22
Future Health Scenarios Strategic Issues for the British Health Service Marcus Longley and Morton Warner The fundamental dilemma facing all industrialized countries is that demand for healthcare always outstrips supply. The National Health Service (NHS) is under pressure all the time as the result of changing factors. One example is technology; perhaps the most significant development on the supply side is the progress of the Human Genome project. Expensive technology is likely to move out of the relatively few centres and professional staff will clearly be influenced both by this and the need for new skills training. New monitoring devices will mean more people able to monitor and treat their own illnesses with lower levels of professional support. Developments in information management will allow distance diagnosis as well as greater public awareness. Trends in society, such as changes in population structure and in individual life styles, will influence the shape of overall demand. Developments in the economy, for example unemployment, lack of finance etc, will impact healthcare delivery. Government policy, the expansion of private financing of care, efforts to increase individual patient influence, concentration of expertise to achieve better results, new services and the changed split between the purchaser and the provider roles, all are determinants in shaping the future. To see what these trends could mean, the Welsh Health Planning Forum worked with four contrasting pilot sites, each of which was asked to quantify the future impact of observable trends in healthcare delivery. Each site adopted a slightly different approach and the four were not necessarily typical of the NHS. Some of the elements in the future of healthcare delivery that emerged include people looking after themselves better, greater cooperation between health and social services, mental illness services based in the community, greater use of day case treatments, and aspects of acute hospital services available nearer to home. Scientific and technological breakthroughs are likely in all areas and their cost efficiency and cost benefit will need to be evaluated. There will be changes in the provision of services, ranging from within primary care to within hospitals. Managers will need to ensure that staff with appropriate skills are substituted for those with inappropriate skills. The pressures of budgetary constraint and patient demand will enforce the more systematic evaluation of effectiveness. The NHS will need to provide services for prevention, diagnosis, treatment and continuing care. It should also help and encourage housing bodies, employers as well as local planners and individuals to act in a way which is conducive to better general health. New horizons for the prediction and management of diseases will be opened. The function and nature of health services are likely to change and the prolonged period of transition will be one of successive challenges. No plans for health and social services in the next century will survive without the local support of the general public. Equal access to high quality care, integration of organizations, resource shifts between sectors, training at all levels, best use of all facilities are among the issues which will need to be addressed by politicians, clinicians as well as by health service management.
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Whose Company Is It? The Concept of the Corporation in Japan and the West Masaru Yoshimori In terms of corporate governance, countries can be divided into three groups. The monistic outlook is shareholder-oriented and is prevalent in the USA and the UK.
Executive Summaries
Future Health Scenarios Strategic Issues for the British Health Service Marcus Longley and Morton Warner
T H E BRITISH NATIONAL HEALTH SERVICE (NHS) is a source of great national pride, and politicians tamper with it at their peril. By international standards it is remarkably cheap, the British system of family doctors is the envy of many, and our leading hospitals are the equal of the best in the world. But if you pick up any British newspaper, the headlines appear to tell a very different story--cash crises, waiting lists, hospital closures, loss of clinical freedom, and so on. Can we really be talking about the same NHS? The fundamental dilemma, shared by each of the industrialized countries, is that the demand for health care always outstrips the supply. This problem has been with us for decades, and is not new. But as we approach the next century, it appears that this old problem is becoming more acute in response to an accelerating pace of change. The level of demand for healthcare is increasing almost exponentially, but our willingness to pay for n e w services is not. This article begins by outlining the strategic background, and then reports on a recent exercise which considered h o w it might be possible to create a different pattern of health care that is fit to meet the demands of a n e w century. It concludes by stepping back from the debate about health services, and asks the question: if our ultimate objective is better health, what will be the necessary contributions of others outside the NHS?
Strategic BackgroundmForces that will Change Health Care The NHS is under pressure all the time as a result of changes in: ~
Pergamon 0024-6301(95)00024-0
The health service in the United Kingdom, along with that of most other industrialized countries, is beginning to come to grips with a series of powerful forces for change. This article summarizes those forces, and then describes a recent strategic exercise which explored their likely implications. This leads to a re-appraisal of the current delivery and organization of services and then suggests a set of key strategic issues for the health service. It ends by re-examining the role of health services in delivering better health.
