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Healthcare Reform in
England …
New Commissioning Arrangements
for Mental Health Services
“Thriving or just about Surviving ?”
Professor Antony Sheehan

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Agenda
NHS Briefest of history lessons!
Some general comments about health
systems
Mental Health’s journey – the last decade
An outcomes based approach
What does the future hold? (Discussion)
….off to Old Trafford!

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 As the debate over how best to look after American patients rages on, Britain's
socialised health care system has increasingly found itself being drawn into
the argument. Critics of the Obama administration's plan to overhaul US health
care say the president is seeking to model the U.S. system on that of Britain or
Canada - places they paint as countries where patients linger for months on
waiting lists and are forbidden from paying for their own medication
 A Republican National Committee ad said that in the UK "individuals lose their
right to make their own health care choices." Another ad by the anti-tax group
Club for Growth claimed that government bureaucrats in Britain had calculated
six months of life to be worth $22,750. "Under their socialised system, if your
treatment costs more, you're out of luck," the ad says, as footage of an elderly
man weeping at a woman's bedside alternate with clips of the Union Jack and
Big Ben.
 Editorial, printed in the Investor's Business Daily, claimed that renowned
physicist Stephen Hawkins, who is disabled, "wouldn't have a chance in the
UK, where the National Health Service would say the life of this brilliant man,
because of his physical handicaps, is essentially worthless."
Healthcare Reform International perspectives
What the US says about the NHS

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What the NHS Costs
The UK government department responsible for
the NHS is the, headed by the Secretary of State for
Health. Most of the expenditure of The Department of
Health (£98.7 billion in 2008-9) is spent on the NHS.
This year the NHS budget is $180 billion, over
$5,000 per household.
13% on behavioural health care.

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5th
July 1948
The NHS…Providing a
comprehensive range of
services for all in need
Bringing organisation to the
work of physicians, barber,
surgeons and apothecaries!
“A fixed quantity of illness in
the community which the
introduction of a health
service, free at the point of
consumption; would
gradually reduce.” !!!
… Doctors and Nurses in charge … for 30 years …

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NHS more business
like
• Introducing an internal
market
• …and general
management
techniques
Until May 1979 …The Thatcher Years

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At one point … Director General…The Department of
Health…
The Blair years….lots of chances to consider
international comparisons with our own system

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Which country has the best system?
A league table of 191 countries published in 2000
Where did the UK rank?
Where did the US rank?
Name the top country in the WHO’s league table
18th
37th
France
The answers

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The ideal system?
Japanese health outcomes
French style patient choice
German levels of access to doctors and hospitals
US levels of hospital efficiency (in the best
performing organisations)
UK work on quality and safety
Chris Ham – CEO
Kings Fund England

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Big challenges for the NHS
Bringing our outcomes up to the best: life
expectancy, infant mortality, cancer survival etc (this
includes addressing inequalities)
Tackling risk factors like obesity, smoking and
alcohol misuse to reduce the future disease burden
Rising to the challenge of chronic diseases through
support for self management, consistently good
primary care, and greater integration of care
…Likely to feature as key outcome areas

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NHS as a real political priority for
investment circa $100B
“Reforms needed to be bold and
many and varied
Encompassing
- Targets
- Performance Management
- Regulation
- National policy
- National Licensing
- Innovation and change support
NHS – The Blair Years
3 priorities CANCER, HEART DISEASE, MENTAL HEALTH

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Standards – National Service
Framework and accompanying
strategies
New Community Teams –
Assertive Outreach, Crisis
Resolution, Early Intervention
Reducing suicide – National
Strategy
Investment - $1.4 b
The National Institute for Mental
Health in England and the
Results …
1999 / 2000 … 2008 / 9
Contrast with Learning Disability

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0
2
4
6
8
10
12
1993/4/5 1995/6/7 1997/8/9 1999/2000/1 2001/2/3 2003/4/5 2005/6/7 2007/8/9 2009/10/11
Suicide rate in England
Death rates from Intentional Self-harm and Injury of Undetermined Intent in England
1993-2007
Death rate per 100,000 population
Target:
20%
minimum
reduction
from
1995-97
baseline
rate
baseline Progress target
Source: ONS
9.2
7.3
7.8
Rates are calculated using the European Standard Population to take account of differences in age structure.
3 year average
Progress since baseline:
A fall of 15.2%

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Number of new Mental Health Teams in place from 2001 to 2009
compared to target
0
50
100
150
200
250
300
350
400
Crisis resolution Assertive outreach Early intervention
Sept 2001
Sept 2002
Sept 2003
Sept 2004
Mar 2005
Jan 2006
Mar 2007
Mar-08
Mar-09
Target
NHS Plan Teams
Source: Service Mapping exercise

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In the last throws of New Labour…?
New Horizons: the next phase of mental health policy
Key points:
• New Horizons sets out the Government’s vision for
improving mental well-being and improving adult
mental health services in England
• There are no new targets for public services or
commitments on future funding
• Public mental health initiatives include targeting
young people, tackling stigma and improving
employment and housing outcomes
• Mental health services need to improve quality and
efficiency, and focus on recovery
• Improving access for vulnerable and hard-to-reach
groups, such as veterans, is key
• Improving transitions and intervening early are
major themes
Currently being re-cast for Launch soon….

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Mental Health and Learning Disability
Coalition

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 “Relative” protection for NHS finances
 Dramatic changes to the commissioning system including new roles for local Government
working with General Practice/Primary Care…NEW OBLIGATIONS
www.capsticks.com
 “Market” strengthening
 A very different Department of Health “Arms length
management” of the NHS through an Independent Board
…and clinicians have influenced this
…ministers with years of shadowing the health portfolio
…and they have been talking to…?
Current position…the NHS has been
liberated…no one can find it….if found please
call 0800…

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What the System looks like now
Dept of Health
SHAs
PCTs GPs
Providers
Quite Linear…

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What the system will look like
Commissioning Board
Dept of Health
GPs Local Government
Market
Relationships?

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Reflections on the reform of the NHS- Lessons
for policy makers, managers and clinicians
Policy making in the opposition is often weak. – No master
plans
Politicians are inexperienced in leading large scale change
It takes time to deliver change
Things may get worse before they get better- the ‘J’ Curve
Improvement is rarely liner
Changes in Leadership may impede progress
Regulation and inspection are likely to become more important
– at least in the English system
Front line staff need to be fully engaged
Levers and incentives need to be balanced

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“What the front line requires is a policy Framework
and goals, not hundreds of micro-announcements…
Now I realise that real ‘delivery’ is about the grind,
not just the grand. It’s the combination of often
small things that build over time, through individual
relationships and genuine expertise and hard work.”
Peter Hyman – School Teacher, North London and former head
of Tony Blair’s Strategic Communications Unit

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Key Shift
Quality of services combined with productivity.
Focus on efficiency of £1.20 billion
Voice of Consumer/Personalisation
Input from Private Sector more real
Quality Accounts as well as Financial Accounts
measuring outcomes: Experience/Safety/Clinical
Strengthened Regulation
(public enquiry into Mid Staffs

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• Specialist Commissioning of MH Services
• Risk for MH and Learning Disability
• Market Exit and Entry
• Need to get close to Consortia – GP “Commissioning”
• - The importance of Doctor to Doctor relationships
• Be Business like
• Clinical Leadership
Reflections on Future Commissioning
Challenges…DISCUSS!!
Thank you and let’s hope Manchester United
beat Blackburn this afternoon!