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Why reforming the NHS doesnt work Why Reforming the NHS Doesn’t Work: the importance of understanding how good people offer bad care

Author: Valerie Iles
Date : 2011

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How is it that good people can offer bad care? How is it that politicians with good intent can insist on reform that makes care more expensive and less caring?

Successive governments attempting to reform the NHS have been strongly influenced by the view of economists that it has been ‘captured by the vested interests’ of those working within it. Health care professionals put the blame elsewhere, often on governments for targets that divert resources from clinical priorities and their refusal to take decisions likely to be unpopular with the electorate.

Rather than blame any of the groups involved, this book suggests that all are subject to a number of forces outside their (our) control, and that it is our responses to these that lead us, collectively, to squander the resources of the NHS while engaging in care that is unrewarding to offer and unacceptable to receive. Furthermore it suggests that these forces interact in a vicious circle, with each attempt at reform spinning the circle ever faster.

It looks at how professionals, managers, policy makers and citizens could respond differently to these forces, halt the vicious circle and enable the NHS to become responsive, caring, productive and affordable.


I would recommend this book to anyone who cares about the NHS. It has the rare quality of asking the right questions – not least the two questions implied by the title. It represents the product of considerable thought and concern to dig beneath constant policy upheaval so as to uncover and ‘name’ the underlying challenges facing healthcare reform. Even those who are not happy with the arguments and analyses the book offers will surely feel that it sets out a fundamentally important agenda.
Alan Cribb
Professor of Bio ethics and Education, Kings College, London

This inspiring book extends beyond economic and management perspectives. It draws upon anthropology, sociology, political philosophy, moral philosophy and history in its quest to understand the nature of professionalism and how to create a truly quality health service. It is a book which makes you think ‘Yes’! You will want to keep reading on.
Annie Cushing
Professor of Clinical Communication, Barts and The London School of Medicine and Dentistry, Queen Mary, University of London

Valerie Iles has written an important and timely book that seeks to address why serial “reforms” of the NHS have failed to achieve their stated objectives while demoralising and confusing those in the front-line of clinical care.
While acknowledging its good intentions, she describes and laments the pervasive effects of the audit culture, and the straightjacket that data has become. The health service cannot be run by rote, and Iles argues that an effective and humane health service needs to make space for creativity, thought and conversation and in this way harness all the talents available to it. She asks us to consider ends rather than means and to aspire to flourishing at every level of the health service, for patients, for professionals, for managers and even for policy-makers. Furthermore she shows us how.
She ends her book with two fairy tales about the effects of the current rounds of “reform” in England: one nightmare, the other dream. Her book might just help us to edge closer to the dream.

Iona Heath
President, Royal College of General Practitioners