Inertia rather than privatisation is the biggest threat facing the NHS

The Prime Minister's summit on implementing the NHS reforms has provided a new focus for debate about what the reforms will mean in practice. The government's critics maintain that competition will undermine the core values of the NHS to the detriment of patient care. Some of these critics go further to claim that competition will result in the privatisation of much health care provision and the end of the NHS as we know it.

History suggests the need to treat these claims with caution, if not scepticism. Ever since Margaret Thatcher's government introduced the internal market reforms in 1991, opponents of choice and competition have warned that the future of the NHS is under threat, and yet it is performing better today than ever before. And as Nick Timmins showed in a recent analysis for the Financial Times, the private sector's share of the market for elective care for NHS patients has remained stable, giving the lie to the argument that widespread privatisation of provision is inevitable.

In the light of this kind of evidence, there is a much greater risk that inertia, rather than privatisation, will block the changes that are needed to address the Nicholson challenge and bring about improvements in the quality of care and patient safety. Inertia is a result of the size and complexity of the NHS and the pressures facing staff to respond to the demands placed on them; it is often easier to live with the current situation than to seek ways of working differently and more effectively.

It is also a legacy of the command and control culture that often results in leaders waiting for permission to act, rather than seizing the initiative to do so. The Health and Social Care Bill and associated reforms risk reinforcing inertia because of the complexity of relationships between the NHS Commissioning Board, clinical commissioning groups, health and wellbeing boards, clinical senates and clinical networks. Unlike former health secretary, Alan Milburn, who warned that the reforms could lead to a car crash, in reality there is a much greater likelihood of a traffic jam as organisations negotiate on how to make change happen.

To be sure, the NHS has shown in the past decade that it is capable of addressing long-standing weaknesses in access to care and quality, but it has done so at a time of unprecedented investment. For the foreseeable future, there will be no extra spending other than that needed to allow for inflation, and the challenge is, therefore, to do more with the same instead of more of the same. Doing more with the same calls for a degree of innovation rarely seen before that is implemented at a pace that reflects the urgency facing the NHS in the most challenging period in its history.

Some of the innovations that are needed may come from the greater involvement of private and third-sector organisations able to bring different ways of delivering care to the table. There is also an opportunity to learn from experience in other countries where new models of care have been established, unconstrained by the traditions that sometimes inhibit change in the west. The example of the Aravind Eye Care System in India, presented at our annual conference in November, is a fantastic illustration of this kind of reverse innovation.

Important as these examples are, much of the innovation that is needed will depend on NHS providers and commissioners showing the way by challenging established models of care and demonstrating how improvement can come 'from within'. To convince the sceptics who argue that the NHS is too big and lumbering to innovate, three things must happen.

First, NHS leaders must be ruthless in identifying and copying best practice wherever it exists. After all, much innovation is really adaptation of ideas initiated elsewhere, and shameless plagiarism is an underrated virtue.

Second, to be able to do this, leaders must create time to look outside their organisations, while also attending to operational imperatives. My experience of working with leaders over the years is that the most powerful learning often occurs through seeing how other organisations work and this should become a higher priority.

Third, and perhaps most important, there is a need to invest in the training and development of staff to enable continuous improvements in the quality of patient care. High-performing health care organisations such as Jonkoping County Council in Sweden and Intermountain Healthcare in Utah, US, do this systematically and are rightly admired for the results they achieve.

To return to my starting point, the most effective response to concerns that the core values of the NHS are under threat is to show that it can adapt rapidly to the challenging environment in which we live. After all, if NHS organisations demonstrate that they can deliver high-quality and responsive care, they have nothing to fear from a further dose of choice and competition.

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#1059 SJ O'Neill
Management consultant
Hallett O'Neill

NHS leaders would have to be able to create true 'learning organisations' if they were nurture the high performing healthcare organisations you point to here. 'Learning faster than or equal to the rate of change' ( Revans ) is the answer to inertia - esp, if done in partnership with patients and the public. The new role within the NCB - marrying informatics and patient engagement - sounds of interest here. But I'm not holding my breath either ...

