Gwyn Bevan

1
Symposium, University of Toronto Regulating
NHS Performance in England
Gwyn Bevan 20 November 2003
2
Regulating NHS Performance in England

• Models of insurance
• Central solutions to the riddle of the NHS
• Unresolved problems

3
Models of insurance
NHS
Social insurance
Taxes
Insurance levy
Cash limit
Hospital income
Global expenditure
Capitation
Insurer
Volume
Global budget
Regulated prices
4
Models of insurance
5
More efficient reduce average costs?
Average costs
?
Total costs
Current
Providers offer
?
Insurers wish
Fixed costs
Volume
Current
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Regulating NHS Performance in England

• Models of insurance
• Central solutions to the riddle of the NHS
• Gridlock (1980s) ? the internal market (1990s)
• Performance assessment by CHI (2000)
• Payment by results patient choice (2003)
• Unresolved problems

7
Gridlock the efficiency trap
NHS inefficient
No growth money
No
Increase caseload
Yes
Local financial crisis
8
Gridlock do no direct harm?

• Incomes and property values are constantly being
  created and destroyed in the normal course of the
  changes that characterise a dynamic economy. But
  social attitudes to losses are much more rigid
  when it comes to losses directly imposed by
  government action. The rule of do not direct
  harm is a powerful force shaping the nature of
  social intervention.
• Schultze (1977) The Public Use of Private Interest

9
Gridlock provider exit?

• We put few obstacles in the way of a
  market-generated shift of industry to the South
  or the substitution of synthetic fibers for New
  England woollens, events that thrust large losses
  on individuals, firms and communities. But we
  find it extraordinarily difficult to close a
  military base or a post office.
• Schultze (1977) The Public Use of Private
  Interest

10
Internal market Money follows the patient in a
provider market?

• Capitation?
• Competition absent?
• Regulate insurers (RPI-X) ? overperformance
• Competition present
• Avoid destabilisation move contracts at marginal
  costs
• Market characteristics
• Provider defines services
• Extra monies for long waiting lists!

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Regulating NHS Performance in England

• Models of insurance
• Central solutions to the riddle of the NHS
• Gridlock (1980s) ? the internal market (1990s)
• Performance assessment by CHI (2000)
• Payment by results patient choice (2003)
• Unresolved problems

12
Performance assessment by CHI

• CHI, through the new Office for Information on
  Health Care Performance rather than the
  Department of Health will be responsible for
  assessing the clinical and organisational
  performance of each part of the NHS a decisive
  shift in the centre of gravity in the NHS. It
  moves towards regulation that is the hands of
  independent regulators rather than Ministers or
  the health service. Secretary of State for
  Health (2002)

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Performance assessment Aspirations

• Limited number of national targets
• Performance Assessment Framework (PAF)
• Traffic lights (Partnership)
• Annual local report card
• New efficiency target
• Identify best trusts using PAF
• Set benchmark for costs of NHS
• All trusts reach benchmark over 5 years

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Performance assessment Aspirations to practice

• Developments
• Traffic lights ? star ratings
• National ? Key targets
• PAF ? balanced scorecard
• Efficiency target ? Payment by results
• Forgotten
• Partnership
• Local report cards

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Development of star ratings
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Process acute model
9 Key Targets
7 CGR components
?
Zero

• balanced scorecard
• patient focus (19)
• clinical focus (10)
• capability capacity (6)

?
?
? ? ?
7 CGR components
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Key Targets (9)

• Waiting times (5)
• Cancelled operations
• Finance
• Cleanliness
• Working lives

18
Clinical Focus (10)

• Clinical Negligence
• 30-day mortality (2)
• Emergency readmission rates (4)
• Infection control procedures
• Methicillin Resistant Staphylococcus Aureus
  (MRSA) improvement
• Thrombolysis treatment time

19
Patient Focus (19)

• Waiting times (6)
• Day case booking
• Cancelled operations
• Breast cancer treatment
• Delayed transfers of care

• Outpatient/AE survey (5)
• Paediatric outpatient did not attend rates
• Patient complaints procedure
• Better hospital food
• Privacy dignity

20
Capacity and Capability (7)

• Data quality
• Staff opinion survey
• Junior doctors' hours
• Consultant appraisal
• Sickness absence rate
• Information Governance
• Fire, Health Safety

21
Strengths weaknesses
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Ambulance key target category A calls in 8
minutes
23
Acute key target waiting (admission) gt 12
months
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Key targets gaming thresholds
Success?
Frequency
Failure?
Waiting times
Target
25
Balanced scorecard?
National Priorities
Policy Divisions CHI
indicators
40 PIs
Data measurement
balanced scorecard
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Regulating NHS Performance in England

• Models of insurance
• Central solutions to the riddle of the NHS
• Gridlock (1980s) ? the internal market (1990s)
• Performance assessment by CHI (2000)
• Payment by results patient choice (2003)
• Unresolved problems

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Current problems

• Insurer
• No transparency or consistency in commissioning
• Hard to move fund activity elsewhere

• NHS Trust
• No incentive
• to examine and reduce costs
• to do more activity
• Funding not related to services
• Cannot retain surplus

28
Payment by results PPS by HRG within finance by
capitation
29
Plurality of providers regulators
Cash limit
Capitation
Regulated Primary Care Trusts (CHAI)
Regulated NHS Trusts (CHAI AC)
Licensed Private Providers (CHAI)
Regulated Foundation Trusts
Licensed Diagnostic Treatment Centres (CHAI)
30
Regulating NHS Performance in England

• Models of insurance
• Central solutions to the riddle of the NHS
• Unresolved problems

31
Unresolved problems

• What does it mean to be more efficient?
• Incentives for partnership working?
• Executive ? democratic accountability?
• Different agents modes of regulation?
• Learning organisation feedback delay?