How do chief executives feel about the latest NHS reorganisation? A survey of reactions to Shifting the Balance revealed some disturbing findings.

Kieran Walshe and Judith Smith report Managers are the foot soldiers of reform in the NHS. It is their job as public servants to implement the government's policy agenda, and to make it work as best they can.

No government over the past 20 years has been able to resist the temptation to reorganise the NHS in search of better structures and systems, and on each occasion managers have been in the front line of change.

1,2 For example, in the early 1990s, managers took the Conservative administration's proposals for GP fundholding, trusts, and the internal market and made them a reality.

Even though many managers had deep misgivings about the reforms, they made them happen.

But no-one knows more about the organisational realities of the NHS than managers, nor is anyone better placed to predict the likely effects of reorganisation on the things that really matter - improving health services to patients. In July, the Department of Health published a consultation document Shifting the Balance of Power in the NHS:

securing delivery, which sets out radical proposals for restructuring the NHS in England.

3 As the NHS moves into yet another reorganisation, Birmingham University's health services management centre and HSJ undertook a survey of chief executives to find out what they really think about the proposals and their likely effects.

Shifting the Balance proposes many changes, but the main ones are:

The abolition of the NHS Executive's regional offices and the creation of four new regional directors at the DoH.

The replacement of the current 95 health authorities with about 28 much larger strategic health authorities that will take on many of the functions of the regional offices.

The transfer to primary care trusts of many health authority responsibilities, with PCTs being created where they do not yet exist.

The brief consultation period for these reforms ended on 7 September, but their implementation has already started.

The main changes are meant to be complete in six months, by April 2002, even though some require primary legislation.

We undertook a rapid survey of all chief executives of NHS organisations in England, using a two-page postal questionnaire.

Over two weeks in early September, we received responses from 304 chief executives - 36 per cent of those approached.This is a very good return rate, given that the survey took place at the end of the holiday period and most chief executives had less than 10 working days to respond.

The questionnaire was sent personally to chief executives by name, and was entirely anonymous and confidential.

Signed up to change?

Chief executives were asked to describe what they saw as the benefits and drawbacks of the Shifting the Balance proposals, and the box opposite summarises their responses.Opinion was mixed, with most identifying both real strengths and significant weaknesses (though chief executives of primary care groups and PCTs were more positive about the changes than those in HAs or trusts).

On the one hand, most praised the plans for moving power and responsibility closer to the front line of clinical care by enhancing the role of PCTs. But many were also concerned about whether PCTs had the managerial capacity and leadership to fulfil those raised expectations, and could continue to focus on their primary care responsibilities.

They supported the planned reduction in management tiers and costs but were worried about the human impact on staff facing job changes or redundancy, and the impact on managerial capacity and continuity.

They were concerned about the scale and pace of change and its impact on service delivery, and felt the proposals lacked clarity and were not fully thought through.Overall, many believed reorganisations often promise more than they deliver, and the NHS had seen too many structural reforms over the years.

What it means for primary care PCTs are clearly the linchpin of the Shifting the Balance reforms. They assume the majority of functions previously carried out by HAs while taking forward the already challenging set of responsibilities defined for them.

Over three-quarters of chief executives cited this transfer of power and decision-making from HAs to PCTs and clinicians as being a strength of the reforms.

This general enthusiasm is underlined by the comment of one chief executive: 'Shifting the Balance offers a significant opportunity to make a difference locally - it is a challenge we should relish.'

But almost half (45 per cent) of respondents were concerned about PCTs' ability to cope with an enlarged set of responsibilities.

Their concerns typically related to the organisational immaturity of PCTs; the relative lack of management capacity and resources available to PCTs; and doubts about the wisdom of relying on GPs and other professionals to make these reforms work when there are doubts about many clinicians' support for the changes.

These worries were articulated by one chief executive: 'Many of the smaller PCTs and some of the newly appointed chief executives are not going to be able to deliver the new agenda.

'It is crucial to tackle this issue and not wait for organisations and individuals to fail.'

These anxieties about the capacity of PCTs, and their ability to keep professional staff engaged with PCT work, echo the findings of two recent evaluations reporting on the progress of PCG/Ts.

4,5 It is clear that despite significant support for the idea of PCTs as champions of the health community, there are real concerns about the capacity of these organisations to meet the challenges expected of them, at least in the next 12 months.

The pace of change - too far, too fast?

Many chief executives raised serious concerns about whether the NHS could cope with the scale and pace of change involved in the Shifting the Balance reforms, especially at a time when it was being asked to meet the demanding targets for service improvement set by the NHS plan.

For example, one chief executive said:

'Governments never learn that reorganisations disrupt delivery, demotivate staff and usually fail in their stated objectives. A programme of sustained development and performance management based around the NHS plan would have been far more likely to achieve the government's stated objectives.'

