Iestyn Williams, Senior Lecturer, Health Services Management Centre

Reaction to the Carter Review of hospital productivity has been somewhat guarded.  Jennifer Dixon from the Health Foundation describes the report’s recommendations as ‘a positive step’ which nevertheless represents merely the ‘tip of the iceberg’.  In order to deliver more substantial change – including turning the £5 billion efficiency savings identified by Carter into the £22 billion savings required to keep the NHS in the black – Dixon argues the need for a ‘national plan’. 

Meanwhile, the Nuffield Trust offers something of a health warning against such a national approach, especially if this is likely to equate to greater centralisation.  Chief Executive Nigel Edwards warns that ‘plans to impose these benchmarks from the top down risk turning into another round of the kneejerk centralisation that has served the NHS badly in recent years.’

These comments reflect deep-seated and long-established problems which arise when national health systems seek to pursue programmes of change, namely the trade-off between national and local approaches to making necessary change.  Carter’s intervention – including a suite of well-reasoned observations on the scope for reducing variation and increasing efficiency – is both practical and constructive.  Jennifer Dixon’s caution is well-founded, especially if we accept the premise that radical, whole-system change is required to meet ambitious overall efficiency targets.  Nigel Edwards’ rejoinder– i.e. that we have had (to paraphrase) quite enough of ‘national plans’ thank you very much – also smacks of common sense.
So where does this leave us?  Well, we can start by welcoming the measure of common ground encapsulated in, and consolidated by, the Carter Review.  There has been a growing acceptance of the problem for some time: that is, the requirement to meet needs that are complex and changing, and to do so in a way that makes the best use of resources whilst preserving equity of access and outcome. What’s more, the menu of possible solutions that are offered has become mercifully more realistic. Carter’s report exemplifies a slow but hopefully inexorable trend in policy guidance towards practical and creative proposals, grounded in knowledge of the system, and a shift away from some of the more sweeping prescriptions offered up in the past.

That is the good news.  Opinions diverge however when it comes to achieving efficiencies in practice.  There is an element of motherhood and apple pie about the Carter recommendations, for no-one would argue against an emphasis on workforce, values, patients, leadership, improvement, measurement, engagement and so on.   And few would dispute that the NHS contains examples of excellence and poor practice in relation to each of these.  As welcome as documents such as the Carter Review might be, it seems unlikely that it will on its own be decisive in changing behaviour or reducing variation.

All of which means we return to a familiar dilemma between the bottom up approach in which we exhort, support and reward local improvement strategies, and the top-down approach of centrally mandated change driven by targets and micro-management from the centre.  History tells us that the former often leads to frustration and inertia, whilst the latter can have damaging unintended effects elsewhere in the system.

Insights from the wider policy implementation literature suggest a more nuanced approach is possible.  In his seminal work Richard Matland identifies two important considerations for governments seeking to put their policies into practice.  The first is the level of ambiguity – to what extent do we know what we are actually trying to achieve?  The second is the level of conflict – how much resistance to change can we expect from those required to put the policy into practice?

These twin concerns are pertinent here.  Whilst ambiguity over problems and solutions has decreased, many of the Carter recommendations are speculative and dependent on context.  For this reason flexibility will be necessary and some level of experimentation at the local level – ‘good’ variation as it were – should be encouraged.  This would suggest a need for a strong element of the ‘bottom up’ in implementation strategies.  By contrast, leadership from the centre will be required to resolve conflict and overcome resistance, for example to proposals to remove treatments or services that have been superseded. Reducing ‘bad’ variation means not just investing in new initiatives but stopping other entrenched activities, and tackling any institutional objections to such changes along the way.  This requires peer-to-peer initiatives such as Choosing Wisely, but also necessitates political courage and consistency from health care leaders.  Finding transparent and constructive ways to implement these difficult decisions is perhaps the greatest challenge facing the NHS, but the pay-off might just be significant enough to justify the effort.