David Oliver: The NHS doesn’t need more “restructuring”BMJ 2019; 366 doi: https://doi.org/10.1136/bmj.l4451 (Published 03 July 2019) Cite this as: BMJ 2019;366:l4451
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David Oliver is quite right that calls for any major structural reforms to the NHS (either involving how it is organised or how it is paid for) are futile and foolish. But there is a good argument that the NHS does need "reform". The mistake is to assume that "reform" means changing the top-down structure or the way the system is paid for.
Politicians on both sides are obsessed by top-down reforms. Labour promises to abolish the internal market in England, a move which is supposed to release vast amounts of cash locked up in bureaucracy (despite compelling evidence from Scotland and Wales that no such money exists). Right wing think tanks (but mostly not, interestingly, conservatives in government) propose radically more private sector involvement and radical changes to the way the system is paid for. The mistake both make is that they assume structural reforms will do anything at all to improve outcomes and efficiency.
I've often thought that these politicians and commentators are one club golfers who don't understand the detail of how the NHS works and can only propose the sort of changes that affect the visible structure. They don't know any other way to intervene.
This is a serious problem. The one thing we are certain of about top-down structural reform is that it costs a lot (in both cash terms and in disruption to existing ways of working) but yields very little if anything in improvement to services (at least in a time scale measured in years rather than decades–which is ironic as we have had major reforms more than once a decade for as long as I can remember).
But that doesn't mean there are not plenty of things the NHS could do better and plenty of practices the system needs to reform. But all of these are bottom-up changes in the details about how care is delivered and not major top-down structural redisorganisations. GPs can and should reform the way they handle patient requests to offer faster, more flexible responses that better match the range of patient needs. Hospitals should plan capacity more effectively, organise their beds and operating theatres to maximise throughput. Surgeons should adopt better techniques. None of these are readily achieved with top-down diktats.
There is one constant that both left and right-leaning politicians seem to agree on, but it is one that has caused more damage to effective bottom-up change than anything else they have done: reduce management costs. The slogan "more resources to the front line" is widely used. And, while it is true that the NHS has many dumb bureaucratic behaviours, the idea that is is top-heavy with managers is a zombie idea and a severely damaging one.
NHS managers account for between 2-3% of NHS staff but everyone else in the British economy has 10-12% of their total staff counted as a manager. Every comparative statistic with other organisations large or small says the NHS was severely undermanaged even before the last two major reforms culled large numbers of managers from across the system.
The consequences of the obsession with culling management are widespread. Good operational managers are exactly the people who, if they do a good job, lubricate the bottom-up reforms that create improvements in outcomes and efficiency (and help organise work so professional doctors and nurses suffer less burnout and stress). Good managers design systems so carers need to spend less time with stressful administration and more with their patients. And they make sure the system as a whole functions smoothly, allocating resources where they are needed now, not where they were habitually spent decades ago. Two recent stories illustrate this last point. The abolition of PCTs culled many management roles including the people who organised vaccination campaigns and who audited GP lists. NHSE are now trying to catch up with the fact that some GP lists are very out of whack with the ONS estimates of the local population. And the UK's low vaccination rates have are not, as the leadership has argued, a result of growing anti-vaccination sentiment but–according to internal analyses–the result of poorly organised vaccination reminders and campaigns (we culled the people who did that work).
The single reform that would most improve the NHS is more attention to bottom-up operational changes. That's a management problem made far too hard by an endemic hatred of management. It won't make good headlines in any party manifesto. And it is doubtful that our generation of professional politicians who have never managed anything of substance in their lives would even understand it. But, if we are going to talk "reform" it is the one area where the NHS needs to change and where the change would make a difference.
Competing interests: No competing interests