news focus - Reorganisations and upheavals

As Parliament prepares to enshrine in law the latest in a long line of NHS reorganisations, Laura Donnelly overcomes a sense of deja vu and wonders what is so good about this year's model

'I think they are in danger of disappearing up their own fundament, ' suggests one former - very senior - official of the Department of Health, deploying the sort of language which only a civil servant of the old school could use.

He is talking about those behind the current structural reorganisation of the NHS. And our source is not alone in his view.

For civil servants and managers whose memories pre-date New Labour, the proposals in Shifting the Balance of Power in the NHS - or Shifting the Deckchairs, as it is increasingly known - are not just alarming, but alarmingly familiar.

It is not just the themes - giving power to GPs, increasing competition and patient choice - but also the process which led to yet another shake-up of NHS management, which remind them of the heady days of former prime minister Margaret Thatcher.

Romola Christopherson, head of press and publicity for the DoH from 1986 to 1998, sees similarities between the crisis that bounced Mrs Thatcher into announcing the review which led to the 1991 reforms, and the course of action which prime minister Tony Blair is embarked on.

Media coverage of the winter crisis of 1987 spiralled when it emerged that an operation scheduled for baby David Barber had been cancelled six times because of a funding crisis. In an interview on the BBC's Panorama, Mrs Thatcher announced a review of the NHS. In 1989, a white paper proposing the internal market was created. In 1991, the purchaser-provider split and fundholding were introduced.

The winter of 1999-2000 was not a good one for New Labour.

Headlines about trolley-waits were stacking up, pundits were on the attack, and old excuses about the state of the service they had inherited from the Tories would not wash any more. Enter Mr Blair, who shocked the NHS with his sudden announcement on the BBC's Breakfast with Frost that European funding would be brought up to European levels.

The result? A review of the NHS, the NHS plan, and now structural change, in the shape of the abolition of health authorities and the creation of strategic health authorities and a halving of the regional offices.

Ms Christopherson says: 'There is a parallel. Margaret Thatcher had the inclination to kick the fridge when things were going wrong. Money was going into the service and why the hell wasn't it producing results? She announced the review, but I do not think she intended anything so far-reaching. In the same way, Blair was caught on the hoof.He was feeling beleaguered and said, 'We'll match European funding'. And that was that. It does smack of plus ca change, plus c'est la meme chose.'

But why does a process which starts with a call for improvements in services lead so inevitably to an administrative shake-up which no-one can remember asking for?

And what impact will the current reorganisation have on service improvement? Commentators think the effects are likely to be negative. Many believe the irresistible urge for ministers to put their stamp on the NHS - coupled with political timescales which mean they are more likely to be judged on their promises than their results - are key factors behind administrative shake-ups.

York University professor of health economics Alan Maynard describes structural reorganisation as 'a wonderful substitute for change'.

He says: 'It is displacement activity. A whole lot of smoke with everybody doing an awful lot, but nothing that creates change at all.

'You change the name, change the sign on the door - what difference does that make to the service? Implementing real change is perhaps a 10-year enterprise. The minister or government is bound to have changed within that time, so It is a question of short-term kudos. Reorganisation distracts everybody - but does concentrate people's minds on the bottom line, which is, 'Am I going to have a job tomorrow?'' Dr Charles Webster, author of the official history of the NHS, says: 'I think the majority of reorganisational changes are done as a surrogate for spending more money.

'They claim they can achieve these results through the organisational change, and then they have to put the extra money in to achieve it. Then they claim the success was because of the reform, when it fact it comes down to the money.'

And he speaks for many in the service with the blunt statement: 'I do not think any of this mucking around does much for morale.'

Our senior civil servant agrees.

He sees three main reasons behind the rush for change.One is a general push throughout the public sector to catch up with public expectation of good service. The second is the fact that money is increasingly out of line with those expectations - in particular, the lethal combination of drugs spending and demographic change. And third, 'there is the political dimension: the average tenure of a minister is - what? two-and-a-half years. They've got to make their mark'.

He is concerned at the current pace of change: 'I think It is wearing very thin on people. Every time a change is made you lose a couple of years because everybody is thinking about where their job is going. I do not think there are any tangible benefits to the changes we are seeing now.

