Views & Reviews Personal View

Local innovation can’t be driven from the top down

BMJ 2011; 343 doi: (Published 21 September 2011) Cite this as: BMJ 2011;343:d5719
  1. Martin Connor, visiting scholar, Stanford University Centre for Health Policy and Primary Care Outcomes Research, Harkness fellow in healthcare policy and practice 2010-11
  1. mjconnor{at}

In a recent presentation to UK physicians at Stanford University, Alain Enthoven produced a revealing insight. He had advised the Thatcher government at the outset of the internal market during the late 1980s. He had made the case that because no one understood how to manage risk in the NHS, managed competition should be piloted in some small areas first and only made a mandatory part of national policy once the lessons had been learnt. In this respect, he was ignored, and the 1989 white paper Working for Patients unrolled a phased but universal introduction of the new approach.

Ministers come and go, but the Department of Health has behaved consistently as if there were a “correct” central policy regarding structures and that its job is to experiment with the NHS while it works out what this policy might be. The sad irony …

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