News

Lost in Translation-what has happened to the Government’s NHS plan?

(16 September 2004)

Although the Government’s plans for modernizing the NHS have achieved important improvements, it is unclear whether these are sustainable in the longer term.

According to a report published by the University of Durham, Lost in Translation: a commentary on Labour’s health policy four years into the NHS Plan, it remains to be seen whether the Prime Minister’s high-risk strategy of ‘disruptive governance’ will deliver the desired outcomes promised in the original NHS Plan published in 2000.

The report’s authors are Professor Sir Kenneth Calman, Vice-Chancellor of the University of Durham and former Chief Medical Officer for England, Professor David Hunter, Professor of Health Policy and Management, University of Durham, and independent researcher, Annabelle May.

They maintain that

‘rapidly changing policies and alterations of agreed policies makes it, on occasion, impossible to see the way forward and properly manage the implementation of new developments’. They go on to argue that

‘rather than constantly creating and dismantling new organizations, the government needs to align its current policies and structures – defining responsibilities, introducing appropriate financial incentives, and clarifying accountability arrangements in order to shift the focus away from processes and management and towards outcomes and quality’.

They claim that

‘politicians have consistently underestimated the damaging loss of capacity in the NHS caused by constant reorganizations, and appear to have ignored the very high transaction costs’.

The report comments on three main areas of policy:

• Health inequalities and public health
• Regulation and inspection
• Public and patient choice and involvement.

Among the report’s key messages are the following:

• The government’s new-found commitment to tackling health inequalities and improving the public’s health is welcome. But it must show that it is as committed to this change agenda as it has been to tackling waiting lists.
• The tension between individual choice and the public interest could undermine efforts to give priority to public health initiatives and narrowing the health gap. Where appropriate, the government must adopt a more interventionist role in order to create the conditions for a healthier population.
• The centre needs to develop a coherent policy framework, with all government departments working together on cross-cutting health issues.
• The pitfalls of the ‘target culture’ are recognized. Despite targets having achieved tangible improvements in some areas, they now risk becoming increasingly counter-productive to good management and the exercise of professional judgement.
• To those in the field, the weight of targets and inspections has been perceived as punitive and excessive, while the impact on the workforce has been negative and dysfunctional.
• Having more doctors and nurses without at the same time changing the way they work will not achieve the government’s policy objectives for an NHS that is not hospital-dominated, is patient-centred, and integrated across professional and organizational boundaries.
• Uncertainty persists around the future structure and number of PCTs and SHAs. But further structural change is not an effective tool if deep changes are sought in organizational processes and culture.
• The future of an improving NHS demands a better balance between measurement, good outcomes, and actual patient and staff experiences. The centre should clearly establish the direction of change, set boundaries, and allocate resources without specifying in detail how to use them, allowing managers and professionals to innovate and to share learning and good practice.
• The patient focus set out in the NHS Plan is in the process of changing the NHS culture for the better. But the government’s approach is not strategic but based on ad hoc initiatives that ultimately risk being self-defeating.
• There needs to be a much more rigorous appraisal of the concept of choice: What choice? For whom? Will it widen the health gap? There are limits to choice, including issues of capacity, the collective good, and the existence of information asymmetry. The pursuit of choice at all costs is ill-considered and risky and could widen health inequalities. The Government must be sensitive to these dangers.
• It is unfortunate that incoherent policies and what appears to be an underlying lack of commitment at the centre have frittered away much of the initial trust and goodwill surrounding early patient and public involvement initiatives. With the Commission for Public and Patient Involvement now abolished, there is a vacuum at national level. The public still needs an independent and authoritative voice at national level.

The report is a follow-up to two earlier critiques published in 2002 and 2001 respectively. Its analysis and conclusions are the product of a series of discussions among a group of senior clinicians, managers and academics. An earlier draft of the report was also discussed at three regional seminars to which NHS staff were invited together with patient group representatives. The seminars were supported by the Nuffield Trust. The production of this report has been supported by the Joseph Rowntree Reform Trust.


Note to Editors

1.Copies of this report, and the two earlier reports, may be obtained by contacting Christine Jawad, School for Health, Wolfson Research Institute, University of Durham Queen’s Campus, University Boulevard, Thornaby, Stockton on Tees TS17 6BH, tel: 0191 334 0360; email: Christine.Jawad@durham.ac.uk.

2. For further information about the report please contact Professor David Hunter:
Office: 0191 334 0362 (direct line); 0191 334 0360 (PA)
Mobile: 07802 501042