'I think these changes have the flavour of something drawn up on the back of an envelope. It doesn't feel very strategic - it feels very reactive.'

David Hunter, professor of health policy and management at Durham University, is concerned that while the changes have echoes of the internal market, 'we do not seem to have learnt anything from the mistakes we made then'.

'What is even more worrying is that at times of other changes, at least one or two parts of the system have been stable. This time, It is everything That is changing. It looks like a recipe for disaster.

'Three years ago, they said, 'The last thing we want is big bang reform'. They seem to have no memory at all.'

Birmingham University's health services management centre senior research fellow Dr Kieran Walshe compares the preparation for previous shake-ups with the tight timescales managers are currently working to.

'The 1974 review had a six-year lead-in. It had a year in shadow form.Now the reorganisations are becoming increasingly frequent. . . if you plotted a line it will not be long before we will be having them twice a week.

'These reorganisations are about moving around the boxes when what's more important is the lines between the boxes.'

There will always be winners and losers when it comes to reorganisation. For ambitious managers, the chance to rip it up and start again can offer lucrative and high-profile opportunities.

But Dr Walshe speaks for many when he says the fall-out from constant change is rarely worth the possible benefits: 'You can be really machiavellian about it and argue that managers actually want structural change because it gives them the opportunity for advancement.

'When we throw up the board and all the cards move, you could end up with a bigger salary and a better car. But I think most managers would rather spend the time on genuine service change.' l How did we get here? 'If it looks like a mess, That is because That is precisely what it is' How did Tony Blair's pledge on matching European spending lead to a decision to bring about wholesale restructure of the NHS?

The review of the service which led to the NHS was widely applauded.So, too, were the NHS plan's priorities and targets - ambitious though they are.

It was during the path from the plan to Shifting the Balance that the government began to lose its fans.

HSJ sources believe changes in the various versions of Shifting the Balance ahead of its publication 'smack of something done in a hurry'.

One says: 'It reads like something that had very little co-ordination, a quick scan by the special advisers, nothing more strategic.'

Another recalls tensions between the Department of Health and ministers over the way the announcement was made, before the details had been finalised.

One says: 'I think the department wanted to make the changes as part of the departmental review and the local modernisation reviews.But the government was determined to make a quick political win.'

He believes that because ministers had 'spun it to The Guardian and The Express , [NHS chief executive Nigel] Crisp ended up making midnight calls to warn senior people'.

The move was met with deep unhappiness in the service.DoH communications director Helen McCallum - who resigned a few weeks later - expressed her disquiet at the way the service learned of the news.

But the problems were not only those of presentation.More significantly, it meant the civil service was left a difficult task of building a policy to fit the solution Mr Milburn had proposed, says one source.

'They had to retro-fit the policy back to the announcement: if it looks like a mess, That is because That is precisely what it is.'

Echoes of the past: 'four wasted years'?

Virginia Bottomley (left), MP for south-west Surrey, was health secretary from April 1992 to July 1995, a period which saw the Conservative reforms which introduced the internal market bed down.Mrs Bottomley believes the NHS has seen 'four wasted years', with too much time spent on 'posturing, gimmicks and trivial initiatives' to a background of 'political invective about getting rid of the internal market'.

But she appears more concerned about the pace of change than the reforms per se .'The establishment of primary care trusts has some merit, but the pressure and speed of change and the lack of confidence in the leadership of the NHS as well as the erosion of trust in managers is deeply regrettable.

'I wouldn't be surprised if a lot of health service managers feel in despair about the situation and the imposition of such major changes at a time when the service is under such immense pressure.'

Mrs Bottomley believes it is a mistake to make structural changes to all parts of the health community simultaneously, and fears 'a state of freefall' in the rush to make appointments and move managers around the country.She also attacks the decision to merge the roles of permanent secretary and chief executive of the NHS.'I think the abolition of the distinct role of chief executive of the NHS at arm's length from the permanent secretary was a retrograde step.'

She suggests that the change has meant that managers in the service have lost their buffer from the worst excesses of politics: 'The spirit of trust which had built up between managers and ministers has been lost.The degree of intimidation and denigration of managers in the present regime is shocking. I regret the degree to which change has been driven by the political agenda.My respect and admiration for NHS managers is second to none. I wish ministers would say to people in the service: tell us what we do not want to hear.

