ANZSOG John Deeble Lecture: What can Australia learn from the UK’s NHS reforms?

The 2019 John Deeble lecture has given health policy makers a first-hand account of the obstacles to health policy reform, what can be learnt from failed reforms to the UK’s NHS, and how we can introduce more evidence to policy making.

Professor Nigel Edwards, CEO of independent British health think tank the Nuffield Trust, delivered the lecture which is sponsored by ANZSOG, and has been established by the Australian Healthcare and Hospitals Association (AHHA) to celebrate the legacy of Professor John Deeble as a distinguished scholar, health economist and health policy leader.

Professor Deeble’s work was essential to the establishment of Medicare, and its predecessor Medibank, and the lecture’s purpose is to bring the idea of, and imperative for, universal health care access back to the centre of policy debate.

Listen to the 2019 Deeble Lecture

 The Lecture, held at Parliament House in October, was followed by a panel discussion reflecting on the complexities of the health system and the way Australian health policy is set and managed, with panellists Professor Ian Frazer (CEO and Director Translational Research Institute) Nicola Roxon (Chair HESTA and former Federal Health Minister), Romlie Mokak (Commissioner, Productivity Commission) and moderator Professor Johanna Westbrook (Director Centre for Health Systems and Safety Research Macquarie University).

Professor Edwards said that health policy was facing increasing challenges because of changes in the environment, in particular the growth of complexity, the increased velocity of debate, the challenges of larger scale and other changes in society.

He said that failed reforms to the UK’s National Health Service offered insights into why reforms failed, and why healthy policy was a particularly difficult area for politician-driven, top-down reforms.

He argued that a key lesson from the UK’s failure was that traditional calls to ‘get more evidence into policy’ missed important aspects of the world we now inhabit, and it was important to have intermediaries who could help all participants by:

Challenging their preconceptions and assumptions
Clarifying the questions and the diagnosis
Synthesising the evidence
Understanding the difference between theory and practice
Connecting issues and different levels – the strategic and the operational
Bring more diverse views and ideas to debates that are often inward looking

Professor Edwards said the experience of former UK Health Minister Andrew Lansley and his attempts at reforming the NHS “follows the structure of a Greek tragedy and illustrates many of the things that go wrong in the policy process.”

“Lansley became secretary of state for health in 2010 having spent an unprecedented six and a half years in the shadow role – he had a plan based on his experience as a civil servant involved in the privatisation of energy and telecoms utilities but it was not really clear who he listened to in developing his ideas,” he said.

“The broad strokes of the plan, formulated in 2007, were to boost the NHS quasi-market, giving GPs purchasing power and organising them into groups to do commissioning. Putting more emphasis on patient choice and competition, including price competition. The half-finished project of making hospitals autonomous would be completed and there would be greater private sector involvement.

“The governance structure was to be simplified with the creation of an NHS Board and an economic regulator to deal with competition and pricing issues. Both of these were to be independent of direct ministerial oversight and would be at arm’s length from government.”

He said that the policy was not substantially revised to reflect the changed funding environment in the UK after the 2008 financial crash.

Listen to the 2019 Deeble Lecture panel discussion

Reform implementation unravels

Professor Edwards said that after Lansley took office, as part of a Coalition government, it soon became clear that the commitment to avoid a major reorganisation didn’t work.

“The reforms created a logic that left many parts of the structure without a clear role. With the added pressure to reduce costs, this led to organisational changes which the then CEO of the NHS described as “so large [they] could be seen from space”. Lansley also lost the support of the British Medical Association. The Treasury and many politicians became very nervous at the idea of £80 billion being handed to independent contractors with what seemed to be very little accountability or oversight – the NHS was already in financial trouble and the reforms risked a complete loss of grip on the money.

“Many aspects of the reforms have unravelled. As is the case with many large complex organisations, you have to really break it to stop it returning to its previous form. Lansley even failed at this and the system has evolved to get around almost all of its most unhelpful and competition-oriented components. Much of the legal framework has been ignored, or worked around.”

He said the governance structure of the NHS was not simplified and although the number of managers fell initially it has since grown back.

Theory did not fit the system, or political reality

Professor Edwards said that Lansley’s reforms were to a large extent based on a theoretical model drawn from the economics and policies of privatisation of utilities that was not always applicable to health policy.

