The Nhs's 50th Anniversary Looking forward

Change and resistance to change in the NHS

BMJ 1998; 317 doi: https://doi.org/10.1136/bmj.317.7150.69 (Published 04 July 1998) Cite this as: BMJ 1998;317:69
  1. Diane Plamping, codirector. (wws@dial.pipex.com)
  1. Urban Health Partnership, Primary Care Group, King's Fund, London W1M 0AN
  • Accepted 9 June 1998

The NHS is 50 years old. Every government since 1948 has re-invoked its founding principles, but there is less agreement about how services based on these principles should be organised. Alongside remarkable stability in the espoused purpose of the NHS there has been almost constant structural change. Health action zones and primary care organisations are the latest offerings. There is a paper mountain of advice on reforms, restructuring, and managing change. Yet many behaviours do not change. The puzzle is why the NHS has been so unchanging, given the barrage of attempts to “reform” it.

Some things have changed, of course, in as much as complex systems can be changed from outside. Bits have been knocked off and elements have been downsized or re-engineered, but these changes have been resisted by most “insiders.” These insiders have been successfully self ordering so that much of what happens in the NHS is unchanged in nature, if reduced in quantity. During all this investment in managing change, most insiders have not come to want the NHS to be different.

In this anniversary year it may not be enough simply to restate values and purpose. A more fruitful approach may be to focus on the behaviour of this complex system and to try to understand what creates the internal dynamics and maintains enduring patterns of order and behaviour.

Summary points

Despite considerable structural change and numerous attempts at “reform,” the underlying nature of the NHS has remained remarkably stable and many behaviours have not changed

This stability could be explained by the stability of the guiding principles that shape behaviour in the NHS—“Can do, should do,” “Doing means treatment,” “Treatment should fix it,” and “I am responsible”

These principles, though once appropriate, may now be reducing the NHS's adaptive capacity

To allow proper reform of the …

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