It's time to end top-down reform of the NHS

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Politicians’ role in the running of the National Health Service (NHS) needs to be better defined to counter interventionist and centralising tendencies that have hampered effective reform to date, says a new report published today by The King’s Fund.

The report, Reforming the NHS from within: beyond hierarchy, inspection and markets, argues that a new political settlement is needed that clarifies the strategic role of ministers in determining funding, establishing priorities and providing accountability to Parliament, and leaves local NHS leaders with the space to innovate and lead service change. This settlement should reflect lessons learnt from the experience of the present government’s health reforms, which have failed to distance ministers from the operational management of the NHS as originally intended.

The report challenges the dominant approaches to NHS reform over the past 20 years – targets and performance management; inspection and regulation; and competition and choice. It argues for a fundamental shift in how the NHS is reformed. The NHS needs to move on from prescriptive, top-down approaches to change by progressing from:

  • large-scale structural reforms towards locally derived solutions
  • ‘heroic’ pace-setting leadership approaches towards supporting staff to lead change and improvement
  • a focus on external pressures such as targets and inspection towards supporting improvement ‘from within’.

The report argues for a stronger emphasis on devolution within the NHS and a more proportionate approach to regulation, learning from the experience of foundation trusts. Foundation trusts are an example of where ministers have previously attempted to devolve accountability and decision-making, but promised freedoms have failed to materialise, with the result that foundation trusts are now as likely to look up to regulators, as out to the communities they serve.

The report draws on examples of high-performing health care organisations here and abroad to show how appealing to the intrinsic motivation of staff to provide the best possible care and strengthening leadership can drive reform from within. These examples demonstrate that a shared culture and patient-centred vision are more important than structural changes in bringing about improvements in care.

The report suggests that future NHS reforms should focus on:

  • embracing complementary approaches to reform
  • demarcating the role of politicians
  • promoting transparency
  • enabling devolution
  • being realistic about inspection and regulation
  • seeing competition as one means to improve care rather than a guiding principle
  • supporting integration of care 
  • promoting collaboration
  • strengthening leadership and developing skills for improvement
  • committing to continuous improvement over the longer term
  • organisations and networks.

Chris Ham, Chief Executive of The King’s Fund and the report’s author, said: ‘Increasingly Secretaries of State have felt the personal pressure to be seen as the visible and activist leader of the NHS. Yet, transforming the NHS depends much less on bold strokes and big gestures by politicians than on engaging doctors, nurses and other staff in improving care. Our report finds that by learning from high-performing health organisations here and abroad, we can move away from top-down change to locally derived solutions. Above all, change must be underpinned by a commitment to put patients first – this commitment has to come from within organisations and cannot be mandated from outside.’

Notes to editors

For further information, or to request an interview please contact: Cara Phillips, Senior Press and Public Affairs Officer, at The King’s Fund on 020 7307 2632 or email

Main Press Office number: 020 7307 2585 / For out of hours assistance: 07584 146 035

  1. Reforming the NHS from within: beyond hierarchy, inspection and markets by Professor Chris Ham will be launched at a breakfast event on Wednesday 11 June at The King’s Fund with Rt Hon Stephen Dorrell MP, former Chair of the Health Select Committee, Professor the Lord Darzi of Denham, Professor of Surgery, Imperial College London, and Sir David Dalton, Chief Executive of Salford Royal NHS Foundation Trust.
  2. Reforming the NHS from within is the final publication in our programme of work, Time to Think Differently which was set up to stimulate debate about the changes needed for the NHS and social care to meet the challenges of the future. The Barker Commission, which is asking whether the post-war settlement that established separate systems for health and social care remains fit for purpose, was convened in response to this programme.