NHS reform: the next shift-change

11 Jun 14
Chris Ham

The government's NHS reforms were meant to devolve power away from Whitehall. In practice the health service remains one of the most centralised in the world. Bottom-up change is urgently needed


NHS reform has relied too much on external pressures such as targets, inspection and competition, and too little on building capabilities for improvement from within. Despite Andrew Lansley’s attempt to distance ministers from involvement in the day to day operations of the NHS through the Health and Social Care Act 2012, performance management and regulation of NHS organisations is stronger than ever. The consequence is that England’s health care system is one of the most centralised in the world, vulnerable to frequent changes in policy and damaging top down structural reorganisations.

A decisive break away from over reliance on external pressures is needed in the next stage of reform. This needs to learn from the experience of high performing health care organisations in England and further afield which achieve great results by investing in the development of their leaders and supporting all staff to improve the quality of care. Salford Royal NHS Foundation Trust in England and the Virginia Mason Medical Centre in the United States are two well-known organisations that have gone down this path.

Reforming the NHS from within does not mean abandoning the role of ministers and national bodies. In a publicly funded health care system, ministers must be held to account by Parliament for the use of taxpayers’ money, and they have an important role in setting the direction of the NHS through the Mandate agreed annually between the government and NHS England. National bodies like NICE also have a role in setting standards of care drawing on the best available evidence supplemented by expert opinion. Within this national framework, there needs to be real devolution to the leaders of NHS organisations at a local level, who should be held to account for operational matters in their organisations.

The implications for the government elected in May 2015 are clear. First, focus on developing a coherent national framework for improving the performance of the NHS but resist the temptation to micro-manage and restructure the NHS. Second, recognise that front line teams and NHS boards are the best defence against poor care and be realistic about the role of inspect and regulators. Third, use competition as just one means of improving care and not as a guiding principle. And fourth, support NHS organisations to strengthen leadership and engage staff in service and quality improvement by investing in training and development.

One of the hardest lessons for politicians to take on board is the need to allow time for sustainable improvements in care to be realised. High performing healthcare organisations make progress through the careful aggregation of marginal gains. These gains do not occur by accident. They are a consequence of intentional actions by leaders at many levels, focused on measuring and tackling variations in performance, eliminating waste and systematically applying quality improvement methods. Such an approach depends on much greater leadership continuity than is usually the case in the NHS and also much greater organisational stability.

More collaboration is also needed between NHS organisations to support reform within the NHS. This is already being demonstrated in the work of academic health science networks such UCL Partners, a network of NHS providers and universities in parts of London, Essex, Hertfordshire and Bedfordshire. Its work supports NHS organisations bring about improvements in care through collaboration and the sharing of clinical and other expertise. Shifting the focus from reform led from the top down to it being achieved bottom up and through collaboration between providers in networks is an urgent priority.

Chris Ham is chief executive of The King’s Fund and author of Reforming the NHS from within: beyond hierarchy, inspection and markets.


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