How to restructure-proof your health service

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 …