Another commented that 'the NHS plan was and is an excellent document to which most staff in the NHS can sign up. To follow it up with such massive structural change so quickly is a major disincentive to progressing the plan. It is a huge shame'.

As figure 1 (overleaf ) shows, three-quarters of chief executives believed the Shifting the Balance reorganisation would delay the delivery of the NHS plan over the next year or so, and a quarter thought the delay would be severe. But in the longer term of the next one to three years, chief executives were more optimistic, with most (57 per cent) thinking delivery would be improved.

The breakneck pace of change is illustrated by the fact that even though the consultation period on the reforms had not ended as our survey took place, most chief executives reported that they were already deeply involved in implementing the Shifting the Balance reforms.

On average, chief executives indicated that they were spending 25 per cent of their time on implementation (40 per cent for HA chief executives) and 69 per cent said they had already been working on implementation for weeks or months.

One chief executive observed that 'policy-making has been rushed and is inadequately informed by understanding of how the NHS ticks'.Another said there was a 'need for a more measured pace if lasting, carefully thought-through reforms are to be achieved'.

Will it save money?

The Shifting the Balance consultation document indicates that the government expects to save£100m a year in management costs through the reforms - presumably because there will be no NHS Executive regional offices and the number of HAs will be reduced by two-thirds.

Chief executives broadly welcomed this aspect of the changes - seeing both the lower management costs and the reduced oversight from above by regional offices as positive developments.

But many were not convinced that the savings would actually materialise, and some argued that the changes actually demanded a greater investment in management capacity in other NHS organisations like PCTs - which ran counter to the demand for management savings.

Moreover, it was clear that in the short term Shifting the Balance would cost money, not save it. First, most chief executives and their senior managers were already investing a substantial proportion of their time in planning for the reforms, with a significant opportunity cost to other priorities.

Second, there will be considerable one-off costs involved in winding down HAs and other organisations, setting up new ones, transferring staff, changing offices and so on. Based on returns from chief executives, we estimate that these costs alone will be over£200m in the coming months.

As with all restructuring of large organisations, there are human as well as financial costs. A fifth of respondents reported that they viewed the human resources implications of the Shifting the Balance reforms, and in particular the likelihood of the NHS losing good and experienced people at a time when the NHS plan is being implemented, as an important weakness.

One chief executive noted: '[The reforms] have been introduced at a most critical time in terms of delivering the agenda, and are naturally making organisations and individuals focus on survival and not on delivering the future.'

The human implications of the reforms are underlined by the fact that over one-third of the The human cost of change chief executives responding to our survey were not planning to work in the NHS as a chief executive in the future.When asked to be more specific about their career plans, 15 per cent were considering or planning to move to a post outside the NHS, 14 per cent were considering or planning early retirement, and a quarter felt they were now less likely to be working in the NHS in five years' time.

These figures are all the more worrying when considered alongside the enormous management and leadership challenge facing the NHS.

If PCTs are to deliver on their daunting responsibilities, and SHAs are to quickly develop and shape a new role as strategic leaders and performance monitors across health economies, they will all require experienced, confident and skilled chief executives.

Organisations better by design?

The Shifting the Balance reforms are based on the implicit assumption that structural change will bring about improvements in the performance of the NHS. Indeed, a fifth of the chief executives saw the reduction of management tiers brought about by the reforms as offering the potential for clearer accountability and performance management, both in relation to PCTs and to trusts. A further 21 per cent saw the reform process as offering a wider view of health and social care, with a greater public health focus being located within PCTs.

These apparent strengths of the new arrangements were, however, countered by a concern expressed by a further fifth of chief executives about a lack of clarity over the future location of many HA and regional office functions. The lack of clarity was seen as being particularly acute in relation to the proposed new regional arrangements, and the exact nature and purpose of franchising.

But it seems risky to expect that rapid and widescale structural reforms will bring about meaningful cultural change. As one chief executive pointed out: 'The supposition that structural reform will enable service reform is contrary to the available evidence, and may prove to be a real distraction to implementing the NHS plan.'

It is clear many chief executives believe the cultural and behavioural change seen by the DoH as being necessary to implement the NHS plan could have been achieved without the destabilising effects of such major structural change in the NHS.

Shifting the balance of opinion?

At the end of our questionnaire, chief executives were given the opportunity to make any general comments they wanted to, and a surprisingly high proportion (170, or 56 per cent of respondents) did so.As figure 2 (opposite) shows, less than a quarter of those comments were positive about, or supportive of, Shifting the Balance.Alarmingly, most (55 per cent) of chief executives expressed negative or critical views of the reforms.While there was some variation across different types of NHS organisations (for example, 34 per cent of PCT chief executives made positive comments, compared with 15 per cent of HA chief executives), across all sectors there were more than twice as many critical or negative comments as supportive or positive ones (see box, right).

