The battle over NHS reform: many shades of grey

When we published an audit of the coalition’s health reforms recently, we expected it to generate plenty of interest as health has become such a central and bitterly fought issue in this election – we were not disappointed.

It’s great that our analysis was read and discussed by so many people. But for an organisation that prides itself on objectivity, it was just as important to us that most who commented in public or wrote to us privately felt that the report was fair, accurate and balanced. The main political parties could all find things to complain about and things that they could draw on to support their cause.

Looking back on the coverage and conversation about the report, I found the most fascinating aspect was how different the debate was on social media compared to traditional media. In particular, the discussion on Twitter focused as much on whether our position on the reforms had changed and the question of ‘whose side we were on?’ as on the validity of our conclusions, which, for the most part, have been accepted.

We are always willing to respond to criticism of the Fund, but it’s often hard to know when it’s right to engage in direct combat via Twitter. Over the week my frustration grew steadily – not with any vocal disagreement over our policy position but with the ongoing discussion on the role of organisations like The King’s Fund and the nature of our relationship to policy development.

The Fund, along with fellow think tanks and foundations, should not only generate debate but improve the quality of debate and the quality of policy-making. To do that it’s important to recognise that, however explosive the political hand grenades being thrown, policy is complex, difficult, and almost always a product of compromise. Even the most carefully crafted policies have unforeseen consequences for good and ill, and those of us who want the best outcomes for patients need to engage with the reality of that process not avoid it.

The health reforms enacted through the Health and Social Care Act 2012 had a long and painful gestation. Nick Timmins’ brilliant Never Again tells the full tale in all its gory detail. Looking back to 2010, I am reminded how consistent the Fund has been in its position. Initially we were criticised by some for being too negative and pessimistic. As opposition grew we were criticised for not campaigning for the Bill to be withdrawn.

We have always said that the reforms had potential benefits; for example, we welcomed the move of public health to local government and GPs being given a greater role in commissioning. We also said that these benefits could have been achieved without legislation and were explicit in arguing that the case for radical change had not been made by the government.

We are not a campaigning organisation. We reflect on and communicate (in public and in private) what we know – the data we gather and analyse, research carried out here and internationally – and on the experiences shared with us by people at all levels of the health and social care system. We work behind the scenes with parliamentarians and others to try to influence policy as well as expressing our views through the media and other channels.

Constructive engagement means just that. You can’t have an impact on policy if you oversimplify complex issues, insist that everyone must be labelled either friend or foe and oppose without suggesting alternatives. Nor can you have influence if you sacrifice your integrity to stay ‘inside the tent’ at all costs. We choose to do neither.

The Fund’s role as an independent foundation enables us to speak truth to power. Our independence is highly valued and is not sacrificed to other considerations. During the build-up to a general election, it’s important to keep in mind that, while NHS policy debates are increasingly painted only in black and white, shades of grey are often more interesting.

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#542949 Lawrence Donaldson
Director Health Service Integration and Innovation
Bayside Medicare Local (Melbourne, Australia)

Beautifully said. The UK is indeed fortunate to have this quality of health policy leadership.

#542986 Calum Paton

Rebecca......or should one say 50 Shades of Gray, not Grey('lol'as they say!): I agree that think-tanks such as the KF should speak truth to power. But keep the Grey metaphor going, that should sometimes involve a spanking rather than a gentle telling-off!

#542992 David Cross
Focus on Disability (

We look to yourselves as a lead in highlighting and commenting on issues that are fed to the public in black and white by the press and elsewhere. This is simply because of the unwieldy mess healthcare is in and no overall panacea is possible. All we have for now and the forseable future is buckets full of pretty meaningless spin and rhetoric from the powers that want votes more than improved health and social care. Focus on Disability will keep posting the black as it comes.

#543155 Jimmy Thomas

The KF were distinctly ambiguous about the Lansley reforms when they came out. There was an opportunity to challenge them that was missed.

Now there is no doubt that they were costly, a distraction and chaotic.

It's is fine to claim independence allows truth to be spoken to power. But it counts for little if rarely if ever used.

#543576 Anne McKee
Director of Educational Research and Innovation
King's College London

I join Lawrence Donaldson is welcoming this balanced, considered and much needed description of the complexity of policy and it's relationship to change. The KF does try to speak truth to power-- but they appear not to be listening --again.

#543577 Anne McKee
Director of Educational Research and Innovation
King's College London

I join Lawrence Donaldson in welcoming this balanced, considered and much needed description of the complexity of policy and it's relationship to change. The KF does try to speak truth to power-- but power appears not to be listening --again.

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