Cl science and technology ~1 society lifestyles ~1 patterns of disease Q the economy and working conditions. This section briefly considers each in turn, and also three intermediate variables--demand, supply, and government policy. The inter-relationship between the various elements is shown in Figure 1.
Advances in Science and Technology An indication of the range of possible developments in healthcare technology is shown in Table 1. Table 2 indicates some of the key issues arising from likely developments in science and technology. These developments are in themselves usually highly Long Range Planning, Vol. 28, No. 4, pp. 22 to 32, 1995 © Crown Copyright 1995 Elsevier Science Ltd. Printed in Great Britain.
Science & technology
Social
~
/
Cultural
Policy
Diseases ~
Supply
Economic
FIGURE 1. Pressures on the National Health Service.
TABLE 1. Possible developments in healthcare technology. Area
Possible Developments
Prevention
[] support for behaviour changes, e.g. the nicotine patch [-1 education approaches, e.g. interactive videos
Diagnosis
[] [] [] [] []
Treatment
successes with immunization, new drugs, health promotion 0 increased transplantation and implantation [] further development of minimal access techniques
Palliation/Rehabilitation
[] [] [] rl rl
Information Systems
131 for clinicians: links, fast retrieval, expert systems [] for the public: better data on health issues
new molecular/genetic techniques wider use of diagnostic kits automation and miniaturization of diagnostic tests greater local availability greater use/local use of diagnostic endoscopy
movement control systems implantable or portable sensory aids lighter more durable prostheses design of environments to support the individual greater emphasis on psychological treatments
LongRangePlanningVol.28
August1995
TABLE2; Some key issues relating to advances
T~LE 3. Some key social trends.
in science and technology, 13 ageing population
El much greater abilityto predict and manage disease as a result of the Human Genome Project El changed professional training and organization El managed introduction of new technology El impact on hospital care El new opportunities in information management
desirable, but they give rise to a number of strategic issues of great significance. Perhaps the most significant development on the 'supply side' over the coming decade will be the progress of the Human Genome project--the 'mapping' of the entire genetic blueprint of human life. Although the pace of this development cannot be predicted accurately, greater understanding of genetics will have huge implications. It is almost certain to increase our ability to predict and manage health problems, allowing for the development of individual health plans and the prevention or minimization of major killer diseases. But there will be difficult ethical issues to tackle. We will return to the implications of this development later. In the past, expensive technology has been concentrated in relatively few centres. In the future this may change. On the one hand, very high costs of some technologies and the need to bring together rare skills may focus some services in a small number of highly specialized centres which have access to very specialized technology and treat sufficient patients to maintain their expertise. On the other hand, falling costs, information transfer and miniaturization may allow greater decentralization of other services. One important constraint will be the need to manage the proliferation of expensive options, not all of which can be provided safely and economically in every locality. Professional staff will be affected by the changes. New forms of technology will require changes in professional education and training. It will not be possible, for instance, for a clinician to have a detailed knowledge of all areas of technology, and this may lead to an increasing emphasis on mastering general concepts of health sciences rather than learning rapidly outdated facts. Increased medical specialization is also likely, and new technologies may erode existing boundaries between specialties. New monitoring devices will allow increasing numbers of people to monitor and treat their own illnesses with lower levels of professional support. Changes in practice have reduced some hospital admissions and length of stay in general has fallen. Another crucial and potentially all-pervasive development will be in relation to information man-
El more fragmented families El smaller households El less community-minded
El more fear of crime and violence El rising levels of education El rising expectations of health services
agement. It could offer support to clinicians by allowing distance diagnosis and fast retrieval of digitized imaging data, and offering expert systems. It could also strengthen the power of the public, by giving easy access to fuller information on health issues, and allowing patients much more control over their own care.
Shifts in Society A number of possible changes in society could have major effects on the demand for health services (see Table 3). Population structure is one factor. Population projections to 2010 suggest a 75% increase in the number of people aged 85+, compared with just a 4% increase in those of working age. Traditional family structures have also been changing, with one in three marriages in Wales now ending in divorce. Children of broken or lone-parent families have on average impoverished life chances which affect their health and other aspects of their lives, and fewer people will be able to rely on their children to care for them in old age. People in future will be increasingly well-educated. They are likely to be more aware of the factors influencing their own health, but they may also be more demanding in terms of the health care they receive.
Changing Lifestyles Individual lifestyles can have profound effects on health, and there are health promotion strategies designed to change individual behaviour (see Table 4). Two questions arise: can the targets be achieved; and if they are, what will be the impact on health services?
