Cowper’s Cut: The big machine or the ecosystem?

There are big problems facing the NHS. There are also real problems facing the NHS. Some are big but not real (privatisation); others are real but not big (health “tourism”).

The problems about which we should care are the ones that are both big and real.

One of the current big, real problems facing the NHS is this: we don’t seem to know whether we want it to be a big machine, or an ecosystem. Legislation dictates the latter, with dear old Lord Lansley’s market aspiring reforms in the 2012 Act and the as yet unrepealed 2003 Act which created foundation trusts.

2012: A Space Cadet Odyssey

What’s been happening in the real world is that NHS Commissioning Board boss Simon Stevens (the Sun King of Skipton House) has been ignoring the living daylights out of the 2012 Act. NHS Improvement treats FTs and non-FTs exactly alike with impunity.

There is not a shred of statutory basis for sustainability and transformation partnerships or new care models: STPs can use the “local tariff variation” loophole and expensive lawyers to argue that their modus operandi is “in the best interest of patients”.

Then there is the imposition of control totals, which doesn’t seem to have any statutory basis, either. The NHS Trust Development Authority could quite legitimately impose them on non-FTs, but Monitor would only be able to once FTs were found to be in breach of their licence and following appropriate consultation – which doesn’t seem to be happening.

We’ve got what looks very much like back door, financial regime induced de facto abolition of FT status instead.

We’ve got what looks very much like back door, financial regime induced de facto abolition of FT status instead.

So, we seem to be trying to run what is legally an ecosystem as if it were a machine. 

(The intellectual Jesuits out there may rush straight to saying “well of course we want the NHS to be both an ecosystem and a big machine”. That’d be a cop out. It’s an understandable cop out, because ever since 1948 there has been a tension between the national bit and the local service bit. But it’s still a cop out: Nye Bevan wanted to hear the sound of a dropped bedpan in Tredegar, and the NHS system was set up accordingly, as a big machine, designed to deliver “the right answer” to the minister of health.)

Socialists for the Lansley reforms!

The tension between these two modes of operation puts the fun into fundamentalism: you can find plenty of theologians to argue the case for both approaches.

At its absolute best, you can see it in the 999 Call For The NHS campaign’s attempt to take NHS England to court over an accountable care organisation contract because they assert that it breaches the 2012 Act.

You can find out about 999 Call For The NHS’s views here.

It is tempting to wonder whether the founders of the 999 Call For The NHS campaign (who are amusingly silent about how they’re funded), who want to “restore a fully democratic & publicly accountable NHS stopping and reversing the break up of the NHS due to marketisation & privatisation” appreciate the irony of their suing the NHS to defend Lord Lansley’s market oriented legislation. Then again, irony may be a thought experiment too far for them.

Keogh surgery

A demob-happy Professor Sir Bruce Keogh, the exiting NHS Commissioning Board medical director, touched on this tension in his interview with the Telegraph.

Keogh calls strongly for a mandatory introduction of proven new patient safety technologies. (I mean, the National Institute for Health and Clinical Excellence could always do these as technology appraisals, given the Budget.)

But Bruce’s main point is a stinging one: that the plurality of organisation in the NHS is letting patient safety down. He said, “where there are solutions to significant patient safety problems, I would like to see a system that mandates the use of those solutions throughout the NHS.

“The difficulty we have is that the NHS is a conglomerate of hundreds of organisations, all of whom have their own board and people in them with their own views… the decision to take up some of these devices or solutions is influenced by financial pressure and I think we need some way of being clear about when a recommendation such as this should override the financial considerations”.

Professor Sir Bruce Keogh’s main point is a stinging one: that the plurality of organisation in the NHS is letting patient safety down.

Bruce’s boss Simon Stevens likes to use the framing of “the exam question” for his analyses of challenges the NHS needs to confront. He has proven the pragmatist’s pragmatist in moving the NHS away from the system of plurality and contestability ushered in by his NHS reforms of the 2000s. On topics from devolution to failure to raise locum pay rates, the NHS is acting far more like a big machine.

Professor Tim Briggs’ GIRFT work provides intellectual ballast; the NHS Improvement study of operating theatre efficiency may do the same (if they ever actually publish it, as opposed to press releasing it).

Machine learning

Clearly, we’re not going to see NHS reform legislation any time soon: Parliament is fully occupied with the hog whimpering stupidity of Brexit, and Lord Lansley’s legislation means that the Conservatives are traumatised on health policy for a generation.

But the exam question we need to address is this: as we improvise system rules and vamp till a new system design arrives, what are the unintended consequences of the current move away from the NHS as ecosystem and towards the NHS as a big machine.