Interview by: Alistair Craven
Dr. Marcus Longley is senior fellow and associate director at the Welsh Institute for Health and Social Care at the University of Glamorgan. He won an Open Exhibition to St John's College, Oxford, where he read Modern History, and many years later finally completed his PhD at Bristol on some of the health policy implications of the new genetics.
He has worked in the UK's National Health Service for 14 years, in a variety of managerial and planning posts (ultimately at Board level), and for two years with the Welsh Health Planning Forum (a WHO Collaborating Centre), before taking up his present post in 1995. Current interests include healthcare futures generally, including the future impact of the new genetics on the organization and management of health care; public and patient involvement in shaping health policy; and the development of the health professions in the future (with a particular interest in pharmacy and nursing).
He has managed and contributed to several major research studies, and has published in these areas. He has also served as Special Advisor to the Royal Pharmaceutical Society of Great Britain since 1995.
Can you explain a little about your role in the Welsh Institute for Health and Social Care? (WIHSC)
Marcus Longley:
The Institute is a part of the University of Glamorgan, and has a remit to develop thinking (through research and consultancy) in a broad range of health policy areas, from public involvement in policy making and professional regulation and development, through to the re-design of health and social care systems. Much of our work is for Wales (particularly relevant in the context of recent UK devolution), but we also work across the UK and as a WHO Collaborating Centre for Regional Health Strategy and Management Development with many other countries in Europe.
What do you see as the biggest challenges facing healthcare managers today?
Marcus Longley:
The key challenges are the age-old ones - how to work with professional colleagues to perpetually re-design services, in order to ensure high quality care for all, at affordable cost.
In the Japanese and major European markets all citizens can gain basic healthcare coverage through statutory health insurance schemes. However, in the US individuals largely take responsibility for their own healthcare needs. What are your views on these two approaches to healthcare provision?
Marcus Longley:
The ideological and practical implications of these two different models have been much debated elsewhere, and there is not space here to summarize all the arguments. But three issues have perhaps received less attention than they deserve.
First, the impending impact of the new genetics - the ability to predict the likelihood of individuals developing common diseases such as cancer and heart disease - will have a severely destabilizing influence on healthcare based on individual risk assessment and insurance. Put simply, genetic foreknowledge can make people almost uninsurable.
Second, individuals' health is in part determined by the health of the others in their community, an obvious example being the need for almost everyone to be immunized if all are to be protected. Any healthcare system which fails to deliver effective public health measures endangers the health of all.
Finally, where there is no direct link between payment and receipt of care, public support for healthcare is vital - there is no option but to partake of the common service. And yet the majority of those who pay for it (healthy, middle aged, middle class) are the least likely to enjoy the benefits. In the UK in particular this poses a severe challenge, as rising disposable income increasingly makes the option of co-payment or opting-out more possible.
What are your general views on the UK's National Health Service and its performance in relation to other European systems?
Marcus Longley:
Increasingly it is not possible to generalize about the health service of the UK - the differences between the four component countries (England, Scotland, Wales, Northern Ireland) are growing apace. But inasmuch as the system still has some common defining characteristics -finance from taxation, marginal levels of co-payment, rationing by waiting times, registration with a general medical practitioner - it can with some justification be described as the victim of its own popularity. For many years (until the 1990s, perhaps) no serious politician was prepared to countenance major reform - the NHS was simply too popular, and change was equated with harm. The result was under-investment and relatively declining standards. The appetite for change is now substantial, and objective measures of input and output are now showing improvement. Change may have arrived just in time!
In a recent article featured on the national website of Wales you outlined that the UK has problems with the retention of nurses who come into the health service highly trained and with high expectations, but who are then put in a position where those skills are not used. What do you think needs to be done to improve the situation?
Marcus Longley:
There are three answers, each dependent for their success on the other two.
First, education. Nurses - or at least a substantial proportion of the profession - should be educated to degree level, so that they demand of the health service a career which uses their high level skills to the full. This will act as a major catalyst for change in the way services are provided.
