs/improve efficiency

35. Fixed (HRG) price market Costs –Quality/cost trade off –Exit from market –Mergers –Cross subsidisation within hospitals –Unavoidable costs/inefficiency –Regulation/monitoring/transaction costs