We are expecting a white paper on the NHS. Unlike in 2012, this time it has been greeted by consensus that reform is necessary. But it is striking that every reorganisation since 1974 contains the seeds of the next one 1/11
That’s largely because most reforms fail to acknowledge five key tensions in the way healthcare is run in this country. The urge is to do something radical in one direction, rather than learning to live with them. 2/11
The first tension is between localism and a desire for national control. Accountability mechanisms to exert control come to be seen as sclerotic and bureaucratic. Often they’re followed by calls to ‘liberate the front line’ which then proves to be difficult to control. 3/11
There is a related tension between political, technocratic and clinical leadership. Ministers want may control but find that the levers don’t work very well, this leads to these being strengthened but at the risk of alienating clinicians. 4/11
It’s said ministers think they are getting blamed without being able to control the system. But, blame is centralised, more control increases the probability of blameworthy things. Reforms might be seen more as a defence against this anxiety than a purely rational endeavour 5/11
The third tension is about scale: administrative units that are too small have difficulties dealing with very large providers. But those that are big enough to do this have problems engaging GPs and local councils 6/11
Related to this is the fourth tension: competing geographies. These are usually council boundaries or hospital catchment areas. Choosing one over the other creates tensions that can be difficult to manage 7/11
The fifth tension is that the NHS is overly fond of different change models which address a particular issue but leads to others being neglected and becoming problems that then need solving. New change models can require new structures. 8/11
An example might be that a focus on integration and the removal of activity based payment methods is helpful for a focus on population health – not so good for waiting times 9/11
Perhaps the advantage of the current proposals is that they allow a little more scope for local variation which may offset some of these tensions. Experience suggests that this is often reversed due to anxieties about variation and, it seems, a desire for neatness. 10/11
The pattern is that the enthusiasts for reform were often equally enthusiastic last time. Failing to learn to adapt to these tensions will mean we go round this loop again sooner than we might wish. 11/11
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