"For a variety of reasons, hospital care should be the last choice - it's dangerous, inconvenient, expensive but this is not a dogmatic argument: in many instances hospital care is the only appropriate course."
Second, there must be a strategic review of who does what in healthcare. Current occupational divisions have developed over time, in response to the latest pressures, and in many instances they make little sense. Isolated attempts to rationalize the divisions of labour often have limited impact - they depend upon change in other areas (in other professional groups, in legislation and regulation, in finance systems). Hence the need for national coordination.
Third, public expectations must be managed. For most people, expectations of the health service are very conservative, and people need to be encouraged to realize that new roles for nurses can actually result in higher clinical standards, improved access and more care (through reduced costs).
An interesting article in our healthcare management community discusses the involvement of patients in improving healthcare service quality. What are your views on this subject?
Marcus Longley:
This is one of those notions which is self-evidently a good thing. But the devil lies in the detail. What do we mean by 'involvement'? What help do patients require to become involved? How does one know which patients wish to become involved and which do not? What are the time and financial implications of such involvement and the exercise of choice? And so on.
The power issues need to be tackled early on - for many professionals, greater patient involvement means loss of power, and that can be unsettling. Many of the other issues will probably resolve themselves as professionals and patients get used to what greater involvement actually means, and the bogey men are put to rest.
A more difficult aspect of this issue is the collective involvement of patients in the planning and development of services - as opposed to involvement of individuals in choices about the care they receive individually. The means for involving local communities in creating the future of their services are generally inadequate at present. There are several reasons for this. One is the serious fracture in the relationship between citizens and the political structures designed to develop public policy, and this is a break which the health service will be hard-pressed to mend on its own.
In 1999 you advocated the view that the health system should offer more care for people at home and in their local areas rather than using hospitals. Do you still stand by this opinion?
Marcus Longley:
Yes. For a variety of reasons, hospital care should be the last choice - it's dangerous, inconvenient, expensive But this is not a dogmatic argument: in many instances hospital care is the only appropriate course.
The trick is to think in new ways about how care can be provided better, freeing ourselves from the psychic prison which leads us to believe that because we have always provided a particular service in hospital, it should continue that way. And then we need to put in place planning mechanisms which are capable of effecting change, and which are appropriately incentivised to do so. The challenges are immense - gathering and evaluating data on clinical and cost effectiveness, the need for pump-priming, re-training of staff, management of public expectations, and coordination of different agencies. If they are to be overcome, there must be a strong, determined and persistent drive for change from the top, and each manager must own the task throughout the system.
What article or book has had the most profound effect on your professional outlook, and why?
Marcus Longley:
Just occasionally, one reads something which perfectly expresses a concept which you had until that point not realized you believed.
Much of the discussion about health policy in recent years has focused on the need for rapid, dramatic change. But in reality, major change usually comes through a series of incremental changes, influenced along the way by a host of policy-makers, managers and clinicians. It was Charles Lindblom, a policy analyst at Yale who, in the late 1950s, described this process in the phrase 'muddling through' (Lindblom, CE (1959) 'The Science of "Muddling Through"' Public Administration Review, 19, 78-88). Instead of being a somewhat shame-faced activity, for which one might apologize, the 'science' of muddling through actually has great strengths, as practitioners and experts at all levels shape and adapt the overall policy context to meet the requirements of service delivery. Once this reality is appreciated, the whole concept of change management is re-framed.
Finally, what is the next important business event/conference in your diary?
Marcus Longley:
It's nothing very 'grand' - a series of meetings with local communities in an area not far from the university about the sort of healthcare they want in the future. These are communities faced with contradictory desires - for local accessibility, the highest possible care, within available budgets - and who have clear ideas about their needs. The meetings (which I am privileged to be leading) are about opening a dialogue between equals - citizens and professional managers - and then jointly creating a future.
To find out more about the University of Glamorgan, visit http://www.glam.ac.uk