Reform reform: an essay by John Oldham

The NHS in England has undergone structural reform more times than I have changed my mobile phone. The driver is almost always political, with the government, of whichever party, reacting to public frustrations with the health and care system. These frustrations express themselves both publicly in the media and more privately in the constituency surgeries of members of parliament. Concerns often reflect the poor experience of patients, but occasionally point to substantial failures of care.1

Secretaries of state come to office determined to use the levers of power to tackle the problems. The last few secretaries of state have all correctly analysed the NHS as lacking a patient centric approach and needing deep reform. The wind of change follows, at least for the tenure of the secretary of state (average 26 months), but the tendency is for the centre of gravity soon to re-establish itself, making the NHS resistant to fundamental change, slow to adopt innovation, slow to learn from good practice both inside the NHS and elsewhere, slow to implement what works, and slow to respond to societal shifts (figure⇓).

Such structural reforms, by and large, have not transformed the day to day experience of patients. We need to understand why that is and what creates the centre of gravity that is so resistant to real improvement. I believe this is because there are fundamentals within the healthcare system that remain untouched