UNIVERSITY CHALLENGE

For a government ostensibly attracted to evidence-based policy, ours has a curious way of demonstrating its enthusiasm.

In at least two key areas of NHS modernisation, the government seems intent on ignoring any potentially useful lessons which evidence-based policy might yield.

First, the evidence from successive NHS reorganisations since the early 1970s is unequivocal concerning the limited value of tinkering with the structure and configuration of health agencies.

Three key messages stand out:

invariably, unrealistic expectations fail to be met;

the costs of reform are always higher than forecast, both financially and, more importantly, in human terms following an exodus of valuable, and often irreplaceable, skills and expertise;

changes never save money - they almost always cost more.

The principal lesson from any attempt to change the culture of an organisation, as distinct from its structure, is that for real, sustainable change to occur critical sections of the organisation have to remain stable. It may be a paradox but it is nevertheless the case.

Yet the government has embarked upon the most significant root and branch reform of the NHS structure since its genesis. Back in 1997, it did not appear to anticipate such dislocation and upheaval. It seems to have been a case of one thing leading to another in a rather ad hoc, piecemeal way.

Whatever the motive, attending to the evidence base and seeking to learn lessons from the experience of undertaking massive organisational change has not figured in the government's treatment of the NHS.

It is a high risk strategy and the consequences of failure will be profound. Indeed, a likely outcome could be the death of the patient that the reform effort is designed to save.

The second area where evidence exists to guide policy concerns the means chosen to make the NHS more effective. As elsewhere in the public sector, the government has pinned its hopes on a raft of targets and performance indicators driving up performance, as managers and practitioners jump to attention to deliver on them.

There is an impressive amount of literature on the shortcomings of such an approach, none of which appears to have registered with the government or its advisers. This apparent unwillingness to listen to counterargument and the tendency to brush aside any criticism has led to hopelessness and deep malaise in the NHS.

Few of those intimately involved in steering the NHS through this Byzantine change process believe the NHS plan will succeed - of course, they cannot say so publicly. The government may dismiss such a reaction and regard it as justifying the vigour of its change agenda.

But it is not so simple. Critics of the government's style have a great deal of sympathy with what the plan is seeking to achieve.

Their grievance is with the means of bringing about that change.

Thirty years ago, in a remarkable book that repays study, Donald Schon wrote about government as a learning system - by which he meant the capacity of governments to undertake a continuing, directed inquiry into the nature, causes and resolutions of new public problems.

1The process involves discarding structures and mechanisms that have grown up around old problems.

The Labour government has correctly identified new public problems, including those facing the NHS, but it is stubbornly applying old solutions to them.

The guru of total quality management, Deming, advises scrapping numerical targets, quotas, annual appraisals and management by objectives in favour of leadership and support for people making difficult decisions. That way, quality will improve and people trusted to do a good job will do one.

It is no good looking to NHS employees to occupy the dissenting vanguard roles that are needed. They feel too threatened by established interests who insist on making policy and imposing their view of the world on them.

We need to look to those in more marginal positions to occupy the roles of prophet, artist and critic in the hope that by articulating the flaws in current models of reform their insights will begin to penetrate the apparent arrogance of those making policy.

So far, the government has refused to budge. But for how long can it remain wedded to a position that is self-evidently ignorant of the available evidence?

Regrettably, long enough for irretrievable damage to be done to the NHS. We are witnessing the unfolding of a Greek tragedy of epic proportions.