#1060 Jonathon

Yet again, Prof Ham's frustration with critics is apparent, and this time he sets up a false dichotomy to labour his point. The evidence, as he well knows, is that continual reorganisation has held back & continues to hold back real reform of the NHS.
Propenents of competition are starting form the premise that the NHS needs competition and then look for justification. What we ought to be doing is asking how the NHS needs to improve and then carefully considering the options instead of fighting hammer & tongs over competition.
Both Sweden and the Netherlands have 'refomed' their public healthcare systems by introducing competition and opening up markets with the private sector The consequences include rising costs, falling satisfaction and detrimental care for the most vulnerable

#1061 Health economist

Lets be clear, we are not privatising the buses and this is important, because the rhetoric around privatisation is based on improving effeciency where one part of the equation is focused on costs. The government have made it clear that organisations will not be able to compete on costs, instead the nirvana is improved quality.

Great we all sign up to that, but for quality to improve we need good metrics that the public can understand (and we cant even agree on the mortality ratio). So the alternative for the public is choice, well great if you live within traveling distance of a couple of providers.

Health care provision isn't like the buses, there aren't lots of them and they dont all come at once and if they prove to be inefficient we cant just stop them because they dont make money.

The danger to heath care in England is, as Jonathon says - continual reorganisation. How many lives have been lost as a result of the reorganisations?

Commissioners need to develop relationships with providers understand the data and dynamics of a trust and make decisions based on the health needs of their population. That cant be done when the commissioning side of the NHS is reorganised every few years - and we all know its politically easier to reorganise than close a hospital!

#1062 Alex

1. You say (para 2): “Ever since Margaret Thatcher’s government introduced the internal market reforms in 1991,…”

2. Sorry if I’ve missed something…but Mrs Thatcher resigned as UK Prime Minister in November 1990, didn’t she?

#1063 Sarah Tucker
Assistant Web Editor
The King's Fund

Hi Alex

The National Health Service and Community Care Act 1990 which brought in the internal market reforms received royal assent in 1990, but the act came into force in 1991. Technically it was a Conservative initiative but brought in under a Labour government.

The blog has been amended to make this a bit clearer - thanks for pointing out.

#1064 Alex

Hi Sarah,

1. Thanks for the reply.

2. My point only was that in 1991 it wasn’t Mrs Thatcher’s government [as originally written], since she’d resigned in 1990.

3. However, I’m confused by your statement: “Technically it was a Conservative initiative but brought in under a Labour government.”

4. It was still a Conservative government in 1991…

#1065 Sarah Tucker
Assistant Web Editor
The King's Fund

Alex - Sorry typo in the comment response but the blog amend was correct.

#1066 E K Bhimani

The biggest threat facing the NHS is abuse,unrealistic public demand and an absolute lack of self care.We have a culture of,"go to the doctor".Roughly 70% of my daily consultations do not need a doctor.
Every patient I see,expects a prescription.

#1067 Harry Longman
Chief Executive
Patient Access

" Doing more with the same calls for a degree of innovation rarely seen before". Absolutely agree with Prof Ham.
"NHS leaders must be ruthless in identifying and copying best practice." Yes again. But experience has shown me that innovation is deeply counter cultural in the NHS, perhaps even more so now that everyone sees their job at risk. We have found much greater opportunity to make change happen at scale by acting for the NHS, but independently.

While we work mainly with CCGs and GPs on "in hours" access, in OOH provision several colleagues have explained how their innovative practice has been ignored or quashed to make way for 111. Politically driven, not evidence based, is the reality faced by those on the inside.

And by the way Dr Bhimani, I believe your experience of 70% of patients not needing to see you. The problem is, they are blocking access for those who really do need the doctor.

