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Reflecting on NHS reform

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Admit it.  For all the paperwork they harassed you with,you'll miss your PCT, even if only because you knew what you were getting.  It's too late to send your farewell card -today they are gone.

I worked for 8-weeksat the Department of Health during 2010 when NHS reform was beingconceived.  I've followed the bumpy pathof its implementation with interest.  Nowseems the right time to reflect on the changes.

The reforms are a top-downreorganisation of the NHS by a coalition which promisedthe opposite.  They are a meddlingwith what has been called a national religion, led by a government believed tohave a poor record managing the NHS.  Controversy was expected, but not to theextent that emerged.

Part of the problem was thatAndrew Lansley is a nuts-and-bolts kind of guy. He had an intricate knowledge of the NHS, having been shadow healthsecretary for longer than any of his predecessors.  You get the impression his plans had beenincubated for years, and he was itching for them to be implemented out of agenuine desire to build what he believed to be a better health service.

It led to two problems.  First, poor communication.  Nuts-and-bolts aren't inspiring.  People are sold on a vision, not on theintricacies of how it will be implemented. Hence Lansley was replaced with the polished Jeremy Hunt.  The second was a speedy implementation that knockedthe wind out of key medical organisations and the public, eventually leading toa ‘pause'.

The resulting controversy forcedthe department to become defensive.  Theapproach shifted from actively driving change, to meekly trying to squeezethrough what could be.

It meant compromise andconcession.  GP consortia became ClinicalCommissioning Groups.  The ideas aroundcompetition were scaled back.  The tenStrategic Health Authorities abolished to remove bureaucracy were replaced by 31offices of the NHS Commissioning Board (now NHS England).

The concessions risked dilutingthe reform so that it achieved nothing more than throwing the NHS into the air, with everything landing in different places with different names.  But I don't think that's happened.  The key elements of the reform remain:clinician-led commissioning, an independent board to protect the NHS frompolitical meddling and local authority responsibility for public health.

My main concern is the assumptionthat clinicians will be competent commissioners.  Buying healthcare and delivering healthcareare very different things.  There's also arisk CCGs may think it all too much bother and employ private consultants instead.  This would just recreate a more fragmentedand privatised version of PCTs.

But it's helpful to keepperspective.  As is often the case, the trueversion of the reform lies somewhere between the unctuous praise by government,and the fears of death and destruction propagated by the media.  Put that way, it doesn't seem so bad afterall.

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