The central question in the current debate over the Government’s NHS reforms is whether the “listening” exercise taking place during the recently discovered “natural pause” in the legislative process is genuine or symbolic. Concerns that the exercise is cosmetic will only be fuelled by an article in yesterday’s Guardian which cites a letter from David Nicholson, the Chief Executive of the NHS, who suggests that the implementation process should press ahead and that there is a need to “maintain momentum on the ground”.

The article includes a quote from Hamish Meldrum from the BMA who states that the BMA has:

… always maintained that changes in the NHS must not anticipate the legislative process and lead to irreversible decisions.

I’ve no idea whether the BMA have always maintained this position. But this quote highlights something very significant about the way policy is currently developing in this field.

Models of rational policy-making run through a series of stages something like this: a problem is identified; the options are appraised; a policy decision is made; the chosen policy is implemented; the success of implementation is evaluated. Such models are criticised for being unrealistic. We usually teach our students that the path of true policy rarely runs so smoothly. The rational model ignores the messiness of real world policy processes.

But the model embodies at least one characteristic that can be highly desirable in real world top-down policy processes: a clear policy decision is made before implementation.

One of the most striking things about the current NHS reforms is the way in which implementation of new structures has been running far in advance of the Parliamentary process that will provide the legal underpinnings for the new system. At the end of March Primary Care Trusts shed hundreds of staff. A range of organisational reconfigurations are underway, or have already occurred. Practitioners have been proceeding on the basis that Mr Lansley’s grand plan is going to be realised.

The rational model of policy making would suggest, in contrast, that it might be a good idea if implementation were to wait until it was clear precisely what sort of structures Parliament decides should be implemented.

The Government’s approach right up to the arrival of the natural pause could be interpreted in different ways. It could be seen as supremely arrogant – they considered there was no likelihood of Parliament forcing any significant modifications on their plans. In this sense the ‘policy decision’ did indeed preceed implementation because it had been made once the Conservatives launched their plan. This interpretation suggests a contempt for Parliamentary process and a failure to appreciate the nature of Coalition government. Alternatively, it could be interpreted as supremely incompetent – in their haste to be seen as radical the Conservatives hadn’t thought through what would happen when Parliament did force significant modifications of their plans. A third interpretation might be that the perceived pressure to save money was so urgent and the scale of change so great that having to wait for Parliamentary approval for action was a luxury the country could not afford. While this interpretation is more charitable, it still raises procedural questions.

However we interpret the approach, it is coming unstuck.

The consequence would seem rather chaotic. We now learn that Strategic Health Authorities have just been given a further stay of execution as a result of the natural pause. The delay associated with this pause mean that some of the managers recently made redundant are going to have to be re-engaged to keep existing structures functioning. And while energy and attention are absorbed in preparing for and coping with seismic change that may or may not actually happen the performance of the health service suffers. Speaking to colleagues in the health field it is clear that if the show is still on the road it is only being kept there on a wing and a prayer.

The rational model of policy making has many weaknesses, and much policy doesn’t fit well with its top-down orientation. But in its insistence on a clear policy decision preceding implementation it highlights a characteristic that good policy-making should at the very least aspire to. In the case of Lansley’s NHS reform, holding on to the idea of securing Parliamentary legitimacy for new structures before implementing them would have done much to quell concerns that irreversible change has already occurred and that the current listening exercise is little more than a charade.