Funding & Performance of UK Countries Healthcare Systems Before & After Devolution Gwyn...

Funding & Performance of UK Countries Healthcare Systems Before & After Devolution

Gwyn BevanProfessor of Policy Analysis

Department of ManagementLondon School of Economics & Political

ScienceR.G.Bevan@lse.ac.uk

January 2012

2

Models of governance in principle

Altruism Low cost & popular Variation & perverse

incentives reward failure

Hierarchy & (central) targets (H&T) Powerful in short run Gaming: dysfunctional

in long run?

Choice & competition (C&C) Responsive & high

performance? Problems in design &

implementation entry & exit

Reputation Powerful Gaming

Individual Organisational

Models of governance since 1991: England

1991-97 1997-2000

2000-05 2005-10 2013?

England Altruism H&T C&C Reputation

& Wales

Wales Altruism C&C

C&C: Internal market (1989-97) Design*

Purchaser / Provider Provider competition

‘money follows the patient’ Selective contracting (no patient

choice) health authorities GP fundholders

*Working for Patients

C&C: Internal market (1989-97) Impact?

Le Grand (1999)* Little evidence of change Incentives too weak & constraints

too strong

Tuohy (1999)** NHS logic

Ministerial accountability Collegial decision making Poor information on prices & quality

* Le Grand (1999) Competition, cooperation, or control? Health Affairs** Tuohy (1999) Accidental Logics. Oxford University Press

C&C Altruism (1997) New Labour manifesto

We will save NHS End Tory internal market

& waiting for cancer surgery

NHS manifesto pledge: 100,000 waiting list

the New NHS 3rd way (Altruism)

17 January 2000: Lord Winston’s verdict gave categorical promises

would abolish internal market ... not done that

want NHS steadily deteriorate rationed & inferior for heart disease & cancer?

NHS “much the worst in Europe”

medical expert & Labour peer

Source: The New Statesman, interview, 17 January 2000

20 January 2000: Most expensive breakfast in British history

2.5

5

7.5

10

1948 1958 1968 1978 1988 1998 2008

4%

2%

We’ve decided to NHS spend to European average (% GDP)

NHS spend (% GDP)

2.5

5

7.5

10

1948 1958 1968 1978 1988 1998 2008

Altruism H&T & Reputation Star ratings (2000-05)

9 Key targets

‘balanced scorecard’ patient surveys clinical outcomes capability & capacity

ZeroClinicalGovernance

Clinical Governance

Star rating: ‘naming & shaming’ of zero stars

‘devastating …hit right down to the workforce – whereas bad reports usually hit senior management upwards …nurses demanding changing rooms .. because being accosted in streets’

Source: Mannion et al (2005)

2001:the dirty dozen

England: Altruism (3rd way)

0

100

200

300

400

1997 1998 1999 2000 2001 2002 2003 2004 2005

>6 months >9 months (2004) >12 months (2003)

Numbers waiting elective admissions (England) (‘000s)

England: Altruism (3rd way) Reputation (star rating)

Numbers waiting elective admissions (England) (‘000s)

Star ratings published

Source: Bevan (2009)

Star ratings published

No/‘000 waiting > 6 months elective hospital admission

England: Altruism ReputationWales: Altruism

England: Altruism ReputationWales: Altruism

Source: Bevan (2009)

Star ratings published

No/‘000 waiting > 3 months GP 1st outpatient appointment

Natural experiment: Altruism & H&T & Reputation

Source: Connolly et al (2010)

% waiting list > 13 weeks for hospital admission (March 2008)

Natural experiment: Altruism & H&T & Reputation

Star ratings published

Target

Source: Bevan & Hamblin (2009)

% Ambulance response times to life-threatening emergencies < 8 minutes

Barber (2007) Instruction to Deliver Awful adequate

Command & control public not satisfied have to keep flogging the system

Adequate good / great quasi market & consumer choice

innovation from self-sustaining systems

C& C: Patient choice (2006 - 10): Design*

Provider competition ‘money follows the patient’ (PbR) standard tariff: quality competition

Selective contracting Primary Care Trusts (World Class

Commissioning)

Patient choice Provider diversity

Foundation Trusts & Independent Sector Treatment Centres

*Delivering the NHS Plan

C& C:Patient choice (2006-10) Impact?

Failure to create functioning market* political interference weak purchasers barriers to exit &

entry changing policies reorganisations

No

* Brereton & Vasoodaven (2010) http://www.civitas.org.uk/nhs/download/Civitas_LiteratureReview_NHS_market_Feb10.pdf

Publications Connolly S, Bevan G, Mays N. Funding and Performance of

Healthcare Systems in the Four Countries of the UK before and after Devolution. London: the Nuffield Trust, 2011 (revised).

Bevan, G. Approaches and impacts of different systems of assessing hospital performance. Journal of Comparative Policy Analysis, 2010, 12(1 & 2): 33 - 56.

Bevan, G. Have targets done more harm than good in the English NHS? No. BMJ 2009; 338: a3129

Bevan G, Hamblin R. Hitting and missing targets by ambulance services for emergency calls: impacts of different systems of performance measurement within the UK. Journal of the Royal Statistical Society (A), 2009, 172(1):1-30.

Publications Bevan G. Is choice working for patients in the English

NHS? BMJ 2008; 337: a935. Bevan G. Setting Targets for Health Care Performance:

lessons from a case study of the English NHS. National Institute Economic Review 2006, 197: 67-79.

Bevan G, Hood C. What’s Measured is What Matters: Targets and Gaming in the English Public Health Care System. Public Administration 2006, 84(3): 517-38.

Bevan G, Hood C. Have targets improved performance in the English NHS? British Medical Journal 2006, 332: 419-422.