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Purpose: In this chapter, we examine the National Health Service (NHS) and Adult Social Care (ASC) in England, focussing on policies that have been introduced since 2000 and considering the challenges that providers face in their quest to provide a high standard and affordable health service in the near future.

Methodology/Approach: We discuss recent policy developments and published analysis covering innovations within major aspects of health care (primary, secondary and tertiary) and ASC, before considering future challenges faced by providers in England, highlighted by a 2017 UK Parliament Select Committee.

Findings: The NHS and ASC system have experienced tightening budgets and serious financial pressure, with historically low real-terms growth in health funding from central government and local authorities. Policymakers have tried to overcome these challenges with several policy innovations, but many still remain. With large-scale investment and reform, there is potential for the health and social care system to evolve into a modern service capable of dealing with the needs of an ageing population. However, if these challenges are not met, then it is set to continue struggling with a lack of appropriate facilities, an overstretched staff and a system not entirely appropriate for its patients.

The Models of Child Health Appraised (MOCHA) project identified the different models of primary care that exist for children, examined the particular attributes that might be different from those directed at adults and considered how these models might be appraised. The project took the multiple and interrelated dimensions of primary care and simplified them into a conceptual framework for appraisal. A general description of the models in existence in all 30 countries of the EU and EEA countries, focusing on lead practitioner, financial and regulatory and service provision classifications, was created. We then used the WHO ‘building blocks’ for high-performing health systems as a starting point for identifying a good system for children. The building blocks encompass safe and good quality services from an educated and empowered workforce, providing good data systems, access to all necessary medical products, prevention and treatments, and a service that is adequately financed and well led. An extensive search of the literature failed to identify a suitable appraisal framework for MOCHA, because none of the frameworks focused on child primary care in its own right. This led the research team to devise an alternative conceptualisation, at the heart of which is the core theme of child centricity and ecology, and the need to focus on delivery to the child through the life course. The MOCHA model also focuses on the primary care team and the societal and environmental context of the primary care system.

Time pressures in paid work and household labor have intensified in recent decades because of the increase in dual-earner families and long and nonstandard employment hours. This analysis uses U.S. time-diary data from 1998 to 2000 to investigate the association of employment and household multitasking. Results indicate that mothers do more multitasking than fathers and the gender gap in household labor is largest for the most intense type of multitasking: combining housework and child care. In addition, mothers employed for long hours spend more time multitasking than mothers employed 35–40h per week. It appears that motivations for multitasking are heterogeneous: some multitasking is done out of convenience, whereas other multitaskings are a strategy used to manage too much work in too little time.

In this chapter, we focus on the major reforms intended to ensure the sustainability of health care in Denmark between 2000 and 2020 and the evidence for the effectiveness of these reforms. We take a broad definition of sustainability and include reforms that aimed to improve the productivity of the health care sector both in terms of increasing activity for the same set of inputs and in terms of improving the quality of care. A characterisation of the Danish health care system as having gone through evolution rather than revolution (Pedersen, Christiansen, & Bech, 2005) is, with one exception, still true today, and reforms have been relatively few. As we demonstrate there is a relative lack of formal evaluations of these reforms.

In the first decade of the period, the majority of new policy measures aimed to increase the quantity of care provided by the health care sector. With the introduction of diagnosis-related groups (DRGs) to measure hospital activity, a wave of reforms created a stronger link between activity and hospital reimbursement, and introduced additional incentives for increasing activity, alongside requirements for increased technical efficiency. A centralisation reform in 2007 reduced the number of administrative units and saw the beginning of a development that would also lead to fewer hospital units. Procurements of medicines were professionalised, and a national council was established to consider the use of expensive hospital medicine.

In the second-half of the period, policy makers began questioning whether increased activity was always for the better, and slowly began experimenting with initiatives that would shift the focus to the quality and appropriateness of care. As in many other countries, this move occurred in the light of a realisation of a shift in the demographic structure of the country and the change this was expected to create for the future demand for health care.

Although some empirical evidence exists, it is striking that few of the changes to the health care sector has been subject to formal academic evaluation – especially when considering the availability of high quality nationwide micro data. We point to a number of important lessons that could be drawn from the Danish experiences.

However, the greatest potential for research into the sustainability of health care in the Danish setting is probably still to be realised by taking advantage of the possibilities of linking micro data on individuals' health care utilisation, schooling outcomes and labour supply, with the possibility of following individuals across decades. For example, Danish micro data make it possible to follow newborns in 1990 until they reach adulthood and simultaneously follow their parents from adulthood until they reach 60 years of age where the prevalence of chronic diseases begins to show.

