Bookmarkers beware: Bookmarks to pages other than the home page may not work after we change servers in April Editor's Choice | This Week in BMJ | Press releases BMJ No 7126 Volume 316 Education and debate Saturday 17 January 1998 The New NHS: commentaries on the white paper A third way? England - yes; Scotland - maybe Greg Parston, Laurie McMahon Much of the comment on the white paper so far has ignored general intention and focused on details of employment, cash flow, and management - or rather the lack of them. Little is being said about the government's bold attempt to construct "a third way" between old bureaucratic command and control systems and the fragmentation and distortions of the internal market. This new path will effectively result in the creation of nationalised health maintenance organisations, led by clinicians but focused on population health. Yet the most commentators seem to be preoccupied with questions about "How do they expect to...?" without much understanding of "Why?" The English health maintenance organisation idea makes a lot of sense; moreover, the lack of detail at this stage is a positive feature. If there is anything to be learnt from the past two decades it is that changing a complex organisation like the NHS is a long and subtle process. Whatever its faults and probably more by default than design, Working for Patients,the white paper that introduced the NHS reforms in 1991, also lacked the detail necessary to prescribe in advance exactly how the system would work. Consequently, those in the NHS charged with implementation had the opportunity to shape the reforms to reflect NHS values. A good example was the way in which purchasers interpreted their role to encompass pursuit of health gain for whole populations. Nothing like that was envisioned in Working for Patients. People on the ground - clinicians and managers - added value to central policies by putting in place the details themselves. The current white paper recognises that the relationships that general practitioners have with their patients and the public, established 50 years ago, are in need of renegotiation; that hospital dominated services suited to the technologies of the 1960s and 1970s need to be modernised; and that new ways need to be found to balance the tensions between local decision making and the centralised performance management regimens imposed in the 1980s. By grouping general practitioners and their patients as the basic building blocks of a renewed national service, the white paper sets out to provoke new thinking and to promote innovation in determining how to make a service suited for modern times. This is a fundamental change in which the voice of primary care professionals, particularly general practitioners, has been deliberately amplified. This is a creative change which encourages testing and emphasises learning - all in the interest of the nation's health. Some observers think that the certainty in the uniform and rapid changes prescribed in Scotland's white paper, Designed to Care,might provide a better way forward for England, too. We are not convinced. Designed to Care re-establishes the financial supremacy of health boards. But rather than "a third way," the Scottish changes could easily become a step back towards the old command and control systems, in which decision makers far removed from patient care and service delivery determine resource allocation and thus service configuration. Given politicial sensitivity to budget deficits, health boards might be tempted to set aside the long term goal of improving public health and use this reinstated hierarchy of command to slip back into operational management, with trusts treated as old style directly managed units. But the biggest difference from the English approach is that Scottish general practitioners come across less as leaders of local services and more as subjugates to local planners and managers. All this is apparently acceptable to Scottish clinicians and managers alike, but moving directly to such a uniform model will allow little learning or means for gradually resolving the differences that really do exist between clinicians and managers. We believe that the English approach allows the system to evolve and adjust over time; indeed, the white paper suggests a 10 year programme of improvement. But in Scotland today's "one best way" may well produce structures and incentives that prove too brittle when stressed with the pressures of change of the next century. We believe that the way forward in England, Scotland, and - with their proposals still coming - Wales and Northern Ireland must entail clear national strategies mixed with large measures of local discretion and flexibility and with strong voices for doctors, nurses, and other primary care professionals. In England, this can all happen provided ministers avoid the temptation to pick up the powerful managerial reins that lie in the traces. In Scotland, with the reins already in their hand, we fear it may not. Office for Public Management, London WC1X 8JT Greg Parston, chief Laurie McMahon, executive director of professional practice Home | Current issue | Past issues | Classified ads | Career Focus | Feedback Collections | About this site | About the BMJ | BMA | Medline