TABLE 4. Some key targets for lifestyle changes.
Reductions in the number of people who El smoke regularly El drink excessively El do not undertake regular exercise El are obese
Future Health Scenarios--Strategic Issues for the British Health Service
TABLE5. Some key changes in disease patterns.
I
0 some major killers declining [3 remaining burden of long-term illness 13 some new diseases emerging, or old ones reemerging 13 greater interest in quality of life 13 no sign of reduction in demand for health services
Though some people are adopting healthier lifestyles there remain significant problems. For instance, there is no change in the proportion of young people w h o smoke, and employment is becoming more sedentary with possible implications for levels of cardiovascular disease and bone weakening (osteoporosis). The central problem is that people follow or adopt particular lifestyles for a huge variety of different reasons--social, economic, cultural, psychological--and individuals often do not have much genuine free choice in these matters. But even if the targets are met, it w o u l d be unsafe to assume that successful health promotion w o u l d necessarily reduce demands on health services, since those who might have died prematurely could in the future live and use hospital services for longer.
Changes in the Pattern of Diseases There is no reason to believe that in the near future the overall demand for healthcare will decrease (see Table 5). Although we have seen the virtual eradication of several major threats to life, and deaths from cardiovascular disease and stroke have decreased, a substantial burden of long-term illness r e m a i n s - 25% of people in Britain, and 32% in Wales report having long-term illness? Some diseases, including AIDS, some forms of cancer, asthma among the young, and fractures among older people are all increasing, and n e w health problems might also emerge. As the population ages, there will also be a growing interest in quality of life issues and possibly an increase in the chronic conditions more common in old age.
Developments in the Economy and in Working Conditions Changes in the economy (see Table 6) bear on demand, supply, and policy:
TABLE6. Some key changes in the economy. 13 widening disparities in income 13 higher male unemployment, with geographical concentrations 13 more female employment 13 more flexible working patterns
TABLE7. Some key issu~ relating to policy. 13 13 13 13 13 13
balance between state and private funding ever-increasing demand for services increasing patient influence more interest in clinical effectiveness new service options dynamic of the internal market
O People's standard of living can affect their health--unemployment, poor housing, disparities in income, poor working conditions and other factors related to the state of the economy all have a demonstrable impact on health. 2 {3 The strength of the economy is likely to have a bearing on the level of resources--both state and private--which can be made available to the health service. [3 The NHS is a major e m p l o y e r - - a b o u t 1 million people in the UK--and therefore will be affected by changes in the labour market. Average real disposable household income per head in the United Kingdom increased by nearly three quarters between 1971 and 1990, but the gap between families at the top and bottom of the scale widened. :~4 There is some evidence to suggest that increased relative deprivation tends to lower national standards of health. 5 A number of studies have associated unemployment with poorer physical and emotional health, although the nature of the impact of u n e m p l o y m e n t remains unclear. Some estimates ~ suggest that male employment rates will continue to fall, and there will remain pools of high unemployment. Illnesses associated with heavy industry, such as pneumoconiosis, will continue to decline.
Government Policy We have seen some of the ways in which supply and demand will be altered; government policy towards the NHS deserves separate attention (see Table 7). There has been a major expansion of private financing of care in the 1980s; although the UK still has a far lower proportion of its health expenditure met from private sources than do most other industrial countries. 7 Continuing increases in both activity and d e m a n d - - a 19% increase in both hospital admissions and waiting lists between 1987 and 19928 for examp i e - - m e a n s that the issue of funding will remain at the forefront of political discourse. In this climate, one major issue is whether the share of funding derived from insurance and other private sources should increase. The government is currently trying to increase the influence of individual patients on the NHS, and there Long Range Planning Vo]. 28
August 1995
is plenty of anecdotal evidence that patients are becoming more aware of their rights, and more assertive. But there is still a long w a y to go, and one may expect even greater pressure on health services from consumers. Evidence continues to emerge that concentration of expertise and continual practice can achieve better results; these include such diverse issues as emergency medical admissions, fractures, cancer care and intensive care for small babies. The lesson is that not all hospitals should provide all services. New options in providing services are emerging here and overseas. For instance, a number of sites are looking at 'patient hotels' as a means of providing cost-effective high quality hotel services on hospital sites for those who do not need 24-hour care. There is a resurgence of interest in community hospitals, and many areas are developing new home services for older people. The split between the purchaser and provider roles has initiated changes in the way services are provided and spotlighted the issues of throughput and quality.
