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Government has “systematically underestimated” cultural shift needed to implement reforms

BMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d330 (Published 18 January 2011) Cite this as: BMJ 2011;342:d330
  1. Nigel Hawkes
  1. 1London

The UK government’s planned reforms of the NHS in England carry a very high level of risk, says the membership body representing most NHS organisations, the NHS Confederation, in a new report.

The “biggest shake-up of the NHS in its history” will succeed only if a series of demanding conditions is met, it says. The report, which resulted from a meeting of doctors, managers, and NHS experts at Leeds Castle in November, says that a degree of optimism is needed to assume that this will be possible.

The greatest problems lie in the implementation of the reforms and in trying to carry them all out at once and in such a short time, the group concluded. It warns the government that this will be “extraordinarily risky.”

The reforms, to be outlined in more detail in the Health Bill, expected to be published on Wednesday 19 January after the BMJ went to press, will transfer commissioning responsibilities to groups of GPs, introduce changes to the NHS tariff and payments systems, alter the basis of accountability for NHS bodies, and create opportunities for new providers of services, including some from the private sector.

The confederation’s report is openly sceptical of the likely effect of GP commissioning, accusing the government of “systematically underestimating” the cultural and behavioural changes required of GPs if it is to work.

Not only will GPs need to retain their role as advocates for patients and their focus on individuals, but they will have to make tricky decisions on rationing care and on reconfiguring services and closing hospitals. But if the effect of the reform is simply for primary care trusts’ commissioning to be carried out by GPs, then the scale of the reform is disproportionate and the results may be unexceptional.

For any chance of success a high level of engagement of GPs will be needed, and consortiums will need to be ready to take up their role “very quickly.” The danger is that too much time spent thinking will push implementation closer to the next election; and the political wisdom, says the report, is that it is impossible to undertake major strategic change, particularly involving hospitals, any closer than two years to an election. And the greater the delay, the worse the financial position of the NHS will be. If it is to be done, “then ’twere well it were done quickly” is the conclusion, though the report refrains from quoting Macbeth.

The report is also sceptical of the impact of markets. Given the right regulatory framework, adequate information, and intelligent purchasers, markets can drive major improvements in efficiency, responsiveness, and quality, it says. “However, it is much less clear that markets are good at solving complex problems such as the configuration of services.”

It worries, in particular, that trauma, cancer, and emergency medicine—all composites of other services—will suffer because the market signals will determine where individual component services are located, swamping weaker market signals for other services of which they form part.

Accountability is another major concern, with the proposed mechanisms “underpowered,” concludes the report. Mechanisms to ensure quality are also lacking, it says. And it questioned the assumption implicit in the health white paper Equity and Excellence: Liberating the NHS that there is no need to reform and improve primary care.

“It seems strange to tap the talents of leading GPs to rethink the delivery of secondary care while leaving the 80% plus of encounters that most patients experience each day unreformed, unaffected by the principles to be applied to the rest of the NHS and with a number of significant issues of quality variation, responsiveness and cost-effectiveness unaddressed,” says the report.

Finally, it warns not to expect too much, too soon, even if all goes well. Major culture change “almost always” takes longer than expected, and drivers of change that excite policy analysts and economists can prove to be underpowered when used in the field.

The report says, “A key lesson that repeated health reforms have failed to learn is not to over-promise, take more care over identifying the risks and have a plan to mitigate them.”

Notes

Cite this as: BMJ 2011;342:d330

Footnotes

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