On route to the ‘fully engaged' scenario?
Tuesday 3 June 2008
Securing our future health – taking a long term view was published in 2002, setting out what might be needed to run a high-quality healthservice 20 years ahead, Sir Derek Wanless told delegates in Tuesday's Royal Society of Health lecture. His report devised three scenarios with modelled outcomes and costs – ‘fully engaged', the most ambitious, ‘solid progress' and ‘slow uptake'. So are we now any closer to being on course to achieve the ‘fully engaged' scenario?
'Overall there is certainly more activity in health services but not as much as the money might have achieved,' he said. ‘Most important, but hardest to measure, is what are the outcomes for people. Mortality is down, life expectancy is up. But both are continuations of long-term trends from years which had lower spending. The bottom line for us researchers is that five years is often too short a period to see effects.'
A major part of last year's Kings Fund-commissioned Our future health secured? review was to look at whether Government decisions over the last few years had met the Cabinet Office's own criteria for sound policy-making. ‘Often they did not,' he said. Fundamental reform has been necessary to improve the performance of the NHS and make best use of available resources, he acknowledged, but the areas of most notable improvements – such as waiting times – have been centrally driven. ‘But at what cost in diversion of resources from other areas?'
Short shelf life
The shelf life of a policy framework driven by targets and active central management is short, he said - the kind of change that requires a long-term perspective and local sensitivity to the way changes are implemented is harder to achieve. 'In many ways inconsistent change has been wasteful of time and resource as well as demoralising,' he added, which is not to say change is not necessary. The evidence available for estimating the impact of the wide range of inter-connected Government policies is also limited, he said.
Achieving the ‘fully engaged' scenario will require a fundamental change in approach, but the prize is potentially huge, he stressed. At the moment the outlook can‘fairly be described as mixed,' he said – ‘some progress, clearly, but with deteriorating obesity pulling down overall performance to a level below "solid progress"'. Large variations in smoking propensity between socioeconomic groups remain but the 21% adult target looks achievable, he said, while the 2004 childhood obesity target – 'despite its modest ambition' – seems unlikely to be achieved. There has effectively been no adult obesity target since the early 90s, and huge problems, costs and inequalities are in store if trends continue, with the recent Foresight study producing some ‘staggering' figures, he said.
High-level group
Public health also remains susceptible to ‘unintended consequences' of large scale change in the NHS, he added, such as the raiding of budgets to meet productivity targets or reduce deficits. There remains a real need for a high level, independent and modestly resourced ‘medical and managerial' group to include representatives of national and local government, business, voluntary and trade union sectors to look at quantified objectives for inequalities and determinants of health, he said. Future National Service Frameworks need to include the best available information about cost effectiveness of activity and interventions, while NICE had been making sound progress towards economic assessments and guidance for public health activity.
Public health support
The recommendations of the 2007 report still requir support from public health professionals, he said. These include the production of regular long-term resource estimates, requiring an understanding of the scope and nature of health and social care services, as well as encouraging use of recent system reforms to communicate best practice.
Monitoring progress and assessing policy and performance is also essential, he said, as is measuring and managing productivity – 'beginning with its definition and building systems designed to achieve it'. It is also necessary to think through workforce capacity and planning to incorporate public health needs, and look at the potential of self care, 'expert patients' and community pharmacists.
'The challenge is to do all of this,' he said. ‘There is a huge prize of keeping our health services sustainable and to making them better value. A prize which is in my view most likely to be attainable – and indeed may only be attainable - if public health raises its game.'