The UK experience of managing a social
insurance model of health care - a public
policy management perspective of the
NHS
Professor Guy Daly
Jakarta
Introduction and contents
▪ Me!
▪ Context
▪ Crisis
▪ Great success story
▪ Health inequalities
▪ Upstream activities
▪ Demography and burden of disease
▪ NHS and the Olympics
▪ Comparisions
▪ The NHS story
Me!
▪Social policy academic – citizenship/health and socail care/choice
▪PVC/Executive Dean Faculty of Health and Life Sciences
▪Local authority elected representative (1990-1998)
▪NHS Trust Board NED
▪Executive Member of Council of Deans of Health
Some questions from me …
…
whose responsibility is it anyway?
Indonesia UK & EU
How popular and trusted is the health system?
How good/safe is the health system?
Healthprofessions’ place in society? Stereotypes and prejudice?
Is this changing? The balance of rights and duties?
CONTEXT
▪ NHS is very popular and is effective
▪ Demography
▪ Ageing society
▪ Inequalities within and across demographic groups
▪ Mortality
▪ Improved life expectancy
▪ Morbidity
▪ co-morbidities
▪ upstream prevention
▪ Societal expectations
▪ Empowered consumers
‘Crisis’ in health and
social care
▪NHS
▪funding & budgets
▪workforce
▪Quality challenges and
misconduct:
mid-staffs/Francis; scandals
▪expectations
▪Social care funding (means and
need)
▪Workforce challenges in both
Yet health care (and public health)
a great success
▪
Commonwealth Fund 2014 research
▪
improvements in mortality and morbidity
▪
BUT inequalities in health persist
▪
Service area
▪
Geographically
▪
Demographically
▪
Age
▪
Ethnicity
Health inequalities persist
▪
Douglas Black Report 1980s
▪
Artefact
▪
Social selection
▪
Lifestyle
▪
Structural inequalities
▪
Whitehead Health Inequalities Report 1990s
▪
Dalhgren and Whiterhead 1990s
▪
2000s Marmott cities including Coventry
A National Health Service or
a national illness service
▪
Very popular
▪
London 2012 Olympic Ceremony
▪
https://www.youtube.com/watch?v=95rugObTMHE
Some high level data
Indonesia UK USA
Population 260M 60M 320M
Mortality rates (women live longer)
69 years (2014) 46 years (1960)
81 years (2014) 71 years (1960)
79 years (2014) 70 years (1960)
GDP per person -2015
$3.6K pa $42K pa $56K pa
GDP on Health 2014
2.8% 9% 17%
Hospital Beds per 1K
0.9 (2012) 3 per 1K (2005) 3 per 1K (2005)
Medics per 1K 0.13 - 2003 2.2 2.3
Public & Private Healthcare Delivery System
The Indonesian health system is largely based on an extensive network of public sector facilities; the public vs. private hospitals split is 70:30 on average.
Desk Research Source: Ministry of Health, Frost & Sullivan Analysis
http://pharmexcil.org/uploadfile/ufiles/1333958694_Indonesia0401201617MrktRprt.pdf
Healthcare facility type
No. (2014)
Funding type Administrato r Typical location Coverage/ population Typical services Government Healthcare centres (PUSKESMAS)
9,731 Central & Provincial government
Provincial government
Urban & rural Caters largely to lower-income groups Primarily outpatient services, with 35% inpatient facilities
GP Clinics c. 19,500 Private Private Urban & rural Caters largely to upper and middle-income groups Basic primary care outpatient services Private hospitals
807 Private Private Urban Caters largely to upper and middle-income groups Services varies between hospitals: general & speciality
Public hospitals 1,599 Central & Provincial government
Central & Provincial government
Public & Private Healthcare Delivery System
The UK health system is largely based on an extensive network of public sector facilities
Healthcare facility type
No. (2014)
Funding type Administrato r Typical location Coverage/ population Typical services
GP Clinics c97% of activity 7.7K Mostly public (drugs/ prescription charges)
NHS via Clinical Commissioning Groups
Urban & rural
Caters largely for all income groups –covers 95-100% of population
Primary care services –and some secondary services Public hospitals (including ED/A&E) c95% of activity 250 Public (via taxes & NI)
