NHS culture depends on enlightened leadership and aligned incentives

Abstract

The recent article on ‘What the NHS needs to improve’ (JRSM 2008;101:7–11)1 identifies four valuable ingredients of a good culture but omits what is needed to achieve it. As a professor of comparative health care systems who has worked closely with many parts of the NHS since the Thatcher reforms, I think the answers are most clearly found in the transformation of the US Veterans Health Administration from a public, politicized system considerably worse than the NHS in the early 1990s to one considerably better that outperforms even the great medical centres. The key elements are a coherent master plan for patient-centred care that rewards quality and value for money, a strong and steady leadership to implement the plan at every level from regional to individual service design, the elimination of perverse incentives, and the construction of aligned incentives at every level. Most of the costly and extensive reforms of the NHS I have witnessed since 1990 have been half-baked and partially contrary to the previous ones so that an accretion of crosscutting changes has developed. Powerful, perverse and non-aligned incentives undermine the development of cost-effective, integrated services. Leaders keep changing, and each new one asserts his or her presence by correcting or reversing previous initiatives and instigating new ones. Current initiatives – such as ‘payment by results’, which has nothing to do with payment by results but rather payment by activity – build in perverse incentives that will distort services in new ways. Until the economics and organisation of services support cost-effective, integrated services of quality for patients, a culture of Confidence, Compassion, Connectedness and Curiosity will not happen.