Development of resilient health policy is possible only when different and opposing voices are heard or else we will keep yoyoing between half baked solutions, notes Richard Taunt

Board talk

In Cape Town, the clock ticks towards Day Zero.

After three years of drought, no one is unaffected. Fights break out at natural springs. Farmers transfer water from the countryside to the city. Restaurant goers are asked not to flush the loo unless, you know, it’s strictly necessary.

Currently, the day when the water runs out – Day Zero – stands at mid-July. It doesn’t need much rain to end the drought but, if it doesn’t come, then the taps get turned off. Planning for 200 water distribution points outside grocery stores is long underway.

Back in Britain, our own countdown started some time ago.

In 2011, seven out of 10 medical students finishing their core training went straight on to specialty training. By 2015, this had fallen to five in 10. By 2017, it had fallen to four. While this fall made the news when it was announced last week, it wasn’t on the front page. If not now, then when? When it falls to two in 10? To one?

This fall could simply be about millennials having a greater penchant for taking a year or two break than their predecessors. But what if it wasn’t?

How were vanguards definitely, absolutely the right answer, then suddenly, definitely not? How was clinical commissioning the one thing everyone could agree about, then suddenly forgotten?

We have over 40 statutory bodies and agencies working on issues relating to the NHS workforce, not to mention 16 Royal Colleges, 18 trade unions, and over 100 professional and specialist institutions. How many people across those organisations are thinking about what happens if we don’t have any doctors?

Not just the need to recruit more from overseas, but unfillable vacancies at an endemic level. Who is thinking about what we would do if our supply of doctors reaches Day Zero?

The answer is no one. Of course it is. Not just because creative workforce policy is criminally underdone, but because in English health policy we think in herds, in gusts, in groups.

In 2015 the future was vanguards. In 2016, sustainability and transformation partnerships. In 2017, integrated care systems. Like eight year olds playing football, we all rush after the ball, ignoring the possibility there might be value to being elsewhere. How were vanguards definitely, absolutely the right answer, then suddenly, definitely not? How was clinical commissioning the one thing everyone could agree about, then suddenly forgotten?

Questioning is important

We simply don’t do nearly enough questioning of whether the answer that we’re all convinced is right, is right after all. This matters. If we stopped to think about what we were doing before rushing off, chances are we wouldn’t change course so often. But also we’d stand a better chance of exposing what we didn’t know we didn’t know.

This isn’t about individual policymakers in national bodies or think tanks (if it were, as a veteran of both, I’d be completely culpable). Rather, our systems and institutions are not strong enough to support the level of debate and discussion we need to make resilient policy.

This is what the Israeli intelligence agencies realised following the October 1973 Yom Kippur War. Too much group think had meant Israel had failed to foresee an impending attack by Egypt and Syria. In response, to ensure different and opposing voices were heard, a “devil’s advocate” office was created within AMAN, the main intelligence agency, with the power to criticise and pick holes in their colleagues’ thinking.

We simply don’t do nearly enough questioning of whether the answer that we’re all convinced is right, is right after all

It was given experienced and talented staff, and has been listened to even when the wider establishment thought their ideas unlikely or improbable. A further reform gave all analysts across the agency the ability to write a “different opinion” memo in which, again, they could criticise the conclusions of their department without reproach.

The changes weren’t imposed on the agencies by others, but came from a feeling within that their professional tools and procedures weren’t up to the task of the challenges they faced. They didn’t wait for someone to tell them they needed to change, they did it themselves.

Somewhere, the NHS’s Day Zero is coming. It might be about medical staffing, or something completely different. But would we be prepared? Would we even know it was here? And how can we be better prepared in the future?