#1068 Phil Willan
Retired NHS Manager

I have no political affiliation. Both Conservative and Labour administrations have done some good things for the NHS .... but both have made some catastrophic decisions.
The NHS does not need the new legislation. It doesn't need more competition. And it certainly doesn't need generalists in charge of the majority of it's budget. Why give responsibility to the clincians who know LEAST about the specifics of their patients' problems?
What we DO need is better management and more sharing of best practice.
I agree that inertia is the enemy here - but private and third sector organisations do NOT have a monopoly in innovation and good ideas. In fact the involvement of the private sector is more likely to mitigate against the sharing of best practice.
I would go further and suggest that we should not be thinking about driving efficiency with the same resources .... but with LESS cash.
As a patient I see massive variability between different out patient clinics for example. Some are clearly "suffering" from having a surfeit of staff borne out of a previous surplus of funding splurged on them from the last Labour government with lots of nurses doing little more than hand holding and tea making for the physicians - whilst others are clearly struggling with too few staff.
A structural, systematic nut and bolt review of all services over time is what is required. As a manager of a specialist NHS service I was once required to continue provision of a service but with only HALF of the previously available funding. We were under immense pressure .... but still managed to reconfigure the service in such a way that we provided a BETTER and much more efficient service after this enforced review.
Whilst I'm not suggesting that this level of efficiency improvement is possible for every area of the service ..... there is clearly scope for improvement in mast areas.
The other thing we certainly DON'T need any more of is the introduction of any more resource "sponges" introduced into the system such as unnecessary replacement of infrastructure such as some hospitals and polyclinics utilising the catastrophically burdensome PFI route.
"Care closer to home"? Give me strength.
We need co-operation and efficiency ...... not even more meaningless mantras.

#1069 Roger Steer

I agree that the NHS needs to be able to innovate but the paradox is that unpopular innovation (like the spinny jenny in textles) requires top down direction and the NHS always shies away from that in the name of localism.
The latest reforms will make it even more difficult to achieve unpopular change as GP localism and FT impregnability will see off any external pressure.
For example pathology modernisation was first discussed twenty years ago and still very little has been achieved.
All shared services organisations have failed to deliver a robust organisational platform(largely because localism has undermined efforts of separate NHS institutions to co-operate) and instead have acted as staging posts to privatisations.
The tariff system still serves to sustain out of date and inefficient practices e.g. pre operation LOS.
The clinical regulators still enable consultants to take on heroic interventions that consultants are not sufficiently trained or exerienced in.
Patients suffering damage are not properly compensated and public scrutiny , clinical audit , quality audit and accountability are all still sub-standard.
Whistleblowers still imperil their careers for pointing out the unacceptable.
It is disingenuous merely to call for Leadership. Leadership starts at the top it cannot be delegated.
That means you Chris!

#1070 Clare
Health services researcher

Chris Ham said: "The Prime Minister’s summit on implementing the NHS reforms has provided a new focus for debate about what the reforms will mean in practice."

Er - that would be the summit to which only a select few were invited - and from which were excluded all of the many professional organisations which have recognised the Health and No Social Care Bill as a highly risky Trojan horse and oppose it accordingly. It is very disappointing to see a King's Fund blog doing Andrew Lansley's PR for him.

#1071 Tricia Woodhead
Consultant Radiologist and Lead for Safety, Quality and Innovation
Weston Area Health Trust, NHS South

There is much written about innovation and in particular it's place in transforming our NHS so it is fit for purpose throughout this century. Chris Ham's point that learning avidly from others is to my mind correct. Innovating organisations actually create and embed structures that source or generate ideas and that test and perfect them for local use. They have a leadership that supports and recognises the discipline that innovation requires if it is to transform the model of business. If this is what Chris Ham is meaning when he speaks of learning from others then the sooner such and approach is mandated the better.
If some aspects of the private and third sector have a lesson to teach us it is that they just 'get on and do it'. It is my view that we seem to spend a great deal of time 'not doing much other than talking and writing'.

