Review

A piece of the jigsaw

EVALUATING THE NHS REFORMS
Ed Ray Robinson and Julian Le Grand
King’s Fund Institute, 1994

The origins of this book lie back in 1989, when the white paper Working for patients had just been released on an unsuspecting world, and the genie we now know as the internal market was still firmly in its bottle. Amid the clamour of criticism which greeted the government’s proposed reforms of the NHS, many voices called in vain for some kind of official commitment to monitoring or evaluation of the reform process.

The then secretary of state for health, Kenneth Clarke, refused, and so eventually the King’s Fund stepped in by funding a wide ranging programme of work aimed at providing at least some objective assessment of how the reforms worked out in reality.

The reports of the seven projects which were funded at that time comprise the body of this book, supplemented by an additional chapter on considerations of equity, and opening and closing chapters. Oddly, it is often these latter, non-empirical contributions which make the most interesting reading.

John Butler’s scene-setting chapter on the origins and early development of the reforms offers a clear and concise political backdrop to the book. It rapidly becomes apparent that, from the outset, the reforms as originally conceived were riven with economic and political contradictions which, far from being resolved early on, have continued to play themselves out as the internal market has developed. The key political judgement in any system of managed competition, as Butler points out, is the degree to which you do in fact manage the competition. Get it wrong — in either direction — and the political fall-out is sure to be damaging.

Of the research reports, which cover regulatory issues, trusts, GP fundholding, patient choice, services for older people, medical audit and the personnel function, the report on the economic performance of trusts is perhaps the most interesting. The lack of clarity over how the performance of the new trusts is to be judged renders attempts at evaluation difficult, to say the least. The authors argue that we do not have any easy model of trust behaviour against which we can assess real-world performance. The need for greater theoretical understanding of how “non-profit” organisations behave is clear.

By contrast, the report on fundholding comes over as an enthusiastic and rather breathless apology for government policy, which is remarkably uncritical of arguably the most controversial component of the reform programme. Perhaps this isn’t so surprising when it becomes clear that the research was heavily based on interviews with new or prospective fundholders themselves.

In sum, this is an important book which adds to the gradually accumulating evidence on the outcomes of the reform process set in train in 1989. Yet it also feels somehow inadequate as a response, even if only partial, to the rapid evolutionary development of a system which seems to grow ever more absurd and capricious by the day. But then, any kind of evidence whatever seems inadequate in the face of a government for whom political expediency is all, and to whom carefully assembled and evaluated facts count for nothing.