Looking to the future Some might wonder why, if senior managers are so unenthusiastic about the Shifting the Balance reforms, they have not voiced their concerns more openly.

The straight answer is that, in the current climate, to do so would put their future careers at risk. Chief executives are expected to be cheerleaders for the reforms, not critics.About 59 per cent of our respondents think their own job will change in these reforms - and those who want to stay as chief executives cannot afford to be seen as disloyal.

But as our survey shows, many feel torn between their loyalty to the NHS and their commitment as public servants to do the government's bidding, because they believe these reforms will damage the NHS.

As one chief executive observed: 'I embrace change and believe we live in a changing world. I am always positive but on this occasion I believe we have got it wrong and are making change for political gain rather than to improve the NHS.'

Chief executives and other senior managers understand the NHS and how it works better than anyone else.

They have extensive experience of previous restructuring, and if the government ignores their concerns about the reforms, it takes a considerable political risk in doing so.

It is unlikely that, having got so far down the road, the government is going to make any significant change to the direction of these reforms - and indeed some of the ideas such as greater devolution of power to PCTs have been widely praised.

However, much more needs to be done to secure and sustain support in the NHS for these reforms.

First, the government needs to lower public and political expectations of service improvements in the NHS over the next two years or so. It is naive to believe that the service can continue to deliver challenging NHS plan targets while this reorganisation is under way, and the sooner some of those pressures are lifted, the better. Second, the timetable for the reforms needs to be more realistic, with some space for dialogue, open debate and organisational development.

Rather than demanding change through administrative diktat, ministers need to engage the service in meaningful consultation and win back hearts and minds.

Third, there needs to be more flexibility and opportunity for experimentation.What looks, at present, like a centralised organisational blueprint needs to become something more enabling than restricting - a set of general principles which allow for local variation and innovation, and which are more concerned with changing NHS culture than rearranging the structural furniture.

Ministers and policy-makers would do well to remember that if the NHS has failed to deliver significant service improvements in three years' time, when the next election looms, voters will not be interested in whether or not it has been restructured.

If this reorganisation means that services have not improved, or have even deteriorated, there will be a high political price to pay.


1 Wa l l A . Icebergs and Deckchairs: organisational change in the National Health Service.London:

Nuffield Trust, 1999.

2 Brown RGS. Reorganising the National Health Service:

a case study of administrative change.

Oxford: Blackwell, 1979.

3 Department of Health.

Shifting the Balance of Power in the NHS: securing delivery.London:

Department of Health, 2001.

4 Wilkin D, Gillam S and Coleman A (eds). National Tracker Study of Primary Care Groups and Trusts 2000/2001: modernising the NHS? Manchester:

NPCRDC. University of Manchester, 2001.

5 Regen E, Smith J, Goodwin N, McLeod H, Shapiro J. Passing on the Baton: third stage report of a national evaluation of primary care groups and trusts. Birmingham: Health Services Management Centre. Birmingham University, 2001.

'The most ill-conceived set of changes in a decade': the view from the top 'After witnessing 20 years of governments reforming the NHS by merging, devolving and changing management tiers- I wonder when politicians will realise this is not the answer to improving health and that many babies are thrown out with the reorganisation bath water.'

'The fundamental issue is that organisational change is an attractive substitute for the behavioural change that is needed to ensure the government's modernisation goals.'

'This is the most ill-conceived, poorly thought-through set of changes in decades.Is the plan to torpedo the implementation of the NHS plan? The impact on senior and middle managers within the service has been very detrimental.'

'This is my sixth reorganisation in a 30-year career in the NHS.I have always responded positively to change previously.However, these proposals are a recipe for disaster - a blend of lack of insight, ineptitude and disregard for staff at all levels.'

'I've been in the service 11 years, and I reckon this is something like my seventh organisational change.When will we learn that shifting the deckchairs doesn't 'secure delivery'- it endangers it? Wholesale change takes up huge resources - time, effort, money and morale.We need to focus it on the clinical/health improvement agenda, not on internal structures.'

'These reforms are a gamble - they may or may not work.Either way, they will inevitably result in more structural changes within the next five years.The government should not implement such risky and costly changes without much clearer analysis and assessment.They... presume structural change can deliver service improvement when the NHS clearly needs more resources.'

'As with all/most reorganisations, short-term costs will be significant and any longterm benefits may not be causally related to the structural changes.'

'This is the most exciting reform in years and holds the potential to change the way the NHS does things and meets health need (not just services).Concerns about capacity and pace.'

'Huge enthusiasm for the direction of travel, but I am concerned that we need to pay more attention to culture rather than structures, and yet currently focus is on latter.'