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Funding & Performance of UK Countries Healthcare Systems Before & After Devolution
Gwyn BevanProfessor of Policy Analysis
Department of ManagementLondon School of Economics & Political
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.
