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Views & Reviews Personal view

How to restructure-proof your health service

BMJ 2007; 335 doi: (Published 12 July 2007) Cite this as: BMJ 2007;335:99
  1. Jeffrey Braithwaite, professor and director, Centre for Clinical Governance Research, Faculty of Medicine, University of New South Wales, Sydney, Australia
  1. j.braithwaite{at}

    Politicians are often criticised for saying one thing and doing another. Is the announcement last week by prime minister Gordon Brown and new health secretary Alan Johnson a further example? They are sponsoring a major review of the NHS while pledging to stop giving top-down instructions and ceasing centrally dictated restructuring.

    What do major reviews produce, other than more instructions and new rounds of restructuring? This is especially contradictory given that Mr Brown and Mr Johnson, in making their announcement, argued that the NHS “cannot stand still,” and the review's terms of reference stipulated that the way forward for the NHS is to be “clinically driven, patient centred, and responsive to local communities.”

    This review will surely try to reorganise from the top the way predecessor reviews did—principally, through above-down measures. It is unlikely politicians will leave implementation to an independent NHS.1 In politicians, the strong desire to be seen to be in charge invariably wins over the weak desire to be at arm's length or encourage bottom-up measures, especially from something that determines votes as much as the NHS does. Something Mr Brown said in announcing the review confirms this suspicion: “No institution touches the lives of the British people like the NHS. It is part of what makes Britain the place it is.” What prime minister would resist wanting to make a personal mark on something so integral to society's fabric?

    So despite the denials, you can feel it in the air—reorganisation is being signalled. We would do well to remember that restructuring health services is a prevalent international activity which the NHS, over almost six decades, has taken to a high art form. It comes in many versions, involving fitting pieces of the health systems jigsaw together in novel configurations. Revamping boxes on the organisational chart is popular.2 Merging NHS trusts3 and combining and recombining services which to a greater or lesser extent are perceived to mesh well (into clinical directorates, for example4 5 6) are some of the most frequent.

    The evidence indicates that top-down measures and restructuring can cause disarray. Rather than accelerating organisational progress, merging can put trusts back by 18 months or more, Fulop et al found.7 Longitudinal research has shown that the gains in efficiency sought through restructuring are elusive at best, and reorganising twice in a six year period created the opposite, with inefficiencies resulting.8 Anecdotal accounts suggest that restructuring is disruptive for most staff, threatening for many, and morale sapping overall, in part because of the uncertainty created and also because everyone is tired of change.9 10 11 Undertaking structural change clearly sends mixed messages; the feelings of disempowerment linger, and, increasingly, there are reports that confusion rather than clarity results from reorganisations.12 13 Continuously rearranging things exacerbates this, creating bewilderment and even incredulity.14 15 16

    Clinical staff need a strategy to counterbalance any disruptive effects from this review, so while it is underway, do this: talk to colleagues, and together call the staff to a meeting. You will undoubtedly need a series of meetings. Involve everyone, including the junior and ancillary staff, and make sure the opinion leaders come. Invite your immediate manager, and even the next one up the line, if he or she is enlightened and responsive to bottom-up initiatives. Secure some input from patients—this is not just trendy, it is an intelligent thing to do. Experienced patients know a lot about what they need and what you should do. They can be your best advocates.

    Resist the temptation to call your gathering the “Restructure-Proofing Meeting,” at least within the chief executive's earshot, but that is what it is. The “Strengthening Our Services Meeting” label works well. Get to work and design a range of enhancements that will build the service and its teams. Try out ways to make your service more streamlined and patient centred. Secure baseline and subsequent data on the changes to patient outcomes, patient satisfaction, and staff morale that result from your initiatives.

    These strategies recognise something that clinicians know and politicians don't: deep in the genetic make-up of effective health services lie people, professionalism, and relationships—not reviews, structures, and imposed targets. It will take a year to get your lines of defence sorted, but this corresponds to the timeline for the completion of the government's review, reporting at the 60th anniversary of the NHS in summer 2008. If you develop your services in a positive direction you will be likely to take the review's findings, whatever they are, in your stride. While other services are buffeted you can maintain your game plan, because your staff and colleagues are committed to the partnership ideal and they have bonded, especially if they have shared a journey towards making genuine improvements.

    Another benefit is that, although you intended to restructure-proof your service, you will find you have remodelled it in the process. There is a delicious irony here. You have data to show you have achieved the gains, without restructuring under external pressure. The political solution, if it comes in the form of fresh instructions or a new structure, has been neatly finessed. You are likely to find that your services are more “clinically driven, patient centred, and responsive to local communities.” That's restructure-proofing with a vengeance.


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