From the east end to the west coast: `a victim of geography’?

1. Inaugural lectureCentre for Public Services Organisations annual lecture21 February 2013WHAT IS THE FUTURE OF THE NHS?Professor Mark ExworthyProfessor of Health Policy and Management

2. From the east end to the west coast: `a victim of geography’? • Loughborough University • Queen Mary & Westfield • Southampton University • London School of Economics • University College London • University of California, San Francisco • Oxford Brookes University • Royal Holloway, University of London Two faces of primary health care: east London & west coast, USA

3. Health policy and management - “a victim of geography”? Geography Health services research Social policy Management

4. Centre for Public Services OrganisationsAnnual Lectures Sir Derek Wanless(former CEO NatWest & adviser to Gordon Brown) • Securing Good Health for the Whole Population - What should the Government do? Prof. Angela Coulter (Picker Institute & Oxford University) • Choice in Healthcare: who wants it and why? Prof. Sue Richards (National School of Government) • Public Service Reform – Continuity and Change David Walker (Audit Commission & Guardian journalist) • The performance of public services: how much does the public really want to know? Lord Nigel Crisp (former CEO of NHS & Permanent Secretary, Department of Health) • The search for global health in the 21st century

5. What is the future of the NHS? • The NHS in a changing world • Recent policy developments • Three fault-lines in NHS policy and management • The NHS in the wider world • Which way for the NHS?

6. National Health Service Treats 1 million patients every 36 hours Employs 1.4 million people (2012) Budget: • £137.4 billion (2010/11 at 2012/13 prices) • £2.642 billion per week / £376.4 million per day • £1,875 per person in England (2011) • 8.2% of GDP → possibly 16% by 2061 • 23% of English public service spending (2012) • Compare: • M&S annual revenue £9.9 billion (2012) • NHS budget similar to national income of New Zealand (2010)

7. Health system challenges in a changing world Access Cost Quality

8. Health system challenges in a changing world Patterns of disease Clinical advances Lifestyles & behaviour Access Info technology Demography Cost Quality

9. Recent NHS policy developments Funding • Feast and now famine* Markets and competition • Commissioning • Patient choice • Private sector (including Private Finance Initiative) Delegation of management • Organisational autonomy via Foundation Trusts Performance management • Centralised “targets and terror” ...and 12 Secretaries of State (since 1989 White Paper)

10. Annual % change in NHS expenditure in England, 1974/75 to 2014-15 Parliament, 2012

11. Recent NHS policy developments Funding • Feast and now famine* Markets and competition • Commissioning • Patient choice • Private sector (including Private Finance Initiative; PFI) Delegation of management • Organisational autonomy via Foundation Trusts Performance management • Centralised “targets and terror” ...and 12 Secretaries of State (since 1989 White Paper)

12. Three fault-lines in NHS policy and management Health Central Profession Local Management Health-care Adapted from Exworthy & Freeman (2009)

13. Fault-line 1: Central - Local NHS traditionally highly centralised • Bevan: "the sound of a bedpan falling in Tredegar Hospital should resound in the Palace of Westminster" Post-1991, increasing fragmentation through: • Decentralisation • Self-governing Trusts & Foundation Trusts • But centralisation persists • Markets & competition • Local commissioners • `Any qualified provider’ • Patient Choice

14. Fault-line 1: Central - Local The `Local NHS’ • Public support for `local’ hospital despite `national’ title • NHS spending remains high localised* Central role remains vital • Accountability for public spending • Equity - the `N’ in NHS Central-local tensions remain; currently: • Post-code lottery and national guidelines co-exist • `Top-down re-organisation’ of secondary care • Clinical Commissioning Groups and National Commissioning Board

15. % of PCT budget allocated to NHS local providers, 2011-12 Mean=0.70 Exworthy, Frosini & Thompson (2012)

16. % of PCT budget allocated to NHS local providers, 2011-12 Exworthy, Frosini & Thompson (2012)

17. Fault-line 1: Central - Local The `Local NHS’ • Public support for `local’ hospital despite `national’ title • NHS spending remains high localised* Central role remains vital • Accountability for public spending • Equity - the `N’ in NHS Central-local tensions remain; currently: • Post-code lottery and national guidelines co-exist • `Top-down re-organisation’ of secondary care • Clinical Commissioning Groups and National Commissioning Board

