Monday 19 December 2011

Why Lansley’s market driven reforms are doomed to fail - the problem of Clincial Leadership and Followership

Without doctors, attempts at radical large-scale change were doomed to fail.”

“The essence of clinical leadership is to motivate, to inspire, to promote the values of the NHS, to empower and to create a consistent focus on the needs of the patients being served”
Department of Health, 2007

Over the last several years it has become widely accepted that clinical leadership and clinical followership are essential to successful healthcare reform. Under the previous Government, the Darzi Next Stage review stated that:
Clinical leadership is a topic central to the success of the health service.”
A recent report by the NHS Institute for Innovation and Improvement and the Academy of Medical Royal Colleges (AoMRC), Engaging Doctors, highlighted a review of the Clinical Leadership literature by Ham and Dickinson and concluded that:
Without doctors, attempts at radical large-scale change were doomed to fail.”
This review also concluded that effective leaders require followers to implement change. The development of ‘followership’ is therefore just as important as the development of leadership.

Clinical leadership is arguably now even more important considering the current reforms have supposedly put clinicians at the heart of the reforms. The NHS leadership website states:
“Effective clinical leadership is critical if we are to achieve an NHS that genuinely has the quality of care at its heart.......With the economic challenges facing the NHS, it is imperative that frontline clinicians have the leadership skills to drive through radical service reform”

The development of effective clinical leadership is dependent on clinical engagement, which in turn requires trust, shared values, and a shared vision of the direction of NHS reform. However, the last 20+ years of NHS reform has seen all 3 main political parties in England support a market based vision for public service delivery.  The Labour MP and former cabinet minister, John Denham summed this up well :
"All public services have to be based on a diversity of independent providers who compete for business in a market governed by Consumer choice. All across Whitehall, any policy option now has to be dressed up as "choice", "diversity", and "contestablity". These are the hallmarks of the "new model public service""
Yet this pro-market vision is the antithesis of what medical professionalism is about. Eliot Friedson stated that medical professionalism was underpinned by an ideology that assigns a higher priority to needs based work rather than to economic rewards. It focuses on the quality and social benefits of work rather than its profitability. Thus medical work is totally unsuited for control by the market or by government or business. [1]

Medical professionalism also presents an obstacle to market reforms because "medical sovereignty" exerts control over the market through a combination of cultural authority on patients and political influence over policy making [2]. Doctors control access the healthcare system and allocate resources. The recent BMA MORI poll confirmed that most doctors want to work collaboratively rather than in competition, and most GPs and patients want to use their local incumbent providers as long as they provide good care.
I therefore subscribe to the view of Professor David Marquand, who stated that public service professionals “are in a profound sense not just non-market, but anti-market”[3]

This all poses a huge problem for Mr Lansley’s pro-market reforms, because his first guiding principle is to “maximise competition.....competition is the primary objective”.
This is why the proposed legislation has aimed to enforce the market on doctors through the powers of Monitor and compulsory membership of GP Consortia for all GPs.

Another key issue surrounding market based reforms and medical professionalism is a concept in market theory called Public Choice Theory. This theory uses methods in economics to analyse the behavior of public officials/servants, who are viewed as "utility maximisers" or "rent-seekers" driven by self interest rather than the public interest. Public Choice Theory rejects the idea of public service professionalism and the public service ethos, and views market competition with increasing use of provide providers as necessarily the route to greater efficiency in public service delivery.  Julian Le Grand's work in this area using the "Knights, Knaves, Pawns and Queens" metaphor has been particularly influential favoring this approach in policy making [4]. Public Choice Theory was also major factor in the rise of New Public Management (NPM), which favors narrow economic priorities and micro-management practices (e.g audit, inspection, performance indicators, league tables, monitoring and centrally imposed targets) over professional judgment [5].

