Reforming the NHS from within: Beyond hierarchy, inspection and markets

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Part of Time to Think Differently

This paper reviews the impact of three approaches to NHS reform in England since the late 1990s: targets and performance management, inspection and regulation, and competition and choice. It argues for a fundamental shift in how the NHS is reformed, learning from what has worked (and what has not) in England and elsewhere.

Such a shift requires a much stronger focus than hitherto on bringing about improvement and change from within health organisations and networks of care. The paper argues that this is the best route to system-wide transformation, particularly given the limited impact of reforms that rely on external stimuli.

Key findings

  • Transforming the NHS depends much less on bold strokes and big gestures by politicians than on engaging doctors, nurses and other staff in improvement programmes.
  • A new settlement is needed in which the strategic role of politicians is clearly demarcated to avoid frequent shifts of direction that create barriers to transformational change.
  • Improvement in NHS organisations needs to be based on commitment rather than compliance, supported by investment in staff to enable them to achieve continuous quality improvement in the long as well as the short term. 
  • The experience of high-performing health care organisations shows the value of leadership continuity, organisational stability, a clear vision and goals for improvement, and the use of an explicit improvement methodology.
  • Leadership in NHS organisations needs to be collective and distributed, with skilled clinical leaders working alongside experienced managers.
  • NHS organisations should prioritise leadership development and training (preferably in-house) in quality improvement methods.

Policy implications

  • NHS leaders need to pursue complementary approaches to reform in which national leadership is combined with devolution, collaboration with competition, and innovation with standardisation. There should be much more emphasis on bringing about improvement and change locally from within, and less emphasis on the use of external stimuli.
  • There needs to be much greater transparency, based on the collection and open reporting of data on performance.
  • There needs to be a more realistic view of what inspection and regulation can contribute. Inspection can only be effective if frontline teams and NHS boards are fully engaged in delivering the best possible care.
  • Competition and choice have a role to play, but should be viewed as just one means to improve care rather than a guiding principle.
  • Integrated  providers or systems are the most promising ways of promoting worthwhile innovations in care.
  • Much greater leadership continuity will be needed in NHS organisations to support new styles of leadership, with a focus on developing leaders at all levels.

Read the case studies from the report

About the paper

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, which established separate systems for health and social care, remains fit for purpose was also born out of this programme.


anne murray

Charge nurse manager,
Comment date
08 August 2014
would like to know more

Kathy Postlethwaite

Consultant orthodontist,
Comment date
20 June 2014
This is the most sense I've read about leadership in NHS in a long time- good common sense & attitudes that certainly 'resonate' with me (58) Gives me some hope for NHS! Unfortunately more influential power brokers seem wedded to 'top down' compliance approach which I find alienating & not inclusive

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