Chris Ham: Inertia rather than privatisation is the biggest threat facing the NHS

The Prime Minister’s summit on implementing the NHS reforms has provided a new focus for debate about what the reforms will mean in practice. The government’s critics maintain that competition will undermine the core values of the NHS to the detriment of patient care. Some of these critics go further to claim that competition will result in the privatisation of much healthcare provision and the end of the NHS as we know it.

History suggests the need to treat these claims with caution, if not scepticism. Ever since the Conservative government introduced the internal market reforms in the early 1990s, opponents of choice and competition have warned that the future of the NHS is under threat, and yet it is performing better today than ever before. And as Nick Timmins showed in a recent analysis for the Financial Times, the private sector’s share of the market for elective care for NHS patients has remained stable,  giving the lie to the argument that widespread privatisation of provision is inevitable.

In the light of this kind of evidence, there is a much greater risk that inertia, rather than privatisation, will block the changes that are needed to address the Nicholson challenge and bring about improvements in the quality of care and patient safety. Inertia is a result of the size and complexity of the NHS and the pressures facing staff to respond to the demands placed on them; it is often easier to live with the current situation than to seek ways of working differently and more effectively.

It is also a legacy of the command and control culture that often results in leaders waiting for permission to act, rather than seizing the initiative to do so. The Health and Social Care Bill and associated reforms risk reinforcing inertia because of the complexity of relationships between the NHS Commissioning Board, clinical commissioning groups, health and wellbeing boards, clinical senates and clinical networks. Unlike former health secretary, Alan Milburn, who warned that the reforms could lead to a car crash, in reality there is a much greater likelihood of a traffic jam as organisations negotiate on how to make change happen.

To be sure, the NHS has shown in the past decade that it is capable of addressing long-standing weaknesses in access to care and quality, but it has done so at a time of unprecedented investment. For the foreseeable future, there will be no extra spending other than that needed to allow for inflation, and the challenge is, therefore, to do more with the same instead of more of the same. Doing more with the same calls for a degree of innovation rarely seen before that is implemented at a pace that reflects the urgency facing the NHS in the most challenging period in its history.

Some of the innovations that are needed may come from the greater involvement of private and third sector organisations able to bring different ways of delivering care to the table. There is also an opportunity to learn from experience in other countries where new models of care have been established, unconstrained by the traditions that sometimes inhibit change in the west. The example of the Aravind Eye Care System in India, presented at our annual conference in November, is a fantastic illustration of this kind of reverse innovation.

Important as these examples are, much of the innovation that is needed will depend on NHS providers and commissioners showing the way by challenging established models of care and demonstrating how improvement can come “from within.” To convince the sceptics who argue that the NHS is too big and lumbering to innovate, three things must happen.

First, NHS leaders must be ruthless in identifying and copying best practice wherever it exists. After all, much innovation is really adaptation of ideas initiated elsewhere, and shameless plagiarism is an underrated virtue.

Second, to be able to do this, leaders must create time to look outside their organisations, while also attending to operational imperatives. My experience of working with leaders over the years is that the most powerful learning often occurs through seeing how other organisations work and this should become a higher priority.

Third, and perhaps most important, there is a need to invest in the training and development of staff to enable continuous improvements in the quality of patient care. High performing healthcare organisations such as Jonkoping County Council in Sweden and Intermountain Healthcare in Utah, US, do this systematically and are rightly admired for the results they achieve.

To return to my starting point, the most effective response to concerns that the core values of the NHS are under threat is to show that it can adapt rapidly to the challenging environment in which we live. After all, if NHS organisations demonstrate that they can deliver high quality and responsive care, they have nothing to fear from a further dose of choice and competition.

Chris Ham is the chief executive of the King’s Fund.

This blog also appears on the King’s Fund website at