Local innovation can't be driven from the top down.

I n a recent presentation to UK physicians at Stanford University, Alain Enthoven produced a revealing insight. He had advised the Thatcher government at the outset of the internal market during the late 1980s. He had made the case that because no one understood how to manage risk in the NHS, managed competition should be piloted in some small areas first and only made a mandatory part of national policy once the lessons had been learnt. In this respect, he was ignored, and the 1989 white paper Working for Patients unrolled a phased but universal introduction of the new approach. Ministers come and go, but the Department of Health has behaved consistently as if there were a “correct” central policy regarding structures and that its job is to experiment with the NHS while it works out what this policy might be. The sad irony might be that no centralised policy is right, and the successive restructurings are exercises in destructive futility. The travails of Andrew Lansley’s reorganisation show how this tendency in the health department remains undimmed. With one side of its forked tongue, it says that “only locally based innovation will get us through” while its behaviour persists in managing through single model centralisation. The closest it comes to flexibility is through pilots focused on models of care, representing “additive experiments,” such as the three telehealth pilots presently under way (http:// bit.ly/mAnvOy). What is the plan if the pilots “work”? If the department performs to type, they will become mandated as part of national policy, like the Darzi polyclinics, and forced on local systems irrespective of local priorities or the local case for change. Although the coalition has manoeuvred the Health and Social Care Bill through its third reading in the Commons, we haven’t seen any change in the centralising tendency insisting that core incentives must apply identically everywhere. Cultural insult is added to organisational injury when the department orchestrates messages that blame different NHS sectors for sclerosis and failure (“it’s the primary care trusts,” “the general practitioners,” “the consultants,” “the managers”), when it should look to its own lack of flexibility for a substantial part of the explanation. Contrast this with the approach to reorganisation of health in the United States. Recently, the Centers for Medicare and Medicaid Services published a major set of regulations for consultation that will allow local healthcare systems to integrate primary and secondary care and benefit from a modified payment system by creating “accountable care organisations” (BMJ Local innovation can’t be driven from the top