Non-market principles upon which the NHS might be reorganised

In the furore over the NHS Bill, there are sometimes accusations that those who oppose it have no alternative. This is, of course, nonsense. Roy Lilley ( has been doing this for some time, and there are posts here which try and put out the beginnings of an alternative view.

Below is my attempt to being to put some non-market principles by which the NHS be reformed. Not everyone will agree with them all, but I hope they do represent a framework for thinking about a different way of organising healthcare that can secure improvements.

Principle 1: No big-bang reforms – answers don’t come from trying to create magical reorganisations, but from hard-work

The eternal problem policymakers bring to the NHS is to believe that they can somehow reorganise it to success. Can you think of a reorganisation that ever worked in the NHS? Sadly this complete lack of success in the past somehow seems to make politicians even more determined – as if they are thinking ‘just one more try!’. No Secretary of State for Health has EVER gone on to be Prime Minister. It’s time to learn that top-down, expensive reorganisations don’t work. We need alternatives.

Principle 2. Improvement by the use of clinically-informed standards and benchmarks, with discretion how they are implemented locally

The key lesson from the QOF is that improvements can be made, but you need to give local decision-makers autonomy in how to make them, and to base targets not on arbitrary numbers, but instead on clinical targets. There are arguments that the QOF wasn’t particularly evidence- based, but perhaps that’s less important than the fact that a considerable amount of time and energy was spent on getting clinical buy-in, and the practices within the QOF often came to be seen as being ‘quality’ in themselves. There is so much to learn about target setting and quality improvement here – in contrast to the game-driven nonsense that we often saw in hospitals based on what seemed to staff to be arbitrary target-chasing.

Principle 3 – There must be consequences for failing to achieve improvement

If we are to have agreed clinical targets, there must be consequences for not achieving them. Failing or substandard services must have their leadership (managerial and clinical) replaced. Not every service in the NHS meets the standards expected of it. There has to be action where there are problems.

Principle 4: Stronger local democracy – scrutiny but also awareness of trade-offs.

No public service is accountable unless it has a strong democratic underpinning. In the past, the NHS has often seen the unedifying spectacle of politicians blaming local managers for failings, while no-one in the DH takes any responsibility. This is unacceptable.

We desperately need stronger local democratic engagement in the NHS. My view is that local public NHS organisations should become the responsibility of local government, as well as being held accountable to it. I would like NHS performance to be a source of debate in local elections, and politicians be held accountable for their ability to hold it to account. Moving the NHS into local authority control might have the additional benefits of reinvigorating local democracy (as it would matter more) and moving away some of the boundaries between health and social care. It may also raise the level of local debate we get over NHS services – which has to be a good thing. We also have to allow greater local diversity of services – it makes no sense for Clacton to have the same health services as Milton Keynes. There need to be national standards, but we need far greater variety in the provision of local healthcare – and as long as this is linked to local democracy it should be legitimate.

Principle 5: Regional bodies are necessary for strategic priority needs

As well as local health organisations, we also have to have some regional co-ordination to allow service and training planning. These bodies have to accountable to local authorities to ensure that they are being proactive in making sure service gaps are plugged through strategic investment.

Principle 6: The private sector is a partner, not a competitor.

The private sector should be a source of short-term additional capacity for the NHS, not as competition for it. Equally, NHS hospitals should only allowed to use pay beds where they are available to NHS patients when needed (waiting times, capacity). Where the NHS is making year-on-year use of a particular private facility, that justifies strategic investment in that service to make such use unnecessary in the future.

The alternative

All of the above is an alternative way of thinking about the NHS. It is about local democratic, accountable improvement through public services only. The Secretary of State would be responsible for the overall performance of the system, as well as for setting national minimum standards, but have little power to reorganise, instead taking a lead on holding local government to account for their performance. The DH would almost be made redundant as it would be a bottom-up system.

We don’t need markets, which won’t work, and which are just another of the quick-fixes governments have attempted to find magic solutions to the hard work of getting the NHS to work better. We need more local democracy and more local local accountability and scrutiny.


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