A Medical Device Daily

Another major review of the UK’s National Health Service (NHS), unveiled earlier this month by new Prime Minister Gordon Brown and Health Secretary Alan Johnson, is being positioned by the government as a means of better meeting the challenges of delivering healthcare over the next decade.

But a researcher writing in the British Medical Journal (BMJ) maintains that the review, which is intended to lead to a report prior to the 60th anniversary of the NHS in July 2008, is likely to lead to “confusion, rather than clarity.”

The BMJ article, written by Professor Jeffrey Braithwaite of the University of New South Wales , noted that Brown and Johnson promised an NHS that is “clinically driven, patient-centered and responsive to local communities.” They also pledged to stop giving top-down instructions and ceasing centrally dictated restructuring.

Braithwaite argued that this review “will surely try to reorganize from the top the way predecessor reviews did.”

He said the strong desire by politicians to be seen to be in charge invariably wins over the “weak desire” to be at arm’s length or encourage bottom-up measures, “especially from something that determines votes as much as the NHS does.”

So despite the denials, Braithwaite said, “You can feel it in the air — reorganization is being signaled.”

The evidence indicates that top-down measures and restructuring can cause disarray, he said. Rather than accelerating organizational progress, the BMJ article said research has found that merging can put trusts back by 18 months or more. Research also has shown that the gains in efficiency sought through restructuring “are elusive at best, and may even result in inefficiencies.”

Braithwaite said anecdotal accounts suggest that restructuring is disruptive for most staff, threatening for many, and morale-sapping overall, in part because of the uncertainty created and also because everyone is tired of change.

He said undertaking structural change “clearly sends mixed messages.” Increasingly, there are reports that confusion rather than clarity results from reorganizations; continuously rearranging things exacerbates this, creating bewilderment and even incredulity.

The “delicious irony,” Braithwaite said, is that clinical staff are likely to find their services are more “clinically driven, patient-centered, and responsive to local communities” without restructuring under external pressure.

The NHS review will include an interim assessment this fall before the final report at mid-year 2008.

Brown and Johnson said the “unprecedented” review is “an opportunity to ensure that the future of the NHS is clinically led. The review will involve patients, doctors, nurses and other practitioners, and consider how best to continue delivering improvements across the NHS.”

One of the key points will be to examine how the NHS can provide better access to safer, high-quality care for all, while delivering value for money spent.

In announcing the review, Brown said: “No institution touches the lives of the British people like the NHS. It is part of what makes Britain the place it is. Yet no modern health service that aspires to respond to its citizens’ needs and expectations can afford to stand still. I believe we need to listen to patients’ experience and expectations to forge a new partnership with doctors, nurses and other practitioners.”

He added, “Lasting change can only come from clinicians and staff. We need to do much more to empower staff, to give them the time with patients that they need to improve care, to put them in the lead in developing ideas on improving patient care, and to respect their professionalism.”

The review will be led by noted surgeon Ara Darzi, the new health minister. Among the challenges he will consider:

Working with NHS staff to ensure that clinical decision-making is at the heart of the future of the NHS and the pattern of service delivery.

Improving patient care, including high-quality, joined-up services for those suffering long-term or life-threatening conditions, and ensuring patients are treated with dignity in safe, clean environments.

Delivering more accessible and more convenient care integrated across primary and secondary providers, reflecting best value for money and offering services in the most appropriate settings for patients.

Establishing a vision for the next decade of the health service which is based less on central direction and more on patient control, choice and local accountability and which ensures services are responsive to patients and local communities.