Modelling the Impact In order to see what possibilities and dangers these changes might present, the Welsh Health Planning Forum worked closely for 18 months with four contrasting pilot sites (see Figure 2)--Neath and Port Talbot, industrial towns on south Wales; Powys, a rural county in mid Wales; Coventry, an English city; and Belfast and the surrounding area in Northern Ireland. The pilot sites were asked to consider a set of nine 'assumptions' about the future of services (see Table 8). The assumptions attempted to quantify the future impact of a number of trends w h i c h are currently observable in health and social services. The pilot sites had to consider how, in their local circumstances, they w o u l d achieve the assumptions. They were asked to assess not h o w far they could get towards reaching them, but to take them as targets they must attain. This required them to identify the obstacles to be overcome and the ways of overcoming them. They were encouraged to be as imaginative and innovative as possible, but certain parameters were set at the start: El Public expenditure on health will be as indicated in government plans. O Methods of financing health and social care will not change dramatically. O Local government will continue to provide social services, with the NHS providing health care. O There will be a continuing emphasis on services
closer to where people live, where this is appropriate and acceptable to patients and users. Having done that, they were then to ask themselves the question 'is the target a desirable one?'--using a common core of values as the benchmark (see Table 9). Each site adopted a slightly different approach, but all involved as wide a spectrum of local interests as possible, including professionals, lay people and voluntary organizations. 9-11 Before going on to describe the results, there are three important caveats to bear in mind in relation to the methodology. First, the four sites were not necessarily typical of the whole of the NHS. Second, there was relatively little public involvement in the discussion about most of the assumptions, so doubt must remain as to whether this scale of change will be acceptable to the general public. Given the radical nature of much of the change proposed, and the importance of involving the public in the discussions, this represents a significant issue to be addressed in the near future. Finally, little can be said at this stage about whether the results of the study amount to an economically viable option. The pilots had to conform to the condition of revenue neutrality, and all the sites made an effort to cost the overall impact of attaining the assumptions. They reported that overall they could meet the condition, though counselling caution on their results, and highlighting the need for pump-priming in some cases. Their conclusions, however, cannot necessarily be applied in all localities, since existing cost patterns and future marginal costs and benefits w o u l d depend upon local circumstances.
The New Health Service Putting together the work from the pilot sites, a picture of health care in the early part of the next decade begins to emerge. Some of the key elements include: O People in some ways looking after themselves bett e r - f o r example, fewer people will be smoking. O Greater co-operation between health and social services - - s o m e of the boundaries between them will have become blurred. El Mental illness and learning disability services based in the community. O Several aspects of acute hospital services available nearer to h o m e - - m o r e specialist consultations and treatment will take place in dispersed settings, more surgery will be carried out in ways which involve less trauma for the patient, and greater use of day case treatments will lead to shorter hospital stays.
Future Health Scenarios--Strategic Issues for the British Health Service
in
300 people
7 ,~ -Rural I -125,000 people ~
~
, -J
ort Talbot ~11 -Urban & rural -125,000 people
FIGURE 2. T h e pilot sites.
TABLE 8. A ~ u m p t i o n s
for testing.
By 2002: 1. 2. 3. 4. 5. 6. 7. 8. 9.
Health promotion targets on smoking, physical exercise and weight are met. For each local community there are arrangements in place for the pooling of NHS and local authority funds to provide local access to minor surgery, a minor accident service, certain specified diagnostic services, therapy services and social work assistance. All mental illness and mental handicap hospitals that were open in 1985 are closed. Everyone over 85 has a keyworker. Referrals from GPs to specialist medical services have been reduced by 20%. 40% of outpatient consultations with specialist medical staff occur in locations other than a District General Hospital (DGH). 80% of surgical interventions are by minimal access ('keyhole' surgery). 60% of surgery is by day case. Acute beds in DGHs have been reduced by at least 40%.
D Some specialist services, however, concentrated on fewer sites. [] The number of beds required in hospitals by the acute specialties declining, largely--but not entirely--as a result of reductions in the surgical bed complement.
