Having written a simple little book, How to Advise the President, it seems only fair that I should offer some advice for free on How to run the NHS. This is prompted by hearing that a former boss and good friend has just had a triple heart bypass and he congratulates the NHS and the team at John Radcliffe on its brilliance.
First, you employ sensible people who realise that creating a group called OUH may seem funny but jokes wear off pretty quick.
More seriously, before trying to say how to run the NHS we have to look at what kind of thing we are trying to run. A simple analysis says it starts as something very complex, hugely collaborative, operating continuously as an ‘ongoing project’ (that is it in neither a new thing or something about to be completed) and it is something that will grow or suffer progressively, not catalytically, that is, it will neither collapse nor succeed overnight.
Having identified the kind of thing we are dealing with we can then decide how each and every one of our thinking processes can be applied to it. Basically we have three types of thinking, a simplification I know, but good enough for looking at a big picture.
We have creative thinking, reasoning (which includes analytic thinking) and intuition. With something big and complex we are likely to be able to benefit from using all three, interactively and from review of the outcomes of each. So each will bring something but each needs to be checked with the other two, and itself, you can check reasoning with reasoning, especially if you add just a dash of creative thinking.
First, let’s apply reasoning. And for this blog I think it will be enough to apply reasoning today and try the others tomorrow and the day after.
With something big and complex, when you apply reasoning you are going to ask if what you are looking at is one thing or many things which artificially come together, but are truly separate. The great Philosophers Russell, Popper and Kant could all help here, as well as some more modern ones like Pirsig.
Peter Carvell in his book Silver Wolf suggests that we cost most in health services from prenatal to 18 months, and then in the last 18 months of our life, NO MATTER HOW OLD WE GET! Now I am not sure if there would be people who would dispute that figure, but it surely suggests that what we offer at the beginning, what we offer at the end and then everything else in between are all different, so different that different kinds of service operations should be provided.
Basically, his message could be, “If you can read this you don’t need a doctor!”
So this would suggest the NHS is sliced so that for the beginnings of life we have a “So you want to get pregnant?” service which helps you all the way through to early toilet training, walking and speaking. A really specialist system, it is a service that listens a lot, does an awful lot of outcomes based research and has an ethic which basically runs on the principle that no matter what it costs, ‘kids are worth it’.
Services for the last 18 months are generally regarded as appalling, as report after report shows. Except for the Hospice services. So as we know the hospice services have a pretty excellent record it seems an easy decision to slice the NHS off at the end of life services and hand them over to the hospice movement (if you have not read Facing Death and Finding Hope by Christine Longaker then you should, before you get there).
Deciding a budget is not as easy as for the first 18 months. For the first 18 months I think it would probably be true that whatever you spend within reason you get back as a long term investment. For the last 18 months that is different, no amount of reasoning is going to come up with an answer, so you need the thinking processes of creativity and intuition to help. So more on that later.
So what about the middle?
For that middle section the situation analysis is now a bit different than it was when we looked at the whole of the NHS. We now have a split, between progressive risk and catalytic risk.
What this means is that for some things like being overweight, eating poor foods, drinking too much alcohol, taking drugs illicit and legal, you get poorly slowly, well, hopefully you are not so indulgent you kill yourself that quickly.
How you react as a system to progressive change, well, it makes little sense to wait until severe damage is done and then treat the damaged article. Your car now has every conceivable monitoring device. Why? Not because the car manufacturers want to save you money, it is because they realise that their record on breakdowns, resale value of car and so on is key to selling cars in the first place so they want you out of the picture, you don’t maintain your car properly, so they have taken over the care and maintenance of your car. I don’t like this at the intuitive level but with reasoning I can see how they are placed.
So, for progressive change we need to be monitoring every aspect of health we can, for every citizen, on a regular basis. That is the only sensible thing to do. To get there we need to do some work on culture change, we need to have creative service delivery to get people to ‘take the car to the garage’, and then let people take over if needed, so we need the other thinking processes of creative thinking and intuition to help us, but the core message is this, the NHS has to have a health monitoring process and stop treating progressive change as something to tackle at the level of illness. The savings would be massive.
Finally, reasoning needs to be applied to catalytic risk.
With regular monitoring we can hope that heart problems, cancers and things like diabetes are simply ‘managed away’, almost to the point of disappearing, that would be the clear goal.
But other things occur. Traffic accidents, broken bones, and wounds of various kinds. On the few occasions I have had the benefit of these kinds of services, for me or my family, I have been totally happy to have a team of people take over my life. Basically, when things go wrong, the best attitude, almost entirely, is they know best.
I think the kind of separation of services that reason suggests would reduce the kind of problems that exist for ‘hospital bugs’. If a team of people take you in as an ‘ill’ person, someone who needs ‘treatment’ and then will see you leave as a healthy person, then a clear part of that would be that everything is clean, neat, tidy. People who run a good garage are easy to spot, as Pirsig tells in his story of Zen and Motorcycles, the guy who does a truly great job has everything where he knows it will be.
The funding for such a service would be basically simple, for all catalytic services which yield a healthy person as an outcome, you have to pay what it costs. But creative thinking, new technologies, competitive servicing, these do make sense as a measure to improve ‘productivity’. Manufacturing processes have had masses of work done on them to deal with this kind of situation and for this kind of thing their knowledge and advice makes sense.
So, simple, but of course there are, in a population of 60 million people, all kinds of other things which would not fit neatly into this cut and slicing.
This is perhaps the only part of the NHS new delivery system which would benefit from the kinds of reforms that are being suggested. Services for mentally and physically handicapped adults are complex, collaborative, progressive and catalytic, by the very nature of the reality of the lives of people who don’t have the easy advantages we mostly have. Reasoning cannot deal with the rights to a full life when the very meaning of life is on uncertain grounds.
But designing an NHS in such a way that it has to incorporate all kinds of health and illness issues is not good for anyone. It reduces efficiencies where they can be obtained and it means that the services that are provided for those outside the easy paradigms tend to be confusing, a lottery, dependent on luck and an excess of love and good will, which is great but it cannot deliver the best.
So for the most complex, the most collaborative kinds of NHS issues, maybe a system of competition between organisations is healthy, organisations which combine all kinds of variations of social enterprise, charity status, and profit, with complex monitoring devices which include market forces, charity watchdogs, and passionate communities.
So, that is what reasoning suggests, as the best current thinking.
Tomorrow I will see what we might provide with intuition and creative thinking.