18. Fault-line 2: Profession - Management NHS had always been subject to: • Provider-capture / shroud-waving → inertia? `New Public Management’ (1980s onwards) supposed to break `institutional stalemate’ • Managers became `agents of the centre’ Led to clinician-managerial conflict • Managers became `stakeholders’ in their own right • Sometimes the solution; often the problem • Subsequently, collaboration and compromise (Exworthy & Halford, 1999)

19. Fault-line 2: Profession - Management Some clinicians (including doctors) have internalised managerialism • Being a `good’ doctor involves engaging with managerialism Some doctors take on managerial roles (hybrids) • Danger that hybrids lose identity with and authority over medical peers (Causer and Exworthy, 1999) • Can they be `good’ doctors and `effective’ managers? • Danger that managerialism fractures the profession

20. Fault-line 2: Profession - Management Example: Public reporting and transparency “The more we are watched, the better we behave” (Bentham) Study: Assessing impact of published mortality rates associated with named surgeons • Although patients rarely use the data, how do doctors respond to increasing surveillance? • What is the impact of more transparency upon clinical performance? Impact: • Demonstrating competence to peer groups • Resistance to performance but some internalisation • Balancing tacit knowledge with explicit awareness Exworthy et al, 2010; Gabe et al, 2012

21. Fault-line 3: Health – Health-care NHS = national `sickness’ service • Overwhelming focus on NHS • Shift on public health to local government (April 2013) • Health-care may only contribute 15% to better health (McGinnis et al, 2002) NHS ill-equipped to tackle “wicked problems” (Rittell & Webber, 1973) • No definitive formulation • No stopping rule • Solutions are not true/false, & no ultimate test of a solution • No definitive list of solutions • Every problem is a symptom of another problem

22. Fault-line 3: Health – Health-care Example: Health inequalities • Health outcomes - systematic gradient* • “…in the wealthiest part of London, one ward in Kensington and Chelsea, a man can expect to live to 88 years, while a few kilometers away in Tottenham Green, one of the capital’s poorer wards, male life expectancy is 71.” (Marmot, 2009, p.35) • Health-care inequalities - Inverse care law* • “The availability of good medical care tends to vary inversely with the need for it in the population served”(Hart, 1971)

23. Fault-line 3: Health – Health-care Age standardised mortality rate by social class, men, aged 25-64, 2011-2003 Marmot Review, 2010, p.49

24. Fault-line 3: Health – Health-care Mortality of men in England, 1981-1992 Marmot Review, 2010, p.69

25. Life expectancy (in years) at birth of those living around London Underground stations, 2012 http://life.mappinglondon.co.uk/#

26. Fault-line 3: Health – Health-care Example: Health inequalities • Health outcomes - systematic gradient* • “…in the wealthiest part of London, one ward in Kensington and Chelsea, a man can expect to live to 88 years, while a few kilometers away in Tottenham Green, one of the capital’s poorer wards, male life expectancy is 71.” (Marmot, 2009, p.35) • Health-care inequalities - Inverse care law* • “The availability of good medical care tends to vary inversely with the need for it in the population served”(Hart, 1971)

27. Fault-line 3: Health – Health-care Number of f.t.e. GPs per 100,000 weighted population by area deprivation. DH, 2008, p.46

28. Fault-line 3: Health – Health-care • “What is striking is that there has been much written often covering similar ground . . . but rigorous implementation of identified solutions has often been sadly lacking.”Wanless 2004, p.3 • “What we know about equity and inequity in health may in the end be less significant than how we think, both about health and about government”Freeman, 2006, p.66

29. Fault-line 3: Health – Health-care Example: Wicked issues of health inequalities • Challenges for NHS decision-makers • Equivocal evidence • Competing priorities • Contested solutions • Governance: • Limited control over those able to contribute to amelioration • Low willingness to tackle the issues

30. The NHS in the wider world • How does the NHS compare with other health systems? • Is the NHS still the envy of the world?