Objective – The first wave of experiences of exemptions policies suggested that poverty-based exemptions, using individual targeting, were not effective, for practical and political economic reasons. In response, many countries have changed their approach in recent years – while maintaining user fees as a necessary source of revenue for facilities, they have been switching to categorical targeting, offering exemptions based on high-priority services or population groups. This chapter aims to examine the impact and conditions for effectiveness of this recent health finance modality.

Methodology/approach – The chapter is based on a literature review and on data from two complex evaluations of national fee exemption policies for delivery care in West Africa (Ghana and Senegal). A conceptual framework for analysing the impact of exemption policies is developed and used. Although the analysis focuses on exemption for deliveries, the framework and findings are likely to be generalisable to other service- or population-based exemptions.

Findings – The chapter presents background information on the nature of delivery exemptions, the drivers for their use, their scale and common modalities in low-income countries. It then looks at evidence of their impact, on utilisation, quality of care and equity and investigates their cost-effectiveness. The final section presents lessons on implementation and implications for policy-makers, including the acceptability and sustainability of exemptions and how they compare to other possible mechanisms.

Implications for policy – The chapter concludes that funded service- or group-based exemptions offer a simple, potentially effective route to mitigating inequity and inefficiency in the health systems of low-income countries. However, there are a number of key constraints. One is the fungibility of resources at health facility level. The second is the difficulty of sustaining a separate funding stream over the medium to long term. The third is the arbitrary basis for selecting high-priority services for exemption. The chapter therefore concludes that this financing mode is unstable and is likely to be transitional.

Improvements in neonatal and paediatric care mean that many children with complex care needs (CCNs) now survive into adulthood. This cohort of children places great challenges on health and social care delivery in the community: they require dynamic and responsive health and social care over a long period of time; they require organisational and delivery coordination functions; and health issues such as minor illnesses, normally presented to primary care, must be addressed in the context of the complex health issues. Their clinical presentation may challenge local care management. The project explored the interface between primary care and specialised health services and found that it is not easily navigated by children with CCNs and their families across the European Union and the European Economic Area countries. We described the referral-discharge interface, the management of a child with CCNs at the acute–community interface, social care, nursing preparedness for practice and the experiences of the child and family in all Models of Child Health Appraised countries. We investigated data integration and the presence of validated standards of care, including governance and co-creation of care. A separate enquiry was conducted into how care is accessed for children with enduring mental health disorders. This included the level of parental involvement and the presence of multidisciplinary teams in their care. For all children with CCNs, we found wide variation in access to, and governance of, care. Effective communication between the child, family and health services remains challenging, often with fragmentation of care delivery across the health and social care sector and limited service availability.

Models of Child Health Appraised (MOCHA) defines school health services (SHSs) as those that exist due to a formal arrangement between educational institutions and primary health care. SHSs are unique in that they are designed exclusively to address the needs of children and adolescents in this age group and setting.

We investigated SHSs have been provided to schools and how they contribute to primary healthcare services for school children. We did this by mapping the national school health systems against the standards of the World Health Organization, and against a framework measuring the strength of primary care, adapting this from an existing, adult-focused framework.

We found that all but two countries in the European Union and European Economic Area have SHSs. There, however, remains a need for much greater investment in the professional workforce to run the services, including training to ensure appropriateness and acceptability to young people. Greater collaboration between SHSs and primary care services would lead to better coordination and the potential for better health (and educational) outcomes. Involving young people and families in the design of SHSs and as participants in its outputs would also improve school health.

Globalization of health care services is becoming an alternative or complementary strategy for some U.S. health care organizations due to increased competition, a stagnant health care market, and nationally imposed cost constraints in the U.S. Additionally, entrepreneurial U.S. firms may see globalization as an opportunity to promote their services in new countries with increasing demand for advanced technological services. If an ambitious American health care firm decides to globalize its product or service lines, what might be some of the primary strategies it would use to enter an international market? To investigate this question, this chapter considers the strategies of two American firms that have entered the Beijing and Shanghai markets since 2000. We conducted numerous telephone conversations and interviews with executives of these firms in an attempt to understand their market entry and early development strategies. These firms’ market entry strategies range from “greenfield” operations, where the hospital does little to change its corporate and managerial style from what it uses domestically, to a “glocalization” strategy, where the firm is quite sensitive to fitting into the Chinese culture and being accepted by the Chinese government. The strategic challenges for international hospital organization developments in China are many, but the potential rewards from becoming among the leading firms in a large nation with an expanding economy are tremendous. What we learn from the experiences of enterprising American hospital firms in Chinese may well portend the future for international developments by many other American-based health organizations.