#1072 Mary Hawking

13 months to go, and we still have little idea of organisational responsibilities - e.g. GP IT system supply and support, registration and maintenance of practice lists with the asociated payments, performers lists, revalidation, premises, management of practice finance (who will validate QMAS returns after 1.4.13?), or even what the management and commissioning budgets for CCGs will be or what they will have to cover.
QIPP (locally helped by more savage rationing than I remember in over 30 years in practice) is the priority: innovation and reorganisation are being introduced - but more slowly than they could be - and I don't think the question of life after Armagedon has been seriously addressed as yet - seeing there is little firm information on which to base plans and budget.
I know a number of GPs planning to leave the NHS before 1.4.13....

#1073 Laura

I think Chris's 3 points are really useful. We know we need to deliver better for less. If we look at successful health care systems such as Jonkoping County Council there are powerful, transferable lessons to learn about how we as NHS organisations or health communities can significantly improve the quality and cost of healthcare. The leadership approach in Jonkoping is widely documented and is being used by several of our senior teams in NHS organisations including CCGs to deliver better for less. Our colleagues are making time to learn from the Jonkoping Community. Acting on this learning they are developing the mindset and conditions within their organisations to enable staff to take on the dual role of both delivering and improving services and are investing in developing staff to deliver on this. The emerging Single Model of Change referred to the NHS Chief Execs Innovation Report (Dec 2011) reflects some of the core principles underpinning the Jonkoping approach - what is crucial is "how" the model/approach to change is owned and led. Learning from Jonkoping would strongly suggest this needs to be from within.

#1074 Jason

History is littered with unfulfilled predictions. Critics of the reforms, of which I am one, are simply looking for worst case scenarios in order to ensure no small holes apppear in big ships. This legislation is riddled with small holes and massive holes and middle-sized holes. It is perfectly possible to improve the NHS to meet the needs of patients and the furture without introducing more space for private companies. I would argue reversing the trend and eradicating all private involvement in NHS matters. The important thing is to ensure there is absolutely no chance of more private sector involvement. Government assurances (whatever they are worth) are no good on their own. There must be cast iron guarantees in any legislation that make it impossible.

#1075 AmyB

We are either an National Health system or we are a private health care system. The Government should be concentating on improving quality and access rather than constantly looking for systems to perormnace manage the system for them. PFI, increasing competition, patient choice, the latest comissioning model, QIPP, CQUINS - this is all a distraction from having the manage the National Health Service from the top...and how many people does it take to dream up these ideas, roll them out and then manage them? Set standards and stick to them. Set a budget and stick to it. Employ good managers and lead clinicians and get rid of the bad ones. What will david Nicholson be doing once is is on the comissioning board...who will be leading the NHS? If tesco had a different set of HR polices for every one of its stores I'm sure they would be pretty inefficient too!

#1076 John Chater

What is often left aside from the debate is the simple fact that many of Mr Lansley's reforms have already been accomplished in everything except name.

Since the Bill was introduced in January 2011 SHAs and PCTs have merges to assume the future boundaries of the regional and local NHS Commissioning Board (four and 50 bodies respectively). Staff have been shed and redeployed in readiness for the changeover and all NHS organisations have gone some way to changing policy and services in preparation. The roles of Monitor, NICE and the CQC have also been modified to reflect the requirements of a post-reform NHS.

In local authorities, health and wellbeing boards are already populated and operating in shadow form, in preparation for their formal establishment and operation, and Public Health England has already published plans for its national and regional presence.

Even if the Bill is abandoned, which is highly unlikely, it is very improbable that the changes to structure and operation already in place could be reversed (would anyone envisage a return to 150 PCTs and 10 SHAs at this stage).

When the Bill receives Royal Assent it will provide the mechanism for the abolition and creation of statutory bodies (which requires primary legislation) but this will in effect more be a renaming and granting of final authority exercise as much as anything else.

As for the dreaded privatisation of the NHS – surely this is a continuation rather than a revolution.

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