He said it was important when using a theoretical model to drive policy, to examine the extent to which it fits with the context and history.

”There is a reason why path dependency is a powerful driver of policy ideas and direction. Having due regard for this is one of the reasons that the 20-year project of reform in the Dutch health system has been successful. The neglect of context and history often leads to bad ideas being resuscitated or borrowed from elsewhere and applied in situations in which they are unlikely to work. It’s also worth checking that the ideas being borrowed actually work as well as is claimed.

“Another element of a poor design process that is far too common and was a major feature of the Lansley debacle, is failing to elicit or listen to feedback – particularly from wider stakeholders beyond the usual suspects or people you can guarantee will agree.”

He said that other key lessons from the failed reforms included:

Poor process and unclear leadership
Timescale: policy makers are very prone to optimism bias, complex change requires continual negotiation and often takes place in unpredictable ways and at varying speeds, and there is little that can be done to compress the time that is needed for these tasks
Insufficient resources especially for double running, organisational development and change management
Not enough attention to workforce, capital, IT, regulatory machinery, payment systems or other infrastructure requirements
More policies and procedures being issued on top of a multiplicity of existing policies and procedures
Pilot projects that are hard to convert into sustainable change
Unintended consequences that are unhelpfully powerful and unexpected
Superficial attempts to change deep culture

“The most obvious design problem comes from the short time horizon of ministers and their need for rapid results. The electoral cycle is a problem in many countries but ministers often come and go even faster which incentivises speed over careful design and engaging with the messy realities. The political will necessary to drive long-term policy-making also tends to dissipate over time,” he said.

Professor Edwards said that Lansley’s attempt to take the politics out of UK debate were naïve, because health policy is always political, the challenge that policymakers needed to discuss was how to avoid the simple trumping the complex.

How independent bodies can improve health policy

Professor Edwards said there had been a lot of handwringing over these and other failures, which had led to attempts to make policy makers pay more attention to evidence when they are forming policy.

“In a number of countries the use of evidence has improved, and organisations that sit between the worlds of research, policy making and management practice, play a key role in making the translation between these different domains,” he said.

He went on to provide a list of ways to improve policy:

Better questions and diagnosis

There needs to be more rigour in testing the questions being posed and in particular the easy emergence of groupthink.

More critical thinking about solutions

Particularly where there is divergence between the rhetoric of policy and the actions being taken, major design problems or ideas where the caveats and qualifications are being downplayed – again this is also a defence against groupthink.

Diversity of disciplines

There is more to do to bring ideas, analytical frameworks and methods from other disciplines such as sociology, political science, anthropology, organisational psychology, geography, etc.

Diversity of views

Getting the right balance between top down and bottom up in policy making is a perennial challenge. Policy makers often need to connect to a wider range of views and voices from different levels of the health system, from different geographies, from patients, carers and stakeholders outside the system. Policy intermediaries can assist with this and reduce the risk of the usual suspects being brought in each time.

Using history and comparative studies

Many policy ideas have been tried before or in other settings and countries. These require care in their interpretation. Better policy evaluation and learning needs to be a strong part of this – ministers are generally reluctant to fund this and so there is a key role for independent bodies.

More experimentation

The complexity challenge means that there is going to be more muddling through and experimentation. Policy makers need to get much better at the design and evaluation of experiments and being able to distinguish between processes that are about discovery and those that are meant to develop models for wider implementation.

Short digestible syntheses of the evidence

It is very difficult for researchers to hear that their 100 page report is unlikely to be read by many people, and hardly ever by senior managers or policy makers. Generally, far too little effort is put into creating a hard-hitting short research summary that captures the key points and that is written in ways that will have impact with policy makers, managers and clinicians.

Bringing these different approaches together will greatly increase the chances that policy will work better. Independent bodies that can speak truth to power or, perhaps less grandly, inject doubt into false certainty, remind people of the history, test that the solutions fit the problems and have the requisite level of simplicity or complexity, occupy a key role and have a duty to speak up and avoid the temptation to be co-opted into the system as well helping to find new pathways to solutions.

We may not be able to see the results of this from space but we ought to experience some improvement closer to home.