Jönköping’s performance is also not the consequence of quasi-market reforms, since choice and competition between providers have been largely absent from Sweden’s public service reform programme. Rather, Jönköping has benefited from a long period of organisational stability, continuity of top-level executive leadership (the chief executive has been in post for almost 20 years), a programme to develop clinical and managerial staff in leadership roles at all levels, a commitment to train frontline staff to bring about quality improvements, and recognition that public service reform involves a long and, at times, slow journey in which there are no quick fixes.

Another element of Jönköping’s success has been the use of information to compare its performance with that of other county councils. The emphasis on devolution of responsibility for improvement linked to transparency in the use of information finds echoes in the analysis of Michael Barber, head of the Prime Minister’s Delivery Unit between 2001 and 2005. Barber argues that where top-down performance management and quasi markets won’t work, devolution and transparency is an appropriate third approach to reform.

Recalibrating the mix

In the messy reality of public service reform, governments rarely adopt a single approach, and it is the mix that distinguishes one period of change from another. The judgement for the Brown government, and for the Darzi Review, is how to recalibrate this mix to enable the NHS to build on its achievements so far in order to move from good to great.

If top-down performance management is necessary but not sufficient, and if the quasi market in its current form is unlikely to deliver on its promise, then engaging frontline staff in the next stage of reform and supporting them to be in the vanguard of improvement is an idea whose time has surely come. Such an idea would be a concrete expression of the Prime Minister’s Strategy Unit’s advocacy of the need to strengthen leadership and capability in public services. In practice, this would entail learning the lessons from Jönköping County Council, including the need for organisational stability, continuity of leadership, leadership development at all levels and equipping staff to bring about quality improvement. It would also mean using devolution and transparency to drive reform through the use of information to improve performance.

In addition, the government should give serious thought to how the quasi market could be developed to address weaknesses in its design. One of the failings of advocates of choice and competition as an approach to public services reform is that they rarely explore in detail how the demand side and the supply side might be structured to realise the potential benefits of competition.

Integrated systems

Evidence from the US, the country that has most experience of using competition in healthcare, indicates that integrated systems have been more successful than others in achieving high levels of performance. This is because they bring together clinical staff with commissioners and sometimes hospitals, rather than separating these roles as has happened in the NHS. Enabling patients to choose between integrated systems in which clinicians are empowered to bring about change, and in which the incentives facing clinicians are aligned with the organisations they work for, is likely to be a more promising route of reform than the quasi market as currently designed.

Profound implications

The last decade has been a period of learning in government about the complex process of public service reform and the impact of the different levers available to bring about change. The NHS reform journey has moved from top-down performance management to the quasi market and has now reached a crossroads at which choices on future direction need to be made. The decisions that emerge from the final report of the Darzi Review will have profound implications for the NHS and its long-term sustainability. These decisions will also determine whether the NHS is indeed able to move from good to great.

Chris Ham is Professor of Health Policy and Management at the University of Birmingham