What can we learn about implementation from previous NHS reforms?

A key test for the ten-year health plan is whether it provides the means to deliver the ends it sets out.

Previous NHS reforms offer both positive and negative lessons on how this might be done. Take the transformation of mental health services from a system centred on large asylums built in the Victorian era, to care based mainly in the community. Advances in treatment and changes in the law and social attitudes facilitated this shift, which began in the 1950s. The number of inpatients fell by 50,000 between 1954 and 1974, facilitated by the growth of residential and domiciliary care in the community - a trend that continued in subsequent decades.

Lessons from experience

A review by The King’s Fund published in 2014 described the transformation as messy, encompassing false starts, dead ends and reversals. Despite these challenges, those leading change learnt from experience and adjusted course accordingly, with beneficial results for many service users. This included allowing scope for local innovation appropriate to the needs of different populations and redesigning how care should be provided, rather than just shifting care to different settings. The importance of providing hospital care for those patients needing it was also acknowledged.

Lessons included the need to fund double running costs and develop a financial framework tied to land sales, dowry payments and new models of financing such as joint finance between the NHS and local government. Linked to this was the importance of investing in new capacity before existing services could be closed and not assuming that services in the community were less expensive than those in hospitals. Another lesson was the value of high-quality and stable leadership and the ability to take a system view of complex changes that involved many participants and organisations.

“Key elements of reform included using capacity in the private sector to treat NHS patients, building independent sector treatment centres, and using financial incentives in the form of money following patients to reward extra activity”

A different example is sustained improvements in access to acute care in the noughties under the New Labour government. These improvements resulted from increased investment and reform of service delivery. Key elements of reform included using capacity in the private sector to treat NHS patients, building independent sector treatment centres, and using financial incentives in the form of money following patients to reward extra activity. The NHS Modernisation Agency contributed by supporting improvements in emergency departments and elective care. By the end of the decade, waiting times had fallen substantially and patient satisfaction approached an all-time high.

These positive examples can be contrasted with attempts to move care from hospitals to the community for people with physical health needs. Recent examples include the ambitions set out in the whit paper Our Health, Our Care, Our Say in 2006 and related developments to promote integrated care in various pilot programmes. At best, these initiatives resulted in small-scale local innovations that failed to shift the locus of care in the direction intended. If anything, the reverse happened with the share of NHS funding going to hospitals increasing and the share allocated to community services declining.

“Moving care from hospitals to the community for people with physical health needs failed because insufficient thought was given to implementation”

The examples of mental health transformation and improving access to acute care illustrate the importance of the means needed to make change happen. In both examples, and with the benefit of hindsight, the means can be characterised as a process of discovering what needed to be done supported by appropriate funding arrangements, rather than implementation of a detailed plan. In the case of acute care, the time required to deliver results was much shorter than mental health but still required a decade before the desired impact became visible. 

Moving care from hospitals to the community for people with physical health needs failed because insufficient thought was given to implementation and how best to challenge power structures within the NHS. The level of ambition was also limited, focusing on pilots rather than whole-system transformation. A major constraint was the inability to move resources from hospitals to the community, fund double running costs where necessary, and ensure that money followed patients to where they were treated.

“Staff are the most important asset within the NHS, and the government should trust and back them to be agents of change”

Delivering the ten-year health plan will require the NHS to work with partners to become an agile learning and continuously improving system. As the NHS Assembly argued in its report on the NHS at 75, staff and local leaders must have the time, space and support to give priority to prevention - care which is personalised and closer to home. It also requires experienced managers to work in partnership with clinical teams in using resources more effectively. 

Staff are the most important asset within the NHS; the government should trust and back them to be agents of change. It should also be realistic about the time it takes for the benefits of change to appear and understand that in a complex adaptive system, reform is often messy and sometimes goes backwards as well as forwards.

Strategic patience at the centre is needed if the next set of reforms are to have the desired impact.

Chris Ham is emeritus professor of health policy and management at the University of Birmingham.