Professor David Gordon

Reform of the NHS:

Choice, Markets, Competition in the NHS – What Does it

Mean for Health Inequality

28th January 2006

2

The imperative for reform is urgent and growing. People want more from their public services, to match the choice, customer service and personalisation they can get from their bank, supermarket or on-line shopping.

Patricia Hewitt Secretary of State for Health December 2005

Health reform in England: update and next steps

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A 2002 Harris Interactive telephone survey of 1,013 U.S. adults, which asked whether they had seen or responded to ratings of hospitals or physicians, found that only 1 percent of respondents had made a decision to change health plans, doctors, or hospitals on the basis of performance evidence

"Ultimately, choice comes at a price. As consumers, we are expected to pay for the privilege of choice, and if we cannot pay, we do not get to choose and, more than likely, do not get at all," ….. "I left the U.S. convinced that having less choice in health care is a price well worth paying for universal coverage.“

Blind Faith and Choice, Rhiannon Tudor Edwards, D.Phil., M.A., Health Affairs November/December 2005 24 (6): 1624–28

Choice in Health Care

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The reforms are inter-related and mutually reinforcing. There are four connected streams of work:

•more choice and a much stronger voice for patients (demand-side reforms);

•more diverse providers, with more freedom to innovate and improve services (supply-side reforms);

•money following the patients, rewarding the best and most efficient, giving others the incentive to improve (transactional reforms);

•system management and decision making to support quality, safety, fairness, equity and value for money (system management reforms).

NHS Reforms: Choice Agenda 2006-2009

5 New Public Management (NPM) and the Choice Agenda

NPM theory originated in the private sector

OECD & UK government are promoting NPM in the public sector

NPM is rooted in neo-classical economic assumptions that every person is actuated only by self-interest. From this, everything else follows. If people are self-interested, they have to be motivated by incentives. Different self-interests lead to endemic conflicts.

To resolve conflicting interests efficiently, markets are best. Self-interest and markets favour competition rather than co-operation, and mandate hierarchy to keep people in line. They also empty management of all moral or ethical concern.

6 New Public Management (NPM) and the NHS

The NHS could never successfully function if self-interest became the main motivating factor for its staff.

The Health Service works on the basis of collegiality, co-operation and trust - what Richard Titmus termed the ‘Gift Relationship’ (Titmus, 1970).

New public management undermines co-operation and trust and promotes competition and vested self-interest in their place.

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Frank Dobson, 1997(Secretary of state for health 1997-1999

“Inequality in health is the worst inequality of all. There is no more serious inequality than knowing that you’ll die sooner because you’re badly off”

8 Age at death by age group, 1990-1995

Source: The State of the World Population 1998

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“The world's biggest killer and the greatest cause of ill health and suffering across the globe is listed almost at the end of the International Classification of Diseases. It is given code Z59.5 -- extreme poverty.World Health Organisation (1995)

Seven out of 10 childhood deaths in developing countries can be attributed to just five main causes - or a combination of them: pneumonia, diarrhoea, measles, malaria and malnutrition. Around the world, three out of four children seen by health services are suffering from at least one of these conditions.World Health Organisation (1996; 1998).

10 Expectation of years of life, at birth

30

40

50

60

70

80

9018

40s

1850

s

1860

s*

1870

s

1880

s

1890

s

1900

s

1910

s

1920

s

1930

s

1940

s*

1950

s

1960

s

1970

s

1980

s

1990

s

Men

Women

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  % Deaths among recorded baptisms

  Under 5 years Under 21 years

British Dukes(Hollingsworth, 1965

 20

 27

Bedfordshire peasants(fairly prosperous)(Tranter, 1966)

  

24

  

31

Lincolnshire peasants(Chambers, 1972)

 39

 60

Mortality of Infants and Young People, 1739-79

12

District Gentry and professional

Farmers and tradesman

Labourers and artisans

       Rural      

Rutland 52 41 38

       Urban      

Bath 55 37 25

Leeds 44 27 19

Bethnal Green

45 26 16

Manchester 38 20 17

Liverpool 35 22 15

Longevity of families, by class and area of residence, 1834-41

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Accidents

Cancers

DigestiveRespiratory

Genitourinary

Circulatory

14 SMRs - From the 1920s to the 1990s, men 20-64

Year SMR by Social Class

I II III IV V Ratio V:I

1921-23 82 94 95 101 125 1.5

1930-32 90 94 97 102 111 1.2

1942 88 93 99 103 115 1.3

1949-1953 86 92 101 104 118 1.4

1959-1963 76 81 100 103 143 1.9

1970-1972 77 81 103 114 137 1.8

1981-1983 66 76 100 116 165 2.5

1991-1993 66 72 113* 116 189 2.9

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Source: DoH 2003

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17 The highest and lowest premature mortality constituencies of Britain

