Intended for healthcare professionals

Analysis Essay

Reform reform: an essay by John Oldham

BMJ 2013; 347 doi: (Published 20 November 2013) Cite this as: BMJ 2013;347:f6716
  1. John Oldham, adjunct professor
  1. 1Institute of Global Health Innovation, Faculty of Medicine, Imperial College, London SW7 2AZ, UK
  1. john.oldham{at}

Sir John Oldham examines why repeated reforms of the NHS have failed to deliver changes in the daily experience of patients, particularly those with multimorbidity

The NHS in England has undergone structural reform more times than I have changed my mobile phone. The driver is almost always political, with the government, of whichever party, reacting to public frustrations with the health and care system. These frustrations express themselves both publicly in the media and more privately in the constituency surgeries of members of parliament. Concerns often reflect the poor experience of patients, but occasionally point to substantial failures of care.1

Secretaries of state come to office determined to use the levers of power to tackle the problems. The last few secretaries of state have all correctly analysed the NHS as lacking a patient centric approach and needing deep reform. The wind of change follows, at least for the tenure of the secretary of state (average 26 months), but the tendency is for the centre of gravity soon to re-establish itself, making the NHS resistant to fundamental change, slow to adopt innovation, slow to learn from good practice both inside the NHS and elsewhere, slow to implement what works, and slow to respond to societal shifts (figure).

The reform cycle

Such structural reforms, by and large, have not transformed the day to day experience of patients. We need to understand why that is and what creates the centre of gravity that is so resistant to real improvement. I believe this is because there are fundamentals within the healthcare system that remain untouched

System built on body parts

The disease burden and the requirements of patients in 2013 are very different from those of patients in 1948. Broadly, the main challenge in 1948 was infectious disease; now it is long term conditions. Yet a …

View Full Text

Log in

Log in through your institution


* For online subscription