UK experience in managing NHS from a public policy management perspective (GD2 10 05 17)
The UK experience of managing a social
insurance model of health care - a public
policy management perspective of the
NHS
Professor Guy Daly
Jakarta
10 May 2017
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
▪ Health markets
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
▪ Member of West Midlands Clinical Senate
Some questions from me …
… whose responsibility is it anyway?
Indonesia
How popular and
trusted is the health
system?
How good/safe is the
health system?
Health professions’
place in society?
Stereotypes and
prejudice?
Is this changing?
The balance of rights
and duties?
Free Health Care?
Choice?
UK & EU
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
▪ Evidence of increased levels of control / dignity and satisfaction level
‘Crisis’ in health and
social care
▪ NHS
▪ funding & budgets
▪ workforce
▪ Quality challenges and
misconduct: midstaffs/Francis; scandals
▪ expectations
▪ Social care funding (means and
need)
▪ Workforce challenges in both
health and social care
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
▪ Class
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
▪ Coventry bus route
Upstream public health
prevention
Dahlgren and Whitehead
Model (1991)
A National Health Service or
a national illness service
▪ Very popular
▪ London 2012 Olympic Ceremony
▪ https://www.youtube.com/watch?v=95rugObTMHE
▪ https://www.youtube.com/watch?v=cgwlmm90Fdk
London 2012 Olympic Ceremony
Some high level data
Population
Mortality rates
(women live
longer)
GDP per person 2015
GDP on Health
2014
Hospital Beds per
1K
Medics per 1K
Nurses per 1K
Indonesia
UK
USA
260M
60M
320M
69 years (2014)
46 years (1960)
81 years (2014)
71 years (1960)
79 years (2014)
70 years (1960)
$3.6K pa
$42K pa
$56K pa
2.8%
9%
17%
0.9 (2012)
3 per 1K (2005)
3 per 1K (2005)
0.13 - 2003
2.2
2.3
0.5??
9.5 - 2011
9.4 - 2011
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 lowerincome 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
Urban & rural
Caters largely
to lower and
middle-income
groups
Services varies
between
hospitals:
general &
speciality
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
Caters largely
for all income
groups – covers
95-100% of
population
Primary care
services – and
some secondary
services
GP Clinics
c97% of
activity
7.7K
Mostly public
(drugs/
prescription
charges)
NHS via Clinical
Commissioning
Groups
Urban &
rural
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
Caters largely to
lower and
middle-income
groups
Services varies
between
hospitals:
general &
speciality
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
▪ Class
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
▪ 2 million due to net immigration
Wider afield – European Union
▪ EU – ageing population more pronounced than UK
▪ 2010
▪ UK 17% over 65
▪ Germany 21%
▪ In 2035
▪ UK 23%
▪ Germany 31%
▪ But recent migrations will affected things
International Position
▪ Ageing population both in developed and developing countries
▪ Fastest growth is in developing countries
Demography – from pyramids to
rectangles
(ref: 7)
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
▪ osteoarthritis
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
▪ alcohol
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
▪ Expectations of state or market support
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
▪ but quasi markets – purchaser/provider split
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
▪ Specialists/hospital consultants for serious health care
problems
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
▪ GPs (self employed) are gatekeepers
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,
and where to put the
apostrophe (!)
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
▪ Currently – STPs – cost and
quality/safety
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
▪ ‘Knights and Knaves’ (Julian Le Grand)
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
▪ What gets measured, gets done …
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
▪ Joint commissioning and joint providing?
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
▪ GPs act as gatekeepers
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
▪ Concentration of clinical excellence at secondary and tertiary levels
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
▪ Class and regional differences (inputs and outcomes)
Some questions from me …
… whose responsibility is it anyway?
Indonesia
How popular and
trusted is the health
system?
How good/safe is the
health system?
Health professions’
place in society?
Stereotypes and
prejudice?
Is this changing?
The balance of rights
and duties?
Free Health Care?
Choice?
UK & EU
Terima Kasih!
Thank you for listening
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-rankslast
▪ 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
▪ 5 Glasby, J. and Daly, G. (2014) ‘Adult Health and Social Care’, in (eds.) Bochel, H. and Daly, G.
