Criticism of market-based approach to service delivery and structure

If criticism grows of the application of health economics and cost-benefit approaches, pressures may grow to develop alternative approaches.

Efforts to rationalise decision making through the application of health economics and cost-benefit approaches have gained footholds in many areas of health management. However, these efforts are often contested in terms of specific applications (as in campaigning against specific NICE decisions). In another example it is also unclear how commissioning through Any Qualified Provider (AQP) will affect service delivery including health promotion and awareness in the public health domain. There are implications in the current financial climate that overall in health care AQP may lead to driving down costs at the expense of quality. This may have implications for long term workforce planning and training as higher degrees of uncertainty will emerge in a more competitive environment.
Several factors could lead to more challenges to these methods, including:

• multiculturalism, where different communities have differing values attached to various aspects of life
• recognition that public health involves informal care with burdens very unevenly distributed (e.g. across gender and income levels)
• extreme cases where application of these methods results in highly publicised anomalies.

Efforts to develop alternative methods and/or to shore up these techniques may take different forms. Therefore, different communities may in practice develop their own approaches, leading to public health and commissioning professionals requiring training in different approaches, and managers having to confront departures from universalism and difficult questions where individual responsibility is seen to play a role in ill health (e.g. smoking, obesity).
This might be seen as part of a shift away from modern assumptions of universal rationality to postmodern experimentation with multiple approaches. On the other hand, a new ethics-of-care approach might be consolidated; it is highly likely that much more attention will be given to ethics in public health in coming years. Note: These public health ideas are liable to be pervasive but may become especially difficult where emergencies create needs for triage or very uneven distribution of resources.

Analysis

This section outlines the projected workforce impacts of the idea.

Impact on sector

• Public health

workforce supply

[4,4,4,4]

workforce demandThe vertical axis represents an increase or decrease in supply or demand from the baseline which is the year 2012.

[4,4,4,4]

Level of confidence in this analysisThe confidence level is based on the confidence of the stakeholder who added this idea in their information.

Low

Low

Comment

"Unable to assess impact as dependent on many scenarios"

"Unable to assess impact as dependent on many scenarios"

Impact on quality of care This is calculated based on the analysis below. An increase receives a score of 1

Overall impact on quality of care: Negatively impacts

SAFETY		Potential decrease
EFFECTIVENESS		Potential decrease
EXPERIENCE		Potential decrease

Level of confidence in this analysis: Low

Impact on financial outcomesThe scale used to assess the impact on financial outcomes is:
significant cost savings (25%+),
moderate cost savings (5%-25%),
minor costs savings (1%-5%),
minor increase in cost (1%-5%),
moderately increases cost (5%-25%),
significantly increases costs (25%+).

Health and social care practitioners		moderate cost savings (5%-25%)
Employers		moderate cost savings (5%-25%)
Training and education providers		moderately increases cost (5%-25%)
Private sector organisations		moderately increases cost (5%-25%)
Commissioners		minor costs savings (1%-5%)
Government (England)		minor increase in cost (1%-5%)

Geographical variance of impacts

Increase imbalances

Level of certainty about impactsThe scale used in this question is:
Very likely (90–100% probability),
Likely (66–90% probability),
About as likely as not (33–66% probability),
Unlikely (10–33% probability),
Very unlikely (0–10% probability).

About as likely as not (33 to 66% probability)

Early signals

This section highlights any warning signals indicating that this idea is unfolding.

The AQP programme results in large profit seeking companies, with capacity to drive down costs, entering public health sector Increasing concerns that price competition will threaten patient care and quality assessed service delivery Private sector providers unable to provide appropriate staff training as too costly Discontinuities emerge in delivery as some private sector providers go out of business as they find they lack capacity (e.g., in another domain, private security contracting for London 2012) Increasing confusion as to financial impacts on all the relevant stakeholders