31. How well does the NHS perform? Equity (access) • Progressive taxation • Universal access but inequalities persist Efficiency (cost) • Spending now above OECD average* • Central control of funding remains and low transaction costs Effectiveness (quality) • Moderate quality; variations in care persist • User responsiveness and experience remain patchy • Life expectancy similar to OECD average

32. Total health expenditure (% of GDP) among OECD countries (2011)

33. How well does the NHS perform? Equity (access) • Progressive taxation • Universal access but inequalities persist Efficiency (cost) • Spending now above OECD average* • Central control of funding remains and low transaction costs Effectiveness (quality) • Moderate quality; variations in care persist • User responsiveness and experience remain patchy • Life expectancy similar to OECD average

34. Commonwealth Fund of New York (2010) “Mirror, mirror on the wall.”

35. So, which way for the NHS?

36. Scenarios for the future NHS (1) "Slow uptake" • People did little to improve their lifestyles • Productivity grows <1.75% • NHS spending rises to £184bn by 2022/23 (2) "Solid progress" • More modest progress on improving public health • NHS spending rises to £161bn by 2022/23 (3) "Fully engaged" • People adopted healthier lifestyles • Rising productivity by <3% pa. • NHS spending rises to £154bn by 2022/23 Wanless, 2002

37. Questions for the future of the NHS? Will the public retain faith in the NHS? • NHS is no longer thought to be the top issue of public concern1 • 44% not confident that a model of health care 'funded by taxation and free to all' will survive2 • 36% expect NHS care to get worse over the next 5 years2 1 Ipsos-Mori, 2012; 2BSA, 2012; • Transparency and quality • How will the NHS respond greater transparency of quality? • Health-care scandals versus support for local hospital • “Friends and family” test

38. Questions for the future of the NHS? Will the public take on greater responsibility for their health? • Where should the NHS stop? • 88% agree that government should be mainly responsible for paying for the cost of health-care. (82% in 1998). (BSA, 2012) • Health systems tend to exclude few services • Who rations? Local commissioners, public consultation? • Example: obesity • Prevalence: 24% women, 22% men (2009; OECD) • What role for government, business, NHS & public?

39. Questions for the future of the NHS? Can NHS balance rising demand within marginal increases in funding? • Increased funding in early 2000s did not lead to greater productivity • Approx.5% increase in funding needed to cope with demography and technological advances • But future funding rises likely to be limited for some time: • Expected £20 billion NHS savings by 2015 • PFI adds further constraint* • How will services be rationed in future and by whom? • What role for local managers, clinicians and public?

40. Annual payment schedule for all NHS PFI schemes over contracts’ lifetimes £ billion 2012-2013 Parliament, 2012

41. Questions for the future of the NHS? Can NHS balance rising demand within marginal increases in funding? • Increased funding in early 2000s did not lead to greater productivity • Approx.5% increase in funding needed to cope with demography and technological advances • But future funding rises likely to be limited for some time: • Expected £20 billion NHS savings by 2015 • PFI adds further constraint* • How will services be rationed in future and by whom? • What role for local managers, clinicians and public?

42. Questions for the future of the NHS? Can a new settlement be found between the public, government, clinical professions and management? • Re-set the policy direction: • Integration should replace competition • England needs to learn lessons from Scotland, Wales & NI • Support for managers and leadership • Research evidence must inform but cannot dictate policy • Overcome `reform fatigue’ within NHS: • Constant organisational change without coherent narrative • Loss of organisational memory • Balance research evidence and social values

43. Questions for the future of the NHS? Can a new settlement be found between the public, government, clinical professions and management? ...Continued • Re-discover `public service’ and `professionalism’ • `Responsible professionalism’ • Balance power (autonomy) with responsibility (accountability) • Co-production: • Providers and public jointly define problems and devise solutions

44. What is the future of the NHS? Final thoughts • NHS has adapted over the past 65 years • Its performance compares well to other countries • But further change is imminent and on-going • Fault-lines of NHS will shape its future • Central-local / Profession-management / Health – health-care • Answers to the questions will determine whether NHS can remain central to British life for another 65 years • Keeping faith with the NHS • Taking responsibility for health • Paying for growing demands • Balancing public, government, professions & management

45. Inaugural lectureCentre for Public Services Organisations annual lecture21 February 2013WHAT IS THE FUTURE OF THE NHS?Professor Mark Exworthy Professor of Health Policy and Management