Education And Debate

Managing the new NHS: breathing new life into the NHS reforms

BMJ 1994; 308 doi: (Published 26 March 1994) Cite this as: BMJ 1994;308:842
  1. Gordon Best, fellow in NHS managementa,
  2. David Knowles, fellow in health service managementa,
  3. David Mathew, fellow in organisational dynamicsa
  1. aKing's Fund College, London W2 4HS
  1. Correspondence to: Mr Mathew.
  • Accepted 6 February 1994

The essence of the NHS reforms is that they bring market forces to bear on organisations providing public services, while allowing those organisations more freedom to respond in ways that will improve the efficiency, effectiveness, and appropriateness of their services. The new structural changes to the NHS--a leaner management executive and fewer, slimmer regions--could be used either to strengthen these features of the reforms or to frustrate them by allowing ministers and top management to intervene even more at local level and “overmanage” the market. To ensure that the aims of the reforms are not frustrated ministers and the management executive must restrict themselves to laying down clear strategies and then allow purchasers and providers to meet those strategies in their own ways. They also need to ensure that the whole NHS can learn and benefit from local experimentation and devise ways of managing the crises that will inevitably arise; otherwise they might be tempted to become involved in managing the market at too local a level, and the NHS will suffer the worst of both worlds: stifling bureaucracy at the top and parochial self interest locally.

The latest round of reorganisation in the NHS is a watershed in the evolution of the NHS reforms. It entails removal of regional health authorities and their replacement by fewer, slimmer bodies that are also executive arms of the NHS Management Executive.1 This could either revitalise the original commitment to decentralisation or create the ideal circumstances for ministers, the management executive, and the Department of Health to “repossess” the NHS and impose even higher degrees of central control.

The temptation for ministers to exert even greater control is high. Not only is there little prospect of any extra funding for the NHS; the very workings of the reforms also pose innumerable possibilities …

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