Avoiding groundhog day: learning the lessons of NHS reforms

As we publish our new essay collection today looking at the history of NHS reforms, Nigel Edwards argues there have been too many plans happening too often.

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Published: 16/10/2018

Over the last 20 years the NHS in England has seen at least six national strategic plans. The spaces in between have been filled with several further reorganisations, and a healthy haul of reforms to contracts, regulation and relations with local government.

NHS leaders are now hard at work on a seventh. Why again? Why now? As so often, the answer is money: a 10-year plan to improve and sustain the NHS is the quid pro quo for the Prime Minister’s commitment to inject £20 billion into the health service by 2023.

It’s entirely legitimate to reassess what the health service can promise to the public in return for billions in additional funding taken from their pockets – particularly as the much-vaunted “Brexit dividend” to fund the NHS pledge is unlikely to materialise.

Yet the political timescales that drive NHS planning also often mean that the time for discussing and refining plans is extremely limited: the regular rhythm of elections and spending reviews all but guarantees that the English system of government will create such a need every four years or so.

Learning the lessons

Our new essay collection today catalogues the sheer rate of revolution and directional change, offering reflections on what we can learn from the NHS’s endless reforms and reorganisations. 

The main lesson is that there are probably too many plans happening too often, rewriting too completely what has come before. This can cause disengagement at the NHS front line, costs money and staff time, and makes it hard to tell what has worked. At the same time, this constant state of flux has contributed to woeful failures in planning the right number of staff, resulting in the worrying workforce shortages we see today.   

Another lesson is to use big, specific, tangible commitments judiciously. Some of the greatest achievements of the NHS in recent years, such as the strides taken against MRSA, have come when it was ordered to aim high and rose to the challenge.

But when this approach is applied more generally to issues for which it is not applicable, these commitments can fail. This is the case, for instance, in the current drive to reduce emergency admissions to hospital. The truth is we don’t really know to what extent doing this is possible or how.

Instead of dropping detailed targets on local health services, we need to encourage, incentivise and enable staff and organisations to feel their way towards the right answers, using trial and error and local knowledge. Less eye-catching, for sure, but probably more likely to work.

A further important lesson is that the highly political nature of the NHS can result in a powerful temptation to promise the impossible. The 2015 Better Care Fund aimed to reduce unnecessary days that people were held up in hospital by 300,000 in one year. That was never going to happen without wider changes: the number actually rose. Context matters, and planners would do well to ground their plans in the realities of today rather than the aspirations of tomorrow.

No perfect solution

Finally, the sheer scale of the NHS means that each new structure always turns out to be poorly suited to some places or types of care, prompting a temptation to replace it. Labour’s current desire to scrap Andrew Lansley’s NHS blueprint is a case in point. Sometimes this temptation may be justified. But the number of reorganisations should serve as a signal that the puzzle has no perfect solution.

There are powerful reasons for the structural flaws in NHS strategic plans we highlight. But they may not be inevitable. If the English NHS is to remain world-leading in its output of grand plans, we have a duty to try to become world-leading in getting them right.  

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