Yet another key point about markets is that they undermine the social contract between doctors and patients and damage the doctor patient relationship, because decision making becomes increasingly based on financial concerns rather than patient needs. This was well summed up by David Coates from The Work Foundation in 2006:
Relationships between medical professionals and patients depend on trust rather than contractual obligations, and attempting to reduce the provision of healthcare to economic transactions erodes the intrinsic motivations on which the doctor-patient relationships depend
It should therefore come as no surprise that the American medical profession lost public support faster than any other profession during the rapid commercialisation of the US healthcare system in the 1970/80s [6]. This was also recognized by Professor Kenneth Arrow in a recent interview with the Atlantic:
One problem we have now, is an erosion of professional standards

Thus, the chair of the BMA General Practitioners Committee, Dr Laurence Buckman, quite rightly rejected the idea of performance related bonuses ("Quality Premiums") for GP Consortia. He stated at the recent BMA Local Medical Committees conference that:
"We will not agree to anything that gives patients the slightest perception that we might be making money out of reducing care to patients. This is utterly unethical"

It is absolutely clear that market based reforms and the medical profession do not sit well together, and therefore it’s not surprising that there has been a sustained political attack on the medical profession associated with the pro-market reforms of the last 20-30 years. This has included exclusion from the policy making process, the rise of New Public Management, loss of self regulation, and control over training and education through the Modernising Medical Careers debacle. No wonder why the BMA keep saying “No”!

So this brings me back to the crucial issue of clinical leadership and its importance in the success of healthcare reform. There is clear evidence that a shared vision is vital to the effective clinical leadership:
“Leadership is ineffective if doctors are not in agreement around a vision for the organisation, and physicians’ expectations of their practice life are incompatible with what change requires of them.” [7]
Since market based reforms undermine medical professionalism and the very essence of what it means to be a doctor, how on earth can doctors share the same pro-market vision as Lansley and the other pro-marketeers of the past 20+ years?
This quote from Professor Arnold Relman, former editor of the New England Journal Medicine, sums up the situation nicely:
Medical professionalism cannot survive in the current commercialized health care market. The continued privatization of health care and the continued prevalence and intrusion of market forces in the practice of medicine will not only bankrupt the health care system, but also will inevitably undermine the ethical foundations of medical practice and dissolve the moral precepts that have historically defined the medical profession.”

I believe that deprofessionalisation and worries about the corrosive effects of privatisation are one of the main reasons why Lansley’s reforms are so unpopular and why there is so much medical opposition. This is why he will never get the medical profession on board and behind him. A few GP enthusiasts will not be enough to deliver the clinical leadership and followership required for successful reform. The reforms are therefore “doomed to fail”. The sooner he realises this and withdraws the bill, the better. In fact, the sooner policy makers from across the political spectrum realise that delivering medical care is incompatible with markets, the better. There will never be effective NHS clinical leadership/followership and successful NHS reform, until the failed market based policies of the last 20+ years are abandoned.

[1] Eliot Friedson Professionalism Reborn: Theory, Prophecy and Policy, 1994.
[2] Starr P. The social transformation of American medicine. Basic Books, New York.1982
[3] Professor David Marquand. Decline of the Public. Polity Press 2004
[4]. Le Grand J. Motivation, Agency, and Public Policy. Of Knights, Knaves, Pawns and Queens. OUP 2006
[5] Bottery M. Education, policy and ethics. Continuum. New York, 2000
 [6] Blendon R. "The public's view of the future of medical care" JAMA
1988 259: 3587-3593
[7] Silversin, J. and Kornacki, M.J. (2000) Leading Physicians Through Change, American College of Physician Executives: Florida


  1. Maximising the opportunities for medical professionals to profit from the reforms, either financially or politically has resulted in the splits in opinion the BMA and the Royal Colleges. It is interesting that some of the strongest opposition from GPs has come from deprived areas, whilst some of the stongest advocates like Michael Dixon of the NHS Alliance and Paul Charlson of Reform are already have private interests like homeopathy and botox. We cannot avoid vested interests but we should aim to minimise them and we need to find ways of aligning the needs of vulnerable patients with the interests of medical professionals

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