Four 'Substitutions' In more general terms, one can describe these changes in terms of a number of 'substitutions': 12 1. N e w Technologies. Scientific and technological breakthroughs are likely in all areas of
Long Range Planning Vol. 28
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I
TABLE9: C o m m o n core of values.
Choice~the users of services should be able to exercise maximum control over their health, and the treatment and care they receive: 0 [3 El [3 [3
Services should support and encourage people to maintain and improve their health
Users and carers should influence the development of services As far as possible, all users should have equal access to the best available care People should have information to enable them to make real choices about the care they receive Whenever appropriate, services should be provided in or near the home, or in a homely setting
Qualitymquality should be judged from the point of view of the person using the service: El Services should strive to provide the most effective treatment and care possible El Care should be geared to the user's needs and not organizational convenience El Staff should be responsive to users and carers Value for money--the maximum possible benefit should be extracted from every pound spent: Q r3 [3 r3
Investment must be in what is effective in meeting the needs of users and clients
Everyone entrusted with resources should ensure that services are managed cost-effectively Staff should have a level of skills appropriate to their job Day-to-day management control should be devolved as close as possible to where care is given
health care, from prevention through to long-term care. This presents a number of significant challenges to the service. There is a powerful need, for example, to evaluate the cost efficiency and cost benefit of n e w technologies before they are introduced. This is not an easy task to manage, particularly when public pressure and medico-legal constraints combine to demand that the latest drug or piece of equipment is available in every hospital, almost without regard to its objective merits. New technologies also demand other changes before they can be introduced, such as improved training of staff.
2. N e w Locations.
As the possibilities for moving care closer to home develop, and as the clinical imperative to centralize other services becomes more insistent, the function and nature of hospitals and community care will change rapidly and profoundly. Some of the likely changes are shown in Table 10. Without careful management, there is enormous potential here to disrupt services and threaten constrained budgets.
3. N e w Staff an d Skills. In this rapidly-changing environment, staff skills can easily become redundant. Managers must therefore ensure that staff with appropriate skills are substituted for those with inappropriate skills. This latter includes those who are both too highly and too poorly trained for the tasks they are required to perform. It currently takes at least 10-15 years to train a doctor, and 3 years to train a nurse. The rapid pace of change envisaged could therefore easily render their skills inappropriate. A major task, therefore, is to anticipate future training needs. In order to do this effectively, it will be necess-
ary to identify what the likely 'common core' skills will be in the future, and also h o w to equip staff to respond to unexpected developments. This implies a re-examination of both basic and post-qualification training, and this is n o w beginning. It also implies an on-going re-appraisal of w h o does what, and the possible emergence of entirely new groups of staff.
4. More E m p h a s i s on Effectiveness. Health services internationally do not have a particularly strong record in evaluating the effectiveness of what they do. It has been estimated, for example, that only about 15-20% of all medical interventions have been proven to be effective b e y o n d all reasonable d o u b t . 13'14 This is perhaps not surprising w h e n one considers the often enormous difficulties of establishing proof in this area, but nevertheless we can and must do more. There has already been a shift at the national and international levels towards more systematic evaluation of effectiveness, and the pressures of budgetary constraint and patient demand are likely to ensure that this continues.
Beyond the Health Service--the Fifth Substitution 'Does the NHS exist to provide high quality, costeffective health services, or does it exist to improve the nation's health?' At first sight this might seem to be a false d i c h o t o m y - - s u r e l y the two ends are parts of the same thing? On closer examination, however, an important difference emerges. 'Health' is defined by the World Health Organization as a 'state of complete physical, mental and
Future Health Scenarios--Strategic Issues for the British Health Service
Movements
Examples
Within primary care
[3 Better co-ordination with: Practice nurses; Psychologists; Social Workers; Physiotherapists; Counsellors [3 Increased adoption of specialist interests at primary care level
DGH to community settings
[3 Shifts in: Paediatrics; Dermatology; Radiology; Psychiatry; Rheumatology; Obstetrics 13 Development of hospital-at-home arrangements
Institutional to community settings
13 Shift in emphasis from medical to social model 13 Shifts of care in Mental Illness and Learning Disabilities
Secondary to tertiary
[3 Concentration of complex work relating to: Trauma; Surgery; Radiology; Obstetrics
Tertiary to secondary
[3 Certain Orthopaedic and Cardiac procedures
Within hospitals
13 From wards to day units: Day Surgery; Minimal Access Surgery 13 Wards to Patient Hotels: Tests; Observation; Post-natal observe.
