Observations NHS Reforms

How to lose friends and alienate people

BMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d3014 (Published 18 May 2011) Cite this as: BMJ 2011;342:d3014
  1. Jonathan Shapiro, senior lecturer in health services research, University of Birmingham,
  2. David Colin-Thomé, visiting professor, Universities of Manchester and Durham, and independent healthcare consultant,
  3. Abeda Mulla, research fellow in health services redesign (Collaboration for Leadership in Applied Health Research and Care (CLAHRC)), University of Birmingham
  1. Correspondence to: J Shapiro j.a.shapiro{at}bham.ac.uk, D Colin-Thomé david{at}dctconsultingltd.co.uk, A Mulla A.Mulla{at}bham.ac.uk

Why are the NHS reforms causing so much unrest as to threaten complete paralysis?

Although the current NHS reforms in England have been developing over the past 20 years,1 their strategic direction has been consistent and inexorable. Three basic elements have emerged: the separation of provision from procurement (to try to reduce the acute sector’s supply-side pressures on demand); the consequent introduction of some degree of contestability to further reduce complacency among providing organisations; and the devolution of decision making as closely to the patient interface as possible to increase clinicians’ sense of personal involvement in making these decisions.

Naturally, the mechanisms have changed and evolved, but the underlying principles of the reforms have managed to weather changes in government, in health secretaries, and in financial circumstances. Indeed, those same principles have underpinned health service reform internationally. So, at first glance, it may seem surprising that the current reforms are causing enough unrest to threaten them with complete paralysis or, worse, with becoming so distorted by realpolitik that their well established momentum is lost completely. Why has this happened, and what can be done about it?

There are probably only two (albeit significant) key issues of contention where the substance of the changes is concerned:

  • What level of competition can the NHS encompass without risking destabilisation?

  • What kind of accountability is appropriate when procurement is led by clinicians who are themselves providers (especially when viewed by other, less involved clinicians)?

There is no definitive answer to the first, but there are lessons to be drawn from both common sense and experience drawn from other sectors. Common sense tells us that although it is probably necessary to take small risks to engender innovation, it would be foolish to endanger any service whose consequent failure would threaten the viability of the …

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