Competition and integration in the English National Health Service

BMJ 2008; 336 doi: (Published 10 April 2008) Cite this as: BMJ 2008;336:805
  1. Chris Ham, professor of health policy and management
  1. 1University of Birmingham, Birmingham B15 2RT
  1. c.j.ham{at}
  • Accepted 12 March 2008

Market based reforms of health care have helped cut waiting times, but Chris Ham argues that a different approach is needed to meet government objectives on disease prevention and chronic diseases

New healthcare objectives are often announced without changing the mechanisms used to implement them, leading to delays and frustration for policy makers. Gordon Brown and the ministerial team at the Department of Health face the challenge of avoiding this problem after the prime minister’s first major speech on the NHS signalled that greater priority is to be given to disease prevention and the treatment of chronic diseases.1 What changes need to be made to the health reform programme to enable these priorities to be implemented?

Policy options

One approach would be for the government to revert to the use of targets and top down performance management to achieve its objectives. Although there are some signs that the government may be moving in this direction—most obviously the instruction to the NHS to undertake a deep cleaning programme of hospitals—it seems unlikely that top down performance management will be the main means used to implement new priorities.

Top down control is known to have important limitations. These include the disempowerment of staff, the stifling of innovation, and the risk that areas of health care not identified as national priorities will be neglected. At a time when Lord Darzi’s review is seeking to engage front line staff in the next stages of reform and to put clinical teams in the driving seat of change, it would be inconsistent to revert to command and control mechanisms.

An alternative approach would be to continue with the implementation of the quasi market reforms introduced by Tony Blair. These reforms, centred on offering patients a wider range of choices between NHS and independent sector providers and ensuring …

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