Once upon a time it used to be thought that the NHS was unassailable. Even hard-line Conservative ministers came unstuck in their ill-advised attempts to persuade the public that better healthcare systems were available. But under New Labour, the NHS has never looked more frail and vulnerable.

The cruel paradox is that this is occurring at a time when longoverdue investment in the NHS is at last beginning to happen.

Conceivably, the government may have concluded that life in the NHS had become unacceptably comfortable, with successive reforms - however radical in appearance - having made little impact on some deepseated problems. There is a respectable school of thought which holds to the view that successful organisations manage on the edge by deliberately fostering a sense of crisis and choosing a strategy of destabilisation and dissonance.

Healthcare has been labelled the most entrenched, changeaverse enterprise - and not just in the UK. An article in the Harvard Business Review last autumn suggested that US 'healthcare is now ripe for disruption'.

1The authors argue that the transformation of healthcare to allow less expensive professionals to do progressively more sophisticated things in less expensive settings is long overdue. These objectives lie at the heart of the NHS plan, if not stated in so many words. The technology exists to allow such a transformation to occur immediately and safely. The resistance comes from those stillpowerful professional clans who feel most threatened by it.

The solution to the deep-seated resistance to change that is a feature of all healthcare systems, regardless of their funding and organisation is the deliberate introduction of disruptive innovations to allow a systemic transformation of the kind sought to occur. It is unlikely that the government is working to a deliberate strategy crafted along these lines.More likely, it has stumbled upon the position in which it now finds itself. But if ministers are not to mess up the opportunities their modernisation project has made possible, how they respond from now on becomes the critical issue.

If it all goes horribly wrong, the result could well be the destruction of the NHS under the glare of an often irresponsible media which will have contributed to its downfall. It could be interpreted as a case of just deserts for a government so obsessed with media management that it failed to see the consequences of its actions.

Demonising doctors, maligning managers, and introducing new performance targets or hitsquads for every local difficulty that has a media spotlight thrown upon it are precisely the wrong tools to effect real change.

It could all look, and be, so different.Were a fresh approach and style of leadership from the top forthcoming, then the welcome disruptive innovations contained within the NHS plan could succeed in transforming the NHS and strengthening public support for it.

First, if we are serious about tackling the upmarket drift in the NHS, where more and more specialised treatments aimed at fewer and fewer patients are carried out while the needs of average patients get overlooked, new investment should be targeted at those technologies that simplify complex problems.

Second, new organisations may need to be created to do the disrupting. For example, care trusts could provide a vehicle for radical change but will fail miserably if subjected to stifling bureaucracy of the kind likely to envelop primary care trusts.

Third is avoiding the inertia of regulation and overbearing performance management. All too often, such well-intentioned efforts to bring about organisational improvement can reinforce and sanction a risk-averse culture.

Finally, leadership is of paramount importance. Not leadership of the mechanistic, brow-beating type perpetrated by the government. Instead, ministers must stand back and facilitate disruption by supporting those at local level who are, at the end of the day, the only sustainable agents of change.

Potential leaders locally have become paralysed by a corrosive political climate, which has progressively denigrated their contribution and abilities.

Leaders with vision will not tolerate for long such an environment.And so it has proved.Many have already exited.

What remains so puzzling is that ministers appear hell-bent on a course of action that may well destroy the NHS. The tragedy is that few dare speak out in an attempt to rescue the service from such an ill-deserved fate.

REFERENCE

1 Christensen CM, Bohmer R, Kenagy J.Will Disruptive Innovations Cure Health care? Harvard Business Review 2000; September-October: 102-112.