The “redisorganisation” of the NHS

The NHS is being reorganised—again. Having declared on taking office in 1997 that it recognised that the NHS had suffered too much structural reform, the re-elected Labour government has embarked on the largest, and least debated, reorganisation of the NHS for two decades.¹ A consultation document, “Shifting the balance of power in the NHS: securing delivery,”² published in July proposed abolishing the executive regional offices of the NHS and two thirds of health authorities and creating new primary care trusts to take on a raft of responsibilities from health authorities. Only the acute NHS trusts emerge from these changes relatively unscathed. The consultation, which lasted six weeks, closed in early September and the government has yet to publish its results. But the reorganisation is steaming ahead regardless, with the aim of completing all the changes by April 2002. Few people outside the NHS management community seem to be aware of the exact nature and implications of these changes, which have their roots in growing public and political impatience with the quality of NHS services.

From two recently published surveys³,⁴ it appears that both medical and managerial support for the government is at an all time low. Over 80% of general practitioners believe that the government's plans for the NHS are not achievable in the proposed timescale³ and more than three quarters of managers consider that the “shifting the balance” reorganisation will delay delivery of the NHS plan.⁴ Governments often regard a degree of medical disapprobation as a sign that their NHS policies are generally heading in the right direction. However, NHS managers have traditionally been stalwarts of public service, implementing government policy because that′s their job, regardless of any personal reservations they may have. Therefore ministers and their advisers should take this evidence of significant concern among the managerial community seriously. In 1997-8 doctors and health services managers were reported to be largely supportive of the Labour government's plans for the NHS.⁵ What has gone wrong in the intervening years?

The roots of the growing disaffection felt by NHS managers precede the current reorganisation. The truth is that this government has never trusted or respected managers. It blames them for the poor state of the NHS (for example, dirty hospital wards and long waiting times in emergency departments) and doubts their competence. While NHS managers are used to being unloved by the public and health professionals, to find that their political masters have little regard for them leaves them isolated and disempowered. Ministers talk the language of empowerment, devolution, collaboration, and support, but their actions speak louder than words. They display an unforgiving, top down command and control style of management (partly a reflection of the lack of trust and respect) in which unrealistic targets and objectives are showered down on managers, who are left feeling undermined and undervalued.

The unhappiness felt by managers does not stem from government's goals for the NHS nor from its diagnosis of the problems facing it, for managers still largely support the overall health goals and priorities set out in the NHS plan.⁶ It is the way that policy is being implemented: through endless prescriptions for change involving unprecedented micromanagement from the centre, which has the effect of constraining and undermining the ability of managers to manage. The command and control style, a never ending stream of “must do” edicts, a “name and shame” culture, and the perpetual obsession with organisational restructuring can only detract from the ability of the NHS to deliver the plan. If managers are to lead the radical changes to services demanded by the NHS plan, they need time and space in which to acquire new skills such as work process control, developing and implementing care pathways, and changing the nature of professional work. Instead they struggle in a macho climate that demands instant delivery. In the midst of the current turbulence the government has established yet another review team to think the unthinkable about alternative approaches to funding and delivering health care.⁷ This merely worsens the situation and reinforces the sense of helplessness and reform fatigue among managers.

It is fashionable to espouse the virtues of evidence based policy making,⁸,⁹ in which robust evidence about the efficiency and effectiveness of policy proposals plays a significant role in policy development and implementation. Yet the government′s NHS reorganisation is an evidence free zone, with no research cited to suggest that the changes will improve the performance of the NHS and plenty that indicates they may do the reverse.^10–12

The NHS does not need a distracting and unproved reorganisation that, for all the rhetoric about devolution, leaves unchanged, or even strengthened, the capacity for the centre to micromanage the service into the ground. What is required is a fundamental rethinking of the relationship between central government and the NHS. The answer could lie in a move to regional government, with the NHS being transferred to the control of bodies like the Spanish regions or the Swedish county councils.¹³ Democratic renewal and devolution offer the potential to prise the NHS out from the grip of government and the hot house atmosphere of Westminster and Whitehall. The price to be paid may be greater local variation and diversity, but given that this already exists between the four countries within the United Kingdom, surely this is a price worth paying.