(2014) Social Policy, London: Routledge
▪ 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
▪ 12 Williamson, C. (2015) Policy Mapping on Ageing in Asia and the Pacific Analytical Report, Chiang Mai –
Thailand: HelpAge International – Pacific Regional Office
insurance model of health care - a public
policy management perspective of the
NHS
Professor Guy Daly
Jakarta
10 May 2017
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
▪ Health markets
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
▪ Member of West Midlands Clinical Senate
Some questions from me …
… whose responsibility is it anyway?
Indonesia
How popular and
trusted is the health
system?
How good/safe is the
health system?
Health professions’
place in society?
Stereotypes and
prejudice?
Is this changing?
The balance of rights
and duties?
Free Health Care?
Choice?
UK & EU
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
▪ Evidence of increased levels of control / dignity and satisfaction level
‘Crisis’ in health and
social care
▪ NHS
▪ funding & budgets
▪ workforce
▪ Quality challenges and
misconduct: midstaffs/Francis; scandals
▪ expectations
▪ Social care funding (means and
need)
▪ Workforce challenges in both
health and social care
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
▪ Class
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
▪ Coventry bus route
Upstream public health
prevention
Dahlgren and Whitehead
Model (1991)
A National Health Service or
a national illness service
▪ Very popular
▪ London 2012 Olympic Ceremony
▪ https://www.youtube.com/watch?v=95rugObTMHE
▪ https://www.youtube.com/watch?v=cgwlmm90Fdk
London 2012 Olympic Ceremony
Some high level data
Population
Mortality rates
(women live
longer)
GDP per person 2015
GDP on Health
2014
Hospital Beds per
1K
Medics per 1K
Nurses per 1K
Indonesia
UK
USA
260M
60M
320M
69 years (2014)
46 years (1960)
81 years (2014)
71 years (1960)
79 years (2014)
70 years (1960)
$3.6K pa
$42K pa
$56K pa
2.8%
9%
17%
0.9 (2012)
3 per 1K (2005)
3 per 1K (2005)
0.13 - 2003
2.2
2.3
0.5??
9.5 - 2011
9.4 - 2011
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 lowerincome 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
Urban & rural
Caters largely
to lower and
middle-income
groups
Services varies
between
hospitals:
general &
speciality
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
Caters largely
for all income
groups – covers
95-100% of
population
Primary care
services – and
some secondary
services
GP Clinics
c97% of
activity
7.7K
Mostly public
(drugs/
prescription
charges)
NHS via Clinical
Commissioning
Groups
Urban &
rural
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
Caters largely to
lower and
middle-income
groups
Services varies
between
hospitals:
general &
speciality
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
▪ Class
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
▪ 2 million due to net immigration
Wider afield – European Union
▪ EU – ageing population more pronounced than UK
▪ 2010
▪ UK 17% over 65
▪ Germany 21%
▪ In 2035
▪ UK 23%
▪ Germany 31%
▪ But recent migrations will affected things
International Position
▪ Ageing population both in developed and developing countries
▪ Fastest growth is in developing countries
Demography – from pyramids to
rectangles
(ref: 7)
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
▪ osteoarthritis
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
▪ alcohol
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
▪ Expectations of state or market support
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
▪ but quasi markets – purchaser/provider split
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
▪ Specialists/hospital consultants for serious health care
problems
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
▪ GPs (self employed) are gatekeepers
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,
and where to put the
apostrophe (!)
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
▪ Currently – STPs – cost and
quality/safety
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
▪ ‘Knights and Knaves’ (Julian Le Grand)
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
▪ What gets measured, gets done …
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
▪ Joint commissioning and joint providing?
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
▪ GPs act as gatekeepers
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
▪ Concentration of clinical excellence at secondary and tertiary levels
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
▪ Class and regional differences (inputs and outcomes)
Some questions from me …
… whose responsibility is it anyway?
Indonesia
How popular and
trusted is the health
system?
How good/safe is the
health system?
Health professions’
place in society?
Stereotypes and
prejudice?
Is this changing?
The balance of rights
and duties?
Free Health Care?
Choice?
UK & EU
Terima Kasih!
Thank you for listening
References and bibliography
▪ 1 Cao, J. and Rammohan, A. (2016) ‘Social capital and healthy ageing in Indonesia’, BMC Public
Health, 16:631
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