(1991-95)

18

60

70

80

90

100

110

120

130

140

150

160

1950-53

1959-63

1969-73

1981-85

1986-89

1990-92

1993-95

1996-98

1999-2000

FirstSecondThirdFourthFifthSixthSeventhEighthNinthTenth

Figure #. Standardised mortality ratios for deaths under 65 in Britain by tenths of population by area, 1950-53 to 1999-2000

19 Low Income in Britain 1961-2003

20

21

22

Shettleston, Glasgow

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•You need a plan and clear, measurable objectives.

•You need belief … Action needs to start with the belief that you can do

something about it.

•You need a cross-governmental plan to address health inequalities –

including the finance ministry.

•Although this work is not about health services alone, the health sector has

an important leadership role to play.

•‘Joined up government’ is very important, particularly at the local level,

where planning and funding mechanisms need to be brought into the picture.

www.who.int/social_determinants/advocacy/wha_csdh/en/

Tackling Health Inequalities: lessons from the UK

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Aims and targets

“The government’s strategy on health inequalities aims to narrow the gap in health outcomes across geographical areas, socio-economic groups, age groups and different black and minority ethnic groups, as well as between men and women and between the majority of the population and vulnerable groups with special needs”

(HM Treasury and Department of Health, 2002)

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In the European Union;

“most countries with quantitative targets have set them in terms of reducing gaps between the poorest and the more affluent, but Scotland and Wales appear to be unique in terms of emphasising the importance of improving the position of the poorest groups per se.”

In Wales & Scotland the targets do not focus explicitly on ‘closing the gap’ but emphasise relatively faster improvements for the most deprived groups.

Source: Judge et al (2005)

Approaches to Health Inequality Target Setting

27 Likely health impact of socio-economic interventions

Source: Mitchell et al 2000

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Very little of the mortality gap by social class can be explained by known ‘risk’ factors

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1. The solutions?

- What can the health service do

Tackling Health Inequalities

Ending the Inverse Care law - equitable, accessible and inclusive health care and health resource allocation

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The term 'inverse care law' was coined by Tudor Hart (1971) to describe the general observation that "the availability of good medical care tends to vary inversely with the need of the population served."

A primary aim of health inequalities audits and impact assessments should be to identify the best method or methods of allocation in order to distribute resources on the basis of health needs and thereby alleviate the problems caused by the ‘inverse care law’.

The Inverse Care Law

31The Inverse Care Law

Average number of GPs per 100,000 by area deprivation, 2002 & 2004

Source: SRGHI 2005

32·     Most effective medical interventions do not reduce disease incidence risk but may improve prognosis and quality of life through primary, secondary and tertiary prevention. ·     In order to reduce health inequalities it is essential that all segments of society share equally in these advances on the basis of clinical needs and not be influenced by spurious socio-demographic factors·        Health care provision must be commensurate with clinical need and unbiased by socio-economic status. A mismatch between need and provision is inequitable. ·    Evidence of clinical effectiveness is essential in interpreting patterns of service provision by socio-economic status as overprovision may be as harmful as under-provision.  ·    Inequity can function at various different domains such as age, socioeconomic status, geography, ethnicity and gender. These domains may act independently or additively. ·       Inequity can occur at primary, secondary and tertiary care levels within the NHS.

Ending inequity in health care

33 Ten Tips For Better Health – Liam Donaldson, 1999

1. Don't smoke. If you can, stop. If you can't, cut down.

2. Follow a balanced diet with plenty of fruit and vegetables.

3. Keep physically active.

4. Manage stress by, for example, talking things through and making

time to relax.

5. If you drink alcohol, do so in moderation.

6. Cover up in the sun, and protect children from sunburn.

7. Practice safer sex.

8. Take up cancer screening opportunities.

9. Be safe on the roads: follow the Highway Code.

10. Learn the First Aid ABC : airways, breathing, circulation.

34Alternative Ten Tips for Health

1. Don't be poor. If you can, stop. If you can't, try not to be poor for long.

2. Don't live in a deprived area, if you do move.

3. Be able to afford to own a car

4. Don't work in a stressful, low paid manual job.

5. Don't live in damp, low quality housing or be homeless

6. Be able to afford to go on an annual holiday.

7. Don’t be a lone parent.

8. Claim all benefits to which you are entitled

9. Don't live next to a busy major road or near a polluting factory.

10. Use education to improve your socio-economic position

35 The Origin of the Choice Agenda: NHS Safe in our Hands