NHS –NHS E, NHS I, CQC, NICE Urban and rural Private GPs/Primary Care c3% Personal payment; personal insurance Employment insurance Private insurance schemes; CQC, NICE Urban and rural
Caters largely to upper and middle-income groups Services varies between hospitals: general & speciality Private hospitals c5% of activity Personal payment; personal insurance Employment insurance Private insurance schemes; CQC, NICE Urban & rural
Yet public health care (and health
care) a great success
▪
Commonwealth Fund 2014 research
▪
improvements in mortality and morbidity
▪
BUT inequalities in health persist
▪
Service area
▪
Geographically
▪
Demographically
▪
Age
▪
Ethnicity
UK Demography
▪Ageing population due to people living longer
▪Also lower birth rate
▪Lower birth rate due to changes to lives of women (birth control) and social and economic improvements
▪Also post 1939-45 war baby boom
▪Somewhat mitigated by immigration
▪4 million increase in UK population 1991-2012
Wider afield
–
European Union
▪
EU
–
ageing population more pronounced than UK
▪
2010
▪
UK 17% over 65
▪
Germany 21%
▪
In 2035
▪
UK 23%
▪
Germany 31%
International Position
▪Ageing population both in developed and developing countries
Demography
–
from pyramids to
rectangles
Burden of disease in UK and
developed world
▪The overwhelming burden of disease is from non-communicable diseases.
▪These include the biggest killers:
▪heart disease,
▪stroke
▪chronic lunch disease
▪ while the main causes of disability are
▪visual and hearing impairment,
▪dementia
Health and
HALE (Health Adjusted Life Years)
▪ Life to years and years to life
▪ Ill health:
▪ Diet
▪ Exercise
▪ Smoking
▪ Alcohol and drugs
▪ Improvements in health
▪ Good diet (cancer, diabetes)
▪ Physical exercise – MSK, cardiovascular
▪ Stop smoking – heart disease, cva, copd
Therefore ….
▪
Developed world:
▪
Live longer
–
mortality
▪
Better infant mortality
▪
Developed health care systems
▪
(but health care doesn’t equal health)
▪
Population pyramid is different - horizontal
▪
Diseases of the developed world
▪
CHD, COPD, CVA, Cancer, Diabetes, Obesity
▪
Individualism
UK Health System (1)
▪
access to health and care services
▪
mostly public/social good not a private good
▪
(we cannot predict who will get ill and when)
▪
Inequalities in health and use of health services
continue to exist
▪
social insurance not markets
UK Health System (2)
▪GP/Family doctors are the gatekeepers
▪Generalists – looking to spot serious health problems
▪7-10 mins per consultation
▪Sometimes difficult to get an appointment – so. go straight to A&E/ED
▪Google health/consumers
▪They refer patients to secondary/tertiary care
So how did we get here? (1)
▪ casting and recasting of socio-political discourse
▪ Bevan and 1948 creation of NHS ▪ Free at the point of delivery, based on
need not ability to pay or contributions
▪ When a bed pan drops in South Wales
▪ “stuff their mouths with gold”
▪ Heath and social care split
▪ Belief that after initial response to historic demand, it would reduce
▪ Reality that demand is infinite
▪ Inequalities between regions (and London) –1970s RAWP
▪ Each area would have a DGH
So how did we get here? (2)
▪Post-war consensus until 1970s – oil crisis/IMF, costs greater than budgets, welfare state crisis …
▪1980s: Margaret Thatcher䇻s -䇺there is no such thing as society, only individuals and their families䇻
▪Early 1990s: John Major䇻s
promotion of citizen䇻s charters,
So how did we get here? (3)
▪Late 1990s-2000s: Tony Blair䇻s
䇺something for something䇻
society, in which 䇺the rights we
enjoy reflect the duties we owe”
▪2010: David Cameron, with the
‘we’re all in it together’ austerity
- health budgets ‘protected’ –
GP/primary care-led NHS and AWP
▪20015 onwards:
▪Quality ▪Brexit
Creating Internal/Quasi Health
Markets (1)
▪ NHS & Community Care Act 1990 …
▪ Commissioning: purchaser / provider split
▪ GPFHs ’purchase’
▪ Secondary and Tertiary care provide
▪ Block and spot contracts
▪ Christmas cards
▪ Not a ‘true market’
▪ Patients are consumers but aren’t purchasers
▪ (yet? –health individual budgets? Maternity £3K)
▪ Have greater choice –Dr Foster etc
▪ GPs purchase and provide –conflict?