'If I have one message for Mr Milburn It is 'do not shoot the managers.'' Stephen Dorrell (left), MP for Charnwood, was health secretary from July 1995 to May 1997, a period which saw the merger of health authorities with family health services authorities and the replacement of regional health authorities with regional offices of the NHS Executive.But he insists his time at the helm was marked by attempts to slow down administrative re-invention of the wheel.

'I am of the view that says that we have had virtually every bureaucratic combination for managing the health service and any model can be made to work. . . during my time as health secretary I did slow down the bureaucratic modelling - which I am not a great believer in.'

Mr Dorrell believes primary care trusts will become like health authorities were - until New Labour got its hands on them.'The spirit of the times in the early 1990s was more power to smaller HAs.We had 192 of them at one point, so that they could be relatively close to the local communities.Then the HAs merged.Now we seem to be reinventing what we already had in the shape of primary care trusts.'

He sees another round of administrative change as 'a soft option'when what is needed is 'more radical thinking about the way the health service is financed'.

'I am not generally seen as an avid supporter of Iain Duncan Smith, but he is right to say we have to look at the way they deliver better care on the continent.What actually needs looking at is service delivery and the way medical services and clinical services can be organised.'

How times change: Milburn demands 'cast-iron'guarantee on future of CHCs In 1994, ambitious young back-bencher Alan Milburn, keen to make his mark, attacked health secretary Virginia Bottomley's failure to 'slim down NHS management'and plans to abolish regional health authorities.

'The NHS management changes outlined in the Queen's speech will bring yet further health trouble to a government who are drowning in a mess of their own making.The secretary of state for health now says that she has learnt all the lessons.She says that the abolition of the RHAs will put matters right by launching a new assault on bureaucracy. . . The abolition of RHAs will achieve at least some of the government's objectives. It will undermine health planning and further undermine local accountability.'

The MP for Darlington also feared for the future of his local community health councils, telling the Commons he hoped minister Gerald Malone would give a 'cast-iron guarantee that the future of the two CHCs is safe, regardless of anything else'or people in Darlington and south-west Durham would be left with 'the impression that, in the new model market NHS, the views of local communities count for absolutely nothing'.


1948 Creation of NHS

1968Merger creates Department of Health and Social Security.

First green paper proposes NHS reorganisation.

1974Following a second green paper, NHS reorganisation creates 14 regional health authorities, 90 area health authorities, 90 family practitioner committees, more than 200 district management teams and creation of community health councils.

1979Royal Commission ordered on structure of NHS.

1982Abolition of area health authorities and creation of 192 district health authorities.

1983Griffiths report recommends general management structure to replace consensus management.

1985US academic Alain Enthoven proposes internal market.

1987/1988Winter crisis hits headlines: it centres on public outcry over cancellation of baby David Barber's heart operation six times.

1988Margaret Thatcher announces review of NHS on BBC's Panorama. DHSS is split.

1989Government unveils Working for Patients white paper setting out the internal market.

NHS management executive created.

1991NHS reforms start; 1 April sees creation of 57 self-governing trusts and 306 GP fundholders.

1995All hospitals, ambulance and community health services have become trusts.

1996Health authorities and FHSAs are merged. Regional health authorities are abolished and replaced by regional offices of the NHS Executive.

1997White paper The New NHS: modern, dependable calls for move from internal market to localised integrated care.

1999Health Act implements The New NHS reforms. Introduction of primary care groups.

1999/2000Winter crisis hits headlines.

January 2000Tony Blair announces plans to increase health spend to European levels on Breakfast with Frost. Consultation on NHS plan starts.

April 2000Primary care trusts are introduced.

July 2000NHS plan published: sets out plans to devolve powers and budgets to front line.

July 2001Shifting the Balance consultation paper on structural change published: it calls for abolition of health authorities, creation of 28 strategic health authorities, increased powers for PCTs and abolition of community health councils.

November 2001NHS Reform and Healthcare Professionals Bill, which sets out these changes, is brought to the House of Commons.