social well-being and not merely the absence of disease'. ~5 If one accepts this as a valid definition, it is immediately apparent that the NHS cannot achieve it on its own. There are m a n y influences--personal, religious, educational, and e c o n o m i c - - w h i c h lie outside its scope. It follows that when considering the role of the health service one must be very clear about what it should be doing. Reducing waiting lists and treating more people every year--a high quality, cost-effective service--are important, of course, but they do not on their own guarantee improved health for the population as a whole. Most people do indeed want both high quality, cost-effective services, and better health! The NHS must therefore do two things: [3 Provide services for prevention, diagnosis, treatment and continuing care--'to assist us to come safely into the world and comfortably out of it, and during life to protect the well and care for the sick and disabled'. ~6 O Help and encourage others--housing bodies, employers, local planners, national policy makers, and individual people--to act in a way which is conducive to better general health. This is captured in the 'strategic intent' of the NHS in Wales: Working with others, the NHS should aim to take the people of Wales into the twenty-first century with a level of health on course to compare with the best in Europe.~7 The first task--the provision of services--has been discussed above. The latter--often called the forging of 'healthy alliances'--has only recently achieved prominence in the NHS, and consequently has few manifestations in practice so far. But its time has
come, and we can expect this sort of approach to grow in importance in the remaining years of this decade. It is the fifth substitution.
Moving On Talking about the future is only useful and interesting if it affects what we do and how we live today.
This work in Wales and elsewhere has helped to illuminate the future. It is evident that many people in the NHS in this country, as well as others in Europe and North America, are coming to similar conclusions about the forces at work, and about the likely future direction of health and social care. 1~ ~4 We can see health services changing considerably over the next decade and beyond. The development of genetics and biotechnology discussed earlier will open up new horizons for the prediction and management of diseases which are currently only amenable to treatment when they are already advanced, and sometimes this is too late; and the growing interest in the NHS working across sectors in partnership with others will broaden the scope of activity. The result is represented in Figure 3. This shows that both the function and nature of health services are likely to change in the coining decades, and that the prolonged period of transition will be one of successive challenges. Last, but not least, the general public must be brought into this discussion. Health and social services are there to meet people's needs and will be judged by the people they aim to serve. An important part of each local strategy is the development of a local vision of the future pattern of health and social services which commands local support. No plans for Long Range Planning Vol. 28
August 1995
Intersectoral
~ i i~ ~ii~ii/~i~ ~ ~i~!~i~!!i~ii
i !ili/, i !
Healthcare
Molecular biology & genetics Intersectoral
1~5
c. 2005
2010
Note: Reproducedwith permissionof WelshHealthPlanningForum
FIGURE 3. Contributions to healthmthe broadening agenda.
health and social services in the next century will survive--or deserve to s u r v i v e - - w i t h o u t that support.
Implication s for Managem en t Essentially, there are two objectives: [3 To achieve the desired goal--a health service in the next decade which is still consonant with our values. Q To manage the transition so that the quality of service does not deteriorate. All of those involved in the management of the health service--which must include politicians and clinicians, as well as those formally designated as 'managers'--must therefore address the following issues:
El Equity--in the face of rapid and sometimes unpredictable change, the need to ensure equal access to high quality care must be at the top of the agenda.
Q Public acceptance--to
obtain public understanding and acceptance of the vision outlined above.
Integration of organizations--to get the various different organizations involved to deliver care to their clients in a 'seamless' way.
El Information systems--to develop systems which can identify the health and social care needs of the population, and measure the impact of services provided.
El Resource shifts between sectors--to ensure that ]ocational substitutions are matched by appropriate resource shifts, without u n d u e disruption of care.
Training at all levels--to ensure that staff and skills remain matched to the tasks to be performed. C3 Best use of buildings and facilities--to use health care facilities appropriately in a changing service. All of this will need to take place in whatever political context the service is required to operate. This context itself is likely to produce another set of potential tensions--the difficulties of introducing an internal market are currently high on most managers' agendas--but if the analysis is correct, all of the issues discussed hitherto will be present whichever government is in power.
Future Health Scenarios--Strategic Issues for the British Health Service
Box 1. The Welsh Health Planning Forum.
