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- Author or Editor: David J. Hunter x
This chapter aims to provide the context for the rest of the book, exploring the NHS in 1990 in terms of its organisational structure and dynamics at that time. The chapter proceeds by presenting the background to health organisation and policy in 1990 to provide a starting point for the account of subsequent reorganisations. It explores in more depth attempts at reorganisation during the 1980s in order to construct the ‘shared vision’ of health politics in the 1990s which provides the starting point, and context, for the book’s analysis.
This chapter first considers the programme theory of the effects of the 1990s internal market reorganisation, before taking the story on to the change in government in 1997 and New Labour’s various attempts to reorganise healthcare in the 2000s. It explores the emergence of new approaches to performance management under more central government control, and institutional changes that saw attempts to get local healthcare organisations to work to central targets. It also examines patient choice and the creation of a mixed economy of care.
This chapter considers how Labour put in place a series of organisational changes based around the goal of achieving greater ‘central control’ over implementation (or ‘delivery’, as it became known) during the 2000s. It considers the use of performance management systems in both hospitals and GP surgeries, but with, the authors argue, very important differences that affected the relative successes of such systems in those different contexts. It also suggests modifications to performance management and clinical governance systems in order to improve their effectiveness.
This chapter reviews research on the introduction of patient choice and competition (alongside the introduction of PbR) and the reorganisation of PPI systems within the NHS. It examines the Quality and Outcomes Framework and the conflicts presented between clinical evidence and increased patient choice. The chapter also makes a comparison of the internal market of the 1990s with the mixed economy of care of the 2000s and looks at lessons from public and patient involvement programmes in the 2000s.
Having elaborated programme theories earlier in the book to produce more detailed accounts of what appears to work, and also, under what circumstances, this chapter explores what the elaborated central control and local dynamic programme theories can tell us about NHS reform after 2010. The chapter considers the nature of the coalition government’s reorganisation, and the prospects for it working based on research evidence from previous chapters. It also compares healthcare reorganisation in England with that of the other countries in the UK. The chapter concludes by arguing against the idea that choice and competition are a means of preventing bad care.
The conclusion considers the use of evidence in health reorganisation and what alternative options exist in place of the current healthcare reorganisation. It considers what it means to be concerned about evidence and health reorganisation, and restates the book’s central ideas and findings. It also offers some alternative principles for more successful healthcare reorganisation, and argues for increased involvement of research, evidence and expertise in future healthcare improvement.
Worldwide, policymakers, health system managers, practitioners and researchers struggle to use evidence to improve policy and practice. There is growing recognition that this challenge relates to the complex systems in which we work. The corresponding increase in complexity-related discourse remains primarily at a theoretical level. This paper moves the discussion to a practical level, proposing actions that can be taken to implement evidence successfully in complex systems. Key to success is working with, rather than trying to simplify or control, complexity. The integrated actions relate to co-producing knowledge, establishing shared goals and measures, enabling leadership, ensuring adequate resourcing, contributing to the science of knowledge-to-action, and communicating strategically.
