A new approach to NHS reform

The NHS has been on a rollercoaster of reform for the past 25 years. Most recent reforms have been based on three approaches: targets and performance management; inspection and regulation; and competition and choice.

While the impact of each one is hotly contested, it is clear that their overall record is mixed. This reliance on external pressures and top-down political initiatives has also resulted in NHS organisations looking up to government and regulators, rather than out to patients and local communities.

It is time to initiate a fundamental shift in how the NHS is reformed, learning from what has worked here and around the world. The experience of high-performing health organisations shows the value of leadership continuity, organisational stability, a compelling vision and a clear focus on improving quality of care. The focus should shift away from placing even more external pressure on NHS organisations to deliver political imperatives towards supporting them to transform care themselves.

A new political settlement to demarcate the role of politicians

While ministers have often expressed a desire to devolve responsibility away from Whitehall, in practice they have been unable to resist managing the NHS from the centre. As a result, the NHS remains one of the most centralised health systems in the world, with a recent history characterised by top-down structural reorganisations, frequent changes in direction and political interference in operational management. Too often, political initiatives have got in the way of the long-term commitment needed to deliver transformational change.

The truth is that transforming the NHS depends less on bold strokes and big gestures from politicians than on engaging doctors, nurses and other staff in efforts to improve services. A new political settlement is needed that clearly demarcates the role of ministers and devolves more power and accountability to the NHS organisations responsible for delivering care. The role of politicians should be strategic – making decisions about funding, setting the direction of policy and being accountable to parliament for the performance of the NHS as a whole – leaving local leaders with the space to improve the quality of services and develop new models of care.

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A focus on reform from within

International experience shows that the success of the best health care organisations, like Salford Royal NHS Foundation Trust here in the United Kingdom, is based on a long-term commitment to improve care and appealing to the intrinsic motivation of their staff to deliver this. There is also compelling evidence that organisations with high levels of staff engagement – where staff are strongly committed to their work and involved in decision-making – deliver better-quality care. Instead of mandating change from above, the next government should promote reform ‘from within’ based on devolution and transparency.

The success of the growing number of public service mutuals highlights the benefits of giving staff a stronger stake in their organisation, while evidence shows that open reporting of performance data is a powerful driver of improvements in care. More proportionate regulation is needed to reduce the burden on NHS organisations to report to national bodies, while competition should be seen as just one means to improve care, to be applied only where evidence shows it will bring benefits. Above all, reform must be underpinned by a commitment to putting patients first – this commitment can only come from within organisations, it cannot be mandated from outside.

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Investment in the right kind of leadership

Research shows that staff satisfaction and patient experience are closely linked – patients receive better care when staff are engaged and well led. This highlights the crucial role of NHS leaders in developing cultures in which staff are motivated and supported to deliver high-quality, compassionate care to patients. This means moving on from the recent reliance on ‘heroic’ leaders, where responsibility is concentrated in a small number of individuals at the top of an organisation, to a more collective approach in which all staff take responsibility for improving care.

Given the evidence that medical leadership improves organisational performance, more doctors, nurses and other clinicians should be encouraged to take up leadership roles. It will also be important to avoid another sterile debate about reducing the number of managers in the NHS. There is no evidence that the NHS is over-managed. Politicians should resist the temptation to slip into lazy rhetoric about ‘NHS bureaucrats’, and efforts to cut spending on administration should be focused on reducing the regulatory burden on NHS organisations, not on further reducing the number of managers.

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