Delivering a healthy improvement – lessons from reforming the UK's National Health Service

We all know what it's like to experience ill health, but for most people the need for a prolonged stay in hospital is thankfully far less common. That said, here in the UK we have the National Health Service (NHS) to fall back on. Since its creation in 1948, it has provided the British people with cradle to grave healthcare, (mostly) free at the point of use. It remains an intrinsic part of British society, woven so deeply into its fabric that Lord Lawson famously observed that "the NHS is the closest thing the English people have now to a religion".

And politicians continue to tamper with the way in which the NHS is organised and governed. Partly this is down to any politician's wish to leave a sustainable legacy from their time behind the ministerial desk. It's human nature. You want to make a positive impact in any job you do. But there are good ways and bad ways to go about implementing change - particularly when you're dealing with an institution as large, complex and sacred as the NHS.  The reform programmes of 2000 and 2010 show how, and how not, to do it - particularly when viewed through the prism of CPI's Public Impact Fundamentals.

Legitimising a plan of NHS transformation

In the year 2000, Tony Blair's government was three years into its first term. Although enjoying positive opinion poll ratings - it would be re-elected with a second successive landslide victory the following year - the poor state of the NHS was a looming iceberg on the horizon. Hospitals were often grim environments and seemingly stuck in the 1940s. Waiting, too, was an unwelcome fact of life - you would have to wait more than 18 months to be admitted for an elective operation - a statistic which fared poorly when compared with the performance of health systems of other countries. Focus groups also highlighted long waiting times for access to the NHS as one of its major weaknesses, which justified the legitimacy of a reform programme to tackle this problem.

Fast forward 10 years and another government was in charge. The coalition government recognised the malaise of successive "redisorganisations" by the previous administration, and so in its programme for government it promised that "we will stop the top-down reorganisations of the NHS that have got in the way of patient care". This promise resonated strongly in both the media and focus groups.

Andrew Lansley's reform plans on coming to office in 2010 were, however, described by the then NHS chief executive, Sir David Nicolson, as so big "you can see them from space". This was part of a proposed major change in governance that aimed to shift the balance of power in the NHS to give GPs more say over the way budgets were spent. Unfortunately, as these proposals contradicted the promise on reorganisation, they lacked legitimacy. They also meant that managers would be preoccupied with the uncertainty of their future careers rather than addressing how the NHS could best cope with austerity.

Making friends, making enemies

How, then, did these two approaches differ? Blair was determined to turn aspiration into implementation and so he turned to his close ally, health secretary Alan Milburn, to transform the NHS. His plans introduced a new system of annual performance "star ratings" (described in the NHS Plan as "traffic lights"). This fundamentally changed the system of sanctions and rewards. No longer did the system reward hospitals' failures to achieve waiting time targets by giving them getting extra money; instead, such failures resulted in their being “named and shamed” and their chief executives threatened with the sack.

What the Millburn and Lansley plans had in common was that both were bold and aimed to be transformational. Where they crucially differed was that Milburn and his colleagues sought - and received - successful stakeholder engagement during the process. Indeed, the British Medical Association, all the Royal Colleges and many others were so firmly on board that they cosigned a preface to the plan, agreeing to commit to a transformation in performance.

Lansley, however, received an array of criticism from stakeholders large and small: the changes were opposed by every professional body, as well as patient groups, unions, think tanks and the other political parties. This was a consequence of the lack of stakeholder engagement.

The results

The contrasting results of the two reform programmes are striking. By 2008, the time you would wait for an elective operation after seeing your GP had fallen dramatically to just 18 weeks. By contrast, Lansley's idea that provider competition will drive future change in  the NHS  was abandoned in 2014 as unworkable, and regrets and blame flew thick and fast.

These are just two examples and doubtless the performances of both reforms are rooted in a myriad of complex factors. But what is clear, however, is that any reform is far more likely to succeed if it meets a demonstrable need and enjoys the backing of its key stakeholders - lessons that Andrew Lansley should perhaps have heeded prior to embarking on his own transformational journey six years ago.

FURTHER READING

• Picking the policy that will have the greatest impact. Overcoming the barriers to policy implementation involves not only the setting of priorities and ambition but also defining what outcome is actually intended, says Sir Michael Barber

• Action stations: advancing to impact. Beth Blauer explains why management, measurement and alignment are critical to the successful transition of a policy into real-world effect

• Recognising and renewing governments' legitimacy. Preserving their legitimacy in such a fast-     changing world should be a priority for governments the world over, says Maryantonett Flumian

• Reform reflections: Dame Una O'Brien on improving the NHS. Dame Una O'Brien's long civil service career culminated in five years leading the Department of Health, a role that directly affects the day-to-day lives of British citizens like few others. She tells us about her experiences and the shape of things to come

• Creating the right investment climate for UK health research. Health research doesn't just deliver new medicines and technologies to tackle killer diseases, explains Mark Samuels of the National Institute for Health Research. Its public impact also extends to the wider economy