STRATEGIC DESIGN MANAGEMENT

Strategic Design Management

Strategic Design Management

Introduction

The NHS reforms initially seemed set to improve the situation of people with disabilities because the quasi-market system was designed to end the system of historically based budgets, which had channeled money toward high-profile acute specialties and away from the so-called Cinderella services (long-stay hospitals and community services that had traditionally suffered from underfunding). However, in practice, spending patterns did not change as much as predicted, and there was little reallocation of resources to community and continuing care services that would meet the needs of disabled people. The concentration of spending on acute services was reinforced by the weight given by the government to surgical waiting times targets, and the way these were presented as a key indicator of the success of the reforms.

Many district health authorities operated “exclusions” policies, usually formulated jointly by public health physicians and managers, which listed treatments that would not normally be purchased. This “postcode lottery” affected some high-cost drugs for disabling conditions, such as beta interferon for multiple sclerosis, anti-TNF medication for rheumatoid arthritis, Riluzole for motor neuron disease, and Memantine for Alzheimer's disease.

Discussion

The Blair reforms introduced after 1997 marked a step away from the language of the market but retained the purchaser/provider split and the basic framework of service contracts. The burden of administration was reduced by a shift from annual to multiyear contracts. However, the government imposed new arrangements for “performance management” based on target setting and review, which increased providers' accountability for outcomes.

There were also new policies on “clinical governance,” which aimed to achieve improvements in quality and safety. In practice, this involved the creation of clinical guidelines for a range of medical conditions, recommendations about whether new and controversial treatments should be provided on the NHS, and the development of a series of National Service Frameworks (NSFs), which defined expected care pathways for different condition groups. Several of these clinical guidelines affect disabling conditions such as chronic heart failure, chronic obstructive pulmonary disease (COPD), multiple sclerosis, diabetes, and “supportive and palliative care,” and the NSFs include frameworks for older people, renal services, and diabetes. Sections of the British medical profession have helped shape these developments, but they go beyond professional self-regulation. Rather, they have emerged from a coalition of political, managerial, and professional groups, and they encapsulate a form of scientific/bureaucratic rationality that sets limits on the discretional decision making of individual professionals.

Changing patterns of health and disease and the rising proportion of budgets directed toward chronic illness and disability must be considered alongside continuing technological advances and resource pressures. Disabled people will expect more, and it will be the management systems that are charged with finding ways of maximizing outputs for a given level of expenditure and placing limits on what a health or social care system can reasonably provide.

Strategic design management in chronic disease means taking actions to ensure the best possible level of health and functioning for the individual and the least amount of disruption of daily ...