A major new book published by The King's Fund today suggests the government must not forget the importance of engaging with the implementers, who will ultimately shape how these grand ideas work out in practice.
Leaders in the NHS remain unconvinced about the government's plans. An Ipsos MORI survey of public sector leaders over the summer found that only one in three health leaders agree with the reforms and one in four believe that they will improve services. Their key concern is funding (63 per cent cited this as the most important factor facing the health sector today).
Many of the same fears raised in response to the present government's plans were voiced about the market reforms introduced by New Labour from 2002 onwards. Having initially rejected the Conservative's internal market, the Blair government introduced patient choice of provider, created a greater role for the private sector in providing NHS-funded care, and gave public hospitals greater freedoms as foundation trusts. Our new book – which includes chapters by many of the leading experts on health policy – reviews the evidence on the impact and implementation of these policies.
We find that these reforms went much further in introducing market competition into the NHS than the Conservatives' internal market in the 1990s. The fears voiced about the reforms were largely not realised, but their impact was also more limited than their proponents had hoped.
The government would do well to pay more attention to implementation if it wants its reforms to have a greater impact. We suggest in the book that the coalition government should:
- have a strong narrative and make sure the purpose of the reforms is clear to those responsible for implementing them
- be open to adaptation and refinement of policies in response to feedback from implementers
- expect the reforms to be diluted during implementation and therefore give them a decent chance to work
- recognise that 'context matters' and the market may have limited application beyond elective care
- not assume that passing new legislation will change the behaviour of those within the system; active steps will be needed to change managerial cultures and relationships.
Ultimately it will be NHS leaders and not politicians who determine whether the NHS is able to deliver the changes anticipated by the reforms. The politicians would do well to remember this.