These are the key points taken from Chris Ham’s very interesting  Reforming  the NHS  from within Beyond hierarchy, inspection and markets:

  • It is time to bring about a fundamental shift in how the NHS is reformed, learning from what has and has not worked in England and elsewhere.
  • Politics and policy work on different cycles, which results in short-term political initiatives getting in the way of the long-term policy commitments needed to deliver transformational change.
  • Large-scale structural reforms under successive governments have proved a major distraction and should be avoided in future.
  • Transforming the NHS depends much less on bold strokes and big gestures by politicians than on engaging doctors, nurses and other staff in improvement programmes.
  • A new settlement is needed in which the strategic role of politicians is clearly demarcated to avoid frequent shifts of direction that create barriers to transformational change.
  • NHS reform has relied too much on external stimuli such as targets and performance management, inspection and regulation, and competition and choice, and too little on bringing about improvement ‘from within’.
  • Complementary approaches to reform should be pursued in which national leadership is combined with devolution, collaboration with competition, and innovation with standardisation.
  • Devolution and transparency, based on the collection and open reporting of data on performance, should be used more systematically to improve performance
  • Improvement in NHS organisations needs to be based on commitment rather than compliance, supported by investment in staff to enable them to achieve continuous quality improvement in the long as well as the short term.
  • The experience of high-performing health care organisations shows the value of leadership continuity, organisational stability, a clear vision and goals for improvement, and the use of an explicit improvement methodology.
  • Innovation and experimentation need to be valued more highly in the NHS, with the emerging academic health science networks having a role to play.
  • Clinical leadership must be strengthened to promote standardisation of care, with greater emphasis on peer review and peer pressure to improve clinical practice.
  • Leadership in NHS organisations needs to be collective and distributed, with skilled clinical leaders working alongside experienced managers, and the role of team leaders given much higher priority.
  • NHS organisations need to prioritise leadership development and training in quality improvement methods; this is best done in-house rather than through national agencies.
  • Integrated systems are well placed to deliver the innovations in care that are needed through aligning incentives, learning from international exemplars.


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  1. I think this article misses the whole point, how do you reform something that has been privatised?

    The main issue is surely to get the private sector out of our NHS.

  2. George Nieman says:

    One of the critical things noticed since the change from the old training scheme we had years ago in the training of nurses now shows that the care is no longer as good as it was. Bring back the three year training for nurses, with days for lectures and days for working under supervision within the wards. Get away from the present degree training, it may sound good but in practice it is not

  3. Alison Scouller says:

    There is of course always room for improvement but degree courses do include practice and theory days. I taught student nurses and midwives (and other health care professionals) on degree programmes in university and clinical settings. The programmes interspersed theory with practice and the balance of supervised practical work had been 50:50 for many years and was moving towards more time spent in practice.

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