From the Editor
‘A really useful editorial’
It resembled a telephone directory but on closer inspection proved to be a copy of The directory of NHS management.1 This tome, of nearly 1,000 pages, contains detailed listings of contributors to every management activity of the NHS organisation in England, Northern Ireland, Scotland and Wales. A small random selection of topics by way of example include medical and nursing management, clinical governance risk management, finance, health promotion, complaints, estates, electronic patient records, and training and education. Names and contact details are included with around 150 entries per page which gives a good sense of the scale of the publication.
It is tempting to suggest that the discovery of this directory might have led to the publication of the White Paper Transparency in outcomes – a framework for the NHS.2 Although not obvious from the title, it proposes to cut swathes through the NHS management structure including the abolition of the specialist health authorities and primary care trusts.
Those with some years of experience in the NHS will have witnessed a huge expansion in the management workforce but, in parallel, it does not require experience in medical management to appreciate the huge demands, for example in measuring and achieving numerous centrally imposed targets and the time and effort needed to put in place the financial aspects and controls in the implementation of contracting. What are the realistic prospects for reining in the number of people employed in NHS management and what would be the outcome for the standards and quality of patient care?
Addressing these questions seemed to provide a good opportunity to write ‘a really useful editorial’ where all the government plans for the NHS could be read and the views expressed analysed and summarised so that clear conclusions could be drawn concerning the benefits and risks of the proposed changes. As in so many endeavours (including the current proposals for change to the NHS), this proved much easier in theory than in practice.
A careful review of the evidence suggests that reorganisation has thus far been a triumph of hope over experience3 and there is little evidence to show that it has produced much or any improvement.4 A recent National Audit Office review of reorganisation of central government pointed to high costs, a poorly managed process, an adverse effect on performance, and benefits which were unclear.5 Initial comments from a large range of experts cover a wide spectrum of opinion but overall pervaded with an air of pessimism.6
Some commentators suggest that the health secretary sets too much store by the ability of GPs to make better use of resources7 and that they are driven more by patient-centred values than government targets.8 GPs will clearly need, and wish, to work together to develop the best outcomes for patient care9 but even at this early stage doubts have arisen as to whether the proposed NHS reforms can ever be implemented.10
Much points to the wide gulf between medical and political planning. The medical, and predominantly scientific, approach for any proposed new developments is a controlled study of the innovation compared to the current best treatment followed by a statistical evaluation of the outcome to distinguish differences between the benefit from the new treatment and that which may have occurred by chance. Further small-scale implementation would then follow to determine the benefits and disadvantages before national implementation could be recommended.
The new coalition has to plan, develop and implement proposals, and demonstrate benefits well before the next election is due – a time span of little more than four years. Resistance can always be expected to any new plans so that unbridled enthusiasm is essential to win the day. There is little time for pilot studies or small-scale assessment. Get the main thrust of the proposals in place and then look at the detail during implementation. Resist attempts to derail the proposals: this development, unlike previous attempts, will succeed. Those resisting change are labelled as old fashioned while supporters are seen as forward-looking individuals. There may be some financial advantage in place for groups joining the new approach in the first wave to encourage doubters.
The editorial hasn't quite answered the questions posed at the outset. This outcome reminds me of the road sweeper in our village who would call every year to ask my father to complete his tax returns: ‘I never did learn to read or write but, mind you, I am talented in other ways.’ And indeed he was. The roads in our corner of the village were never as well looked after either before or since his time in the job. The ‘really useful editorial’ may not have achieved its original purpose but has perhaps been valuable ‘in other ways’.
- Royal College of Physicians
References
- ↵ Binley's directory of NHS management. Basildon: Beechwood House Publishing, 2009.
- ↵
- Department of Health
- ↵
- Edwards N
- ↵
- Oxman A,
- Sackett D,
- Chalmers I,
- Prescott T
- ↵
- National Audit Office
- ↵ More brickbats than bouquets?. BMJ 2010;341:228–31
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