▪ Monopolies and monopsomies
Creating Internal/Quasi Health
Markets (2)
▪Quality
▪CQC, NHS I, NICE
▪Benchmarks and league tables
▪KPIs
▪GP in seven days?
▪7 day a week NHS
▪4 hour A&E
▪18 week RTT
Creating Internal/Quasi Health
Markets (3)
▪Provides some leverage (‘fettered competition) ▪Now AWP?
▪NHS hospitals can do 49% private work
▪STPs (Sustainability Transformation Plans/Partnerships)
▪Response to budget/expenditure and clinical challenges
▪Everyone wants a centre of excellence in their village/town/city
▪ACSs (Accountable Care System)
▪Shared controlled total
Current and future
Targets/KPIs:
▪7 day a week NHS?
▪See a GP within a week?
▪In A&E - seen in 4 hours
▪Seen in Out-Patients within 18 weeks (RTT)
▪What is measured, gets done – perverse incentives/game playing
▪Overall
▪try to spend less on acute care downstream and to attend to preventative upstream activities
Lessons from managing
UK health care (1)
▪ Health is a social / public good
▪ Patients and service users more empowered (experts by experience)
▪ Choice?
▪ Do quasi markets have (some) utility
▪ Fettered competition?
▪ Move from competition to collaboration via ACSs
▪ Data is king
▪ What is measured is what gets done
▪ Primary care as gatekeeper
▪ Specialism within primary care / amongst GPs
Lessons from managing
UK health care (2)
▪Mostly publicly funded and provided – c95%
▪GPs are gatekeepers
▪Regulation – NICE/CQC/NHS I
▪Workforce (Human Resources) shortages – GPs/consultants/nurses
▪Quality
▪generally good
▪need expertise concentrated but people want local access
Some questions from me …
…
whose responsibility is it anyway?
Indonesia UK & EU
How popular and trusted is the health system?
How good/safe is the health system?
Healthprofessions’ place in society? Stereotypes and prejudice?
Is this changing? The balance of rights and duties?
Terima Kasih!
References and bibliography
▪ 1 Cao, J. and Rammohan, A. (2016) ‘Social capital and healthy ageing in Indonesia’, BMC Public Health, 16:631
▪ 2 Commonwealth Fund (2014) US Health System Ranks Last Among Eleven Countries on Measures of Access, Equity, Quality, Efficiency, and Healthy Lives,
http://www.commonwealthfund.org/publications/press-releases/2014/jun/us-health-system-ranks-last
▪ 3 Daly, G. (2009) ‘LinkAge Plus: The Benefits for Older People’, London: UK HMG –Department of Work and Pensions
▪ 4 Daly, G. (2012) ‘Citizenship, choice and care: an examination of the promotion of choice in the provision of adult social care’, Research, Policy and Planning, 29 (2), 179-190
▪ 6 HelpAge International (2015) Critical choices in developing comprehensive policy frameworks on ageing in Asia and the Pacific, www.helpage.org
▪ 7 Lodge, C., Carnell, E. and Coleman, M. (2016) The New Age of Ageing, Bristol: Policy Press
▪ 8 Sri Moertiningsih Adioetomo and Ghazy Mujahid (2015) Indonesia on the Threshold of Population Ageing: , United Nations Population Fund: UNFPA Indonesia Monograph Series –No. 1, www.indonesia.unfpa.org
▪ 9 Stefanoni, S. and Williamson, C. (2015) ‘Review of Good Practice in National Policy and Laws on Ageing’ http://ageingasia.org/ good-practice-policies-on-ageing.
▪ 10 West, K. (2014) ‘Older People, Population Ageing, and Policy Responses, in (eds.) Bochel, H. and Daly, G. (2014) Social Policy, London: Routledge
▪ 11 WHO (2016) Global strategy and action plan on ageing and health (2016-2020),
http://www.who.int/ageing/global-strategy