Provides advice on issues of strategic importance in health to government in Wales (population 3 million), and to the health service. Its membershi p consists of clinicians and managers in the health service, civil servants, academics, consumer representatives, and others; and it works---through a variety of networks--with several hundred professionats.and managers at any one time. In the late 1980s it pioneered a new approach to health service planning, and has subsequently used its extensive networks to develop this approach in practice. The work of the Forum has twice received the European Healthcare Management Association's Baxter Award Certificate of Distinguished Contribution, and in 1991 was commended in the Twenty-first Century Innovators Award. In 1992 it was appointed as a World Health Organization Collaborating Centre for Regional Health Strategy and Management Development in Europe. It currently advises governments in Hungary, Lithuania, and the autonomous regions of Basque, Catalonia, and Valencia in Spain, and various national organizations in the UK.
References 1. Welsh Office, Annual Report of the Chief Medical Officer 1992, Welsh Office, Cardiff (1993). 2. G. Davey Smith, M. Bartley and D. Blane, The Black report on socio-economic inequalities in health 10 years on, British Medical Journal301, 373-377 (1990). 3. Central Statistical Office, Social Trends 22, HMSO, London (1992). 4. A. Goodman and S. Webb, For Richer, For Poorer--The Changing Distribution of Income in the United Kingdom, 1961-1991. The Institute for Fiscal Studies, London (1994). 5. R. G. Wilkinson, Glasgow, Edinburgh and the health divide. British Medical Journal, 305, 1239-1240 (1992). 6. Central Statistical Office, Social Trends 22, HMSO, London (1992). 7. The World Bank, World Development Report 1993, Oxford University Press, Oxford (1993). 8. Welsh Office, Health and Personal Social Services Statistics for Wales No 19, Welsh Office, Cardiff (1992). 9. Eastern Health and Social Services Board. Framework for Health and Social Care 2010, Progress Report, Eastern Health and Social Services Board, Belfast (1992). 10. Powys Health, Health and Social Care 2010, The Powys Response, Powys Health, Brecon (1992). 11. West Glamorgan Health Authority/West Glamorgan Family Health Services Authority, Health and Social Care 2010, The West Glamorgan Response, West Glamorgan Health Authority, Swansea (1993).
Marcus Longley is Strategic Planner (Organizational Development), Welsh Health Planning Forum.
12. Adapted from M. Warner, Health strategy for the 1990s: five areas for 'substitution', In A. Harrison and S. Bruscini (eds), Health Care UK 1991:An Annual Review of Health Care Policy, King's Fund Institute, London (1991). 13. H. D. Banta and S. B. Thacker, The case of reassessment of health care technology. Once is not enough, Journal of the American Medical Association 264 (2), 235-240 (1990). 14. R, Smith, Where is the wisdom ... ? The poverty of medical evidence, British Medical Journal 303, 798-799 (1991 ). 15. World Health Organization constitution. 16. T. McKeown, The Role of Medicine--Dream, Mirage or Nemesis?, p.192, Basil Blackwell, Oxford (1979). 17. Welsh Health Planning Forum, Strategic Intent and Direction for the NHS in Wales, Welsh Office/NHS Directorate, Cardiff (1989). 18. Anderson Consulting, The Future of European Health Care, Anderson Consulting, London (1993). 19. D. Banta, Emerging and Future Health Care Technology and the Nature of the Hospital, Welsh Health Planning Forum, Cardiff (1990). 20. J. Goldsmith, The reshaping of healthcare. Part 1, Healthcare Forum Journal May/June, 19-27 (1992); J. Goldsmith, The reshaping of healthcare. Part 2, Healthcare Forum Journal, July/August, 34-41 (1992).
Morton
Warner
is
Executive Director, Welsh Health Planning Forum.
21. J. Hughes and P. Gordon, Hospitals and Primary Care: Breaking the Boundaries, King's Fund Centre, London (1993).
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22. M.-L. Lagadere, C. Meyer, M.-L. Pibarot and C. Roger-Lacan, Sant~ 2010, La Documentation Fran(;aise, Paris (1993). 23. Steering Group on Future Health Scenarios, HetZiekenhuis in de 21e Eeuw, STG, Rijswijk (1989). 24. Steering Group on Future Health Scenarios, Primary Care and Home Care Scenarios 19902005, Kluwer Academic Publishers, Dordrecht (1993).
Future Health Scenarios--Strategic Issues for the British Health Service
