Elements of decentralisation in plans to reform NHS may prevail

BMJ 1998; 317 doi: https://doi.org/10.1136/bmj.317.7160.753 (Published 12 September 1998) Cite this as: BMJ 1998;317:753
  1. Chris Ham, Director
  1. Health Services Management Centre, School of Public Policy, Birmingham B15 2RT

    EDITOR—Klein and Maynard correctly diagnose centralising tendencies in the government's approach to the management of the NHS.1 What they fail to acknowledge is that there are also decentralising tendencies, and it is unclear which of the two approaches will prevail.

    Decentralisation is most evident in the establishment of primary care groups. These groups will play a major part in the commissioning and provision of services in the future. The reluctance of some doctors to participate in primary care groups, for fear that they will be made responsible for rationing and have to accept responsibility for unpopular decisions, indicates that the phenomenon of “blame diffusion” in the NHS (which Klein has analysed over many years) is alive and well. Whether the emphasis on setting national standards for the NHS and intervening to ensure that these standards are achieved will prevail over the attempt to empower doctors and nurses locally to bring about improvements in services remains uncertain.

    The third way in health policy espoused by the new government is replete with such tensions and potential contradictions. It is not at all clear how the government will respond when difficulties arise in the future. Klein and Maynard are right to warn that an overcentralist approach may well backfire on politicians, which is why the elements of decentralisation within the reform package may yet prevail.


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