Intended for healthcare professionals

Education And Debate

Improving NHS performance: human behaviour and health policy

BMJ 1999; 319 doi: (Published 04 December 1999) Cite this as: BMJ 1999;319:1490
  1. Chris Ham, director (
  1. Health Services Management Centre, University of Birmingham, Birmingham B15 2RT
  • Accepted 4 November 1999

Policies towards the NHS in the postwar period reveal a variety of assumptions on the part of politicians about the motivations of managers and clinicians. For much of this period, the NHS was a classic example of the centralised, bureaucratic organisation in which politicians at the apex sought to control the behaviour of staff at the periphery through a combination of central planning and national directives. The weaknesses of this command and control system led the Thatcher government to introduce radical reforms to the NHS in the 1990s. At the heart of the Thatcher reforms was devolution of control to NHS trusts and general practitioners and the use of competition to improve performance.

In turn the weaknesses of the market model have prompted the Labour government elected in 1997 to make still further reforms, trying to bridge the gap between centralised control and market mechanisms—the so called “third way.”

Summary points

Policies about managing the NHS reflect changing beliefs about what motivates clinicians and managers

Command and control mechanisms have given way to market forces and now, in Labour's “third way,” to a variety of mechanisms used according to the circumstances

One omission in government thinking is failure to recognise that NHS staff are motivated to deliver improvements and simply need training and support to do so

Why reforms?

The Thatcher government was particularly concerned to tackle the perverse incentives facing hospitals. Specifically, hospitals were penalised for productivity improvements because they operated within fixed budgets that were insensitive to changes in activity.

At the heart of the reforms introduced in the 1990s was the devolution of control to NHS trusts and general practitioners and the use of competition to improve performance. Within the so called internal market, the intention was that money should follow patients in order to reward hospitals and other healthcare providers …

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