Why no top-down NHS reorganisation will work – the hubris of policymaking

“We’re an empire now, and when we act, we create our own reality. And while you’re studying that reality — judiciously, as you will — we’ll act again, creating other new realities, which you can study too, and that’s how things will sort out. We’re history’s actors . . . and you, all of you, will be left to just study what we do.” – Senior Aide to George Bush, at http://www.nytimes.com/2004/10/17/magazine/17BUSH.html

The government promised us in the last election that there would be no top-down reorganisation of the NHS. I think in their own world that Lansley, Cameron and Clegg may have started out believing that the present reforms weren’t ‘top-down’ – that they were about passing responsibility (and control) over funding down to GPs, so creating a kind of bottom-up change (albeit one implemented in a top-down way)

But I’d like to refer to a phrase other than ‘top-down’ in that last sentence – the ‘in their own world’ bit.

I’d like to start from the assumption, which I actually believe, that politicians genuinely want to do good (no sniggering at the back there). They then construct plans to try and make the world better, but of course start off with their own prejudices and beliefs, and work out from there.

More than that, politicians tend to hang about with, and listen to people, who support their prejudices and beliefs. This is perhaps why it’s so dramatic when blogs like Conservativehome come out against the NHS reforms (http://conservativehome.blogs.com/thetorydiary/2012/02/the-unnecessary-and-unpopular-nhs-bill-could-cost-the-conservative-party-the-next-election-cameron-m.html) – we expect political parties to be homogenous places (but don’t worry – here’s Baroness Warsi to make it all better (http://conservativehome.blogs.com/platform/2012/02/sayeed-warsi-torychairman-as-conservatives-it-is-our-duty-to-support-the-nhs-bill.html).

The internet makes this tendency worse. A range of commentators have pointed out that we now have unparalleled ability to only see the news we want to see, with our prejudices built in. Jaron Larnier (http://www.amazon.co.uk/You-Are-Not-Gadget-Manifesto/dp/0141049111/ref=sr_1_1?ie=UTF8&qid=1329475840&sr=8-1) shows how this can stifle inventiveness and deaden our social interactions with others – because we don’t have to engage with those we disagree with, or work out how to argue with them.

Now – the quote with which this piece began. Imagine you’d been in a political party for years, never really had to engage with others outside of your own views (except for those tedious electoral campaigns, but even then, if you have safe seat you don’t see too many of them), you had the Institute of Economic Affairs talking such extreme nonsense (http://www.iea.org.uk/blog/how-to-abolish-the-nhs) that they make you feel moderate, and you find yourself to be Secretary of State for Health. Not only have you not really been much exposed to detailed debate about a topic, but you also now have power. In these circumstances you might believe that you genuinely can ‘create your own reality’. You’ve studied the NHS. You know what’s wrong. And you’re going to fix it.

So you prepare your plans, you publish them. The first battle is getting them into law. That means that other people pay attention to your proposals for the first time, and they start objecting. You make assertions which are taken as common-sense in your own community, but you find out that others don’t share them.

That gives you a choice. You can either begin to seriously question the common-sense you and your communities hold, or you can try and get the plans through by giving away a few concessions, or even try and just bluster through. More often than not, your plans eventually get to become law, even though you might be dead wrong, because you can rely upon the whips in Parliament, and because you are the majority government. Second chambers can be a pain to get your legislation through, but in the end, you can over-rule them.

Then comes the really tricky bit. You then have get people who have been campaigning against you to implement your reforms. The best you can do is to include the legislation game-changing alterations that mean that the whole structure of your reforms force people to do things differently. The disastrous rail reforms of the mid-1990s are a good example of this – they tried to create competition when there really could be none, and did nothing to address under-investment in rail infrastructure – something that was only really faced up to after some appalling rail disasters.

The NHS Bill goes some way to forcing people to do things differently. PCTs are abolished and CCGs will be given their responsibilities. The boundaries between public and private providers will get blurrier (at least, until, the latter either go bankrupt or leave the NHS again). However, having created so much anti-feeling amongst NHS workers, an awful lot of people now have a stake in undermining the reforms. They won’t (I hope and believe) undermine patient care, but there is certainly scope for undermining the introduction of market forces through local collaborative agreements, and of using commissioning to similar ends.

But what this shows above all is the hubris of policymaking. It is hubris to imagine you can, as a new government, change public organisations from top to bottom and expect everyone within them to go along with your plans, and for them to work. To assume you know better than those working in public services how they should be organised and delivered.

That’s one reason why top-down NHS reorganisations don’t work, but I’d go further and say they can’t work. Policymakers are too closed off from viewpoints other than their own to have to talk through their ideas properly. But more importantly, there is no right answer to NHS reform that can be imposed from the centre. We need greater plurality and local adaptation for health services, and much stronger local democratic links. We can have national standards but allow local areas to work out or adapt how to achieve them best for them. Top-down plans won’t work – they are hubris.


3 Responses to “Why no top-down NHS reorganisation will work – the hubris of policymaking”

  1. The Jobbing Doctor Says:

    Thank you for these thoughts. They very much mirror those of many average Dr Ordinaries, like me.

  2. gpprotest Says:

    Thank you, Ian. Yes, I agree that this is one of the core problems. It does not help that the mainstream media are, for the most part, quite ignorant about how the health care system works, and they accept whatever they are told by the politicians-Department of Health, without applying critical thought.

    I think we will see in the coming months more and more examples of how ‘it does not work’, as things unravel. As a GP writes in the current issue of the BMJ, we have been ‘duped’

    I have been blogging about this for a year; if interested, here is a piece about the importance of having a sound methodology:


    Good luck!

  3. Dave Neary (@DaveNeary1) Says:

    This is an age old conundrum – national policy from politcians and civil servants and local implementation by professionals and bureacracies – and the NHS is just the latest example. I want a national service with NICE approving drugs on the basis of effectiveness and cost rather than post code lottery but I also recognise that localities are very different. The issues in sparsely populated Cumbria are somewhat different to metropolitan Liverpool or London.

    For me, it is about freedom within boundaries for local organisations – PCTs (CCGs), trusts (Foundation Trusts and Any Qualified Provider) and people (taxpayers/patients) – to decide priorities. However, there must be national guidelines, standards and ultimately political accountability (Bevan’s bedpans rattling through Westminster?) for the resources, organisation and performance of the NHS.

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