The NHS is being reorganised—again. Having declared on taking office in 1997 that it recognised that the NHS had suffered too much structural reform, the re-elected Labour government has embarked on the largest, and least debated, reorganisation of the NHS for two decades.1 A consultation document, “Shifting the balance of power in the NHS: securing delivery,”2 published in July proposed abolishing the executive regional offices of the NHS and two thirds of health authorities and creating new primary care trusts to take on a raft of responsibilities from health authorities. Only the acute NHS trusts emerge from these changes relatively unscathed. The consultation, which lasted six weeks, closed in early September and the government has yet to publish its results. But the reorganisation is steaming ahead regardless, with the aim of completing all the changes by April 2002. Few people outside the NHS management community seem to be aware of the exact nature and implications of these changes, which have their roots in growing public and political impatience with the quality of NHS services.

From two recently published surveys 3 4 it appears that …

https://www.bmj.com/content/bmj/323/7324/1262.full.pdf

The "redisorganisation" of the NHS: another reorganisation involving unhappy managers can only worsen the service

The Government's proposals to create new ‘foundation hospitals’ are moving forward rapidly, despite considerable political opposition not least within the Labour Party itself, and deep scepticism about the ideas in many quarters of the National Health Service and the professions. Advocates claim they will lead the way to a new understanding of public services and public ownership, ‘set the NHS free’ from the iron grip of Whitehall control, and make health services more accountable to and responsive to patients and local communities1. Critics argue that the ideas are, at best, a half-baked, reheated version of NHS trusts launched in the early 1990s2. At worst, they assert, foundation hospitals are the start of the break-up of the NHS, a creeping form of privatization that will undermine the fundamental values of social solidarity, care according to clinical need rather than ability to pay, and equity in healthcare provision on which the NHS was founded. Although the necessary legislation has yet to be passed, the Government has already issued a prospectus for potential applicants for foundation status, and set out a timetable that would see the first foundation hospital identified this year and coming into being in April 20043.

This paper examines the case for foundation hospitals, and tries to set it in the wider context of health policy development and NHS reform over the past two decades. It argues that there is a need for a fundamental change in the systems for governance and accountability in the NHS and examines how the creation of foundation hospitals might help to meet that need.

https://journals.sagepub.com/doi/pdf/10.1177/014107680309600302

Foundation hospitals: a new direction for NHS reform?

The aim of New Labour's health policy is to shift more of the balance of power and responsibility for services to the local level. But, while the government proclaims a new decentralized NHS, doubts exist about the extent to which the reality on the ground matches the tone of policy. This article reports empirical work examining the level of autonomy purchasers have over budgetary allocation. A case study analysis of purchasing within a single district was undertaken for the financial year 2001/2 which included semi-structured interviews with key officers responsible for budget allocation. Purchasers approach a new financial year with a starting position that matches the previous year's allocation—the “baseline”, this is adjusted for inflation and, as has happened over the last few years, increased further in real terms by “growth funds” for service modernization and government initiatives. The analysis shows a clear dissonance between policy and practice; although purchasers have complete control over their “baseline budgets”, the study found that this does not “ring true” at the local level. Only about a fifth of growth funds were at the discretion of purchasers as most are taken by national priorities and pay and price inflation. Further decentralization is planned, which includes transferring more control of funds to primary care trusts by 2004, the extent to which these measures will change the perceptions of those working in the service remains to be seen—only then will the government be able to claim a truly decentred service.

Decentring the NHS: A Case Study of Resource Allocation Decisions within a Health District

Recently, the career changes and challenges facing managers have gained almost critical mass. From modernisation to The NHS Plan, from the Learning from Bristol report to Shifting The Balance Of Power, it seems the only constant is change. Change which will make or mar the NHS' future. How well conceived are the new plans? Is there meaningful consultation? What will be the effects on the future career of managers? Is there a forum for dialogue and discussion, when new ideas are felt to be unwise, ill-founded or just plain wrong? Can managers feel free to speak out if they wish? In a desire to see these questions given due attention, British Journal of Health Care Management has asked a range of experienced figures to voice their concerns. A commentary on these views is given by respected US health care academic Professor Ted Marmor (who will give December's Rock-Carling Lecture).

Allyson Pollack

Papers

Across the great divide: discussing the undiscussable