Why the NHS needs a ‘slow policymaking’ movement

In 1986, a protest about the opening of a McDonald’s near the Spanish Steps in Rome helped to spark a new culinary movement called Slow Food. The movement appreciates culinary traditions, focuses on the source of food and its sustainability and recognises the central importance of the experience of eating together. 

Given the frenzied policymaking we have seen recently in the NHS – a proliferation of new plans, organograms, models and frameworks – is it time we took these principles and began a movement calling for ‘slow policymaking’? 

Slow policymaking is a type of policymaking that: 

• appreciates and builds on the past, rather than assuming the existing policy framework is broken and needs to be ripped up to ‘correct’ past mistakes – perhaps it is not the policy framework that is broken? 

• is realistic in its ambition, recognising the limits of policy to deliver detailed operational change. 

• provides a solid base that can evolve – this does not mean avoiding fast-paced innovation and big new ideas – but adding them sparingly as capacity allows, rather than lurching from one silver bullet to the next. 

• prioritises maintaining and nurturing relationships between staff and organisations – perhaps ‘the’ critical feature of successful policy implementation. 

• aligns with other policy areas in health and beyond, slowing down enough to build coherence and avoid competing incentives and accountability structures.  

What would slow policymaking look like?  

If NHS commissioning had embraced slow policymaking 20 years ago, I suspect a lot of wasted effort would have been avoided in what Nigel Edwards recently badged the most reorganised part of the most reorganised health system in the world. Perhaps we would have around 150 NHS commissioning organisations aligned with local authorities, underpinned by decadeslong relationships between local planners and providers. Maybe integration would have been easier, because leaders at all levels would have been more likely to stay in place for years – enabling systems to leverage the power of consistent leadership and the relationships that come with it, which can be a critical success factor for transformation. We might have a small number of strategic health authorities covering larger areas, working with combined authorities to align policy and strategy across public services. 

Perhaps we would have progressed further in building meaningful cross-sector datasets to support commissioning, had this been a laser focus for policymakers rather than reorganising the bodies responsible for it. Maybe we would now have a world class system for training strategic commissioners – and cohorts of world class planners skilled in assessing need and designing pathways across all services that support health. A sustained focus on developing people, skills, coherent accountability frameworks, infrastructure and sharing learning about innovative pathways might have nudged the system more towards community-based provision and prevention. This could have been more successful than developing and abandoning a series of complex incentives, contracting mechanisms and organisational forms. The time spent slowly developing and aligning planning structures and approaches across departments might have birthed the health mission earlier and kept it alive longer than the most recent attempt. 

Slow policymaking would produce fewer headlines (‘This updates what came before’ doesn’t get clicks), and would require politicians to look to outcomes, not announcements, to demonstrate their impact to the public. It would require policymakers to spend as much time working across government as within their own sector, and a humbler approach to policymaking. And it would require stability in policy teams, to preserve institutional memory – an essential capability for slow policymaking to work. 

You could argue that ‘slow’ is unrealistic in a world where politicians need to demonstrate impact and change from what went before. But our goals for the health system change slowly (even if expectations rise faster): the government’s three ‘shifts’ to transform the NHS have guided policy for decades. And fast is not necessarily radical or innovative, as we’re seeing across the NHS right now. Fast can lead to inertia and a system paralysed by contradictions and change.  

The NHS doesn’t lack ideas; it lacks the time, stability and relationships to see them through. In a system bloated on fast-food-style policymaking, slowing down might be the most radical step the government could take right now.