In his book Adapt: Why success always starts with failure, Tim Harford retells a moving and excellent story about Archie Cochrane’s efforts to conduct a clinical trial in a German internment camp.
Cochrane’s most famous book was Effectiveness and Efficiency: Random Reflections on Health Services published 40 years ago this year. In it he clearly set out the scarce resources imperative for health care to be cost effective. Anything less than this did not just mean wasted money, but wasted lives.
For Harford, Cochrane’s efforts at collecting clinical data was a counter to the ‘God complex’. This was the tendency amongst some doctors to dismiss the need for evidence on the basis that ‘they just knew what worked.’ Doctors are not the only ones to suffer from this complex of course.
More widely, Harford’s book emphasises, if not a new idea, a set of principles that certainly bear repeating: be willing to fail; make failure survivable; spot failure, face up to it and adapt to gain success.
This evolutionary or Darwinian view of human progress fits well with the way markets are supposed to work. Entrepreneurs take risks, some go out of business, but others survive by adapting to whatever the economic environment throws at them.
As in nature, survival is the definition of success. Winners don’t have to look pretty, the process doesn’t have to be fair and the extinction of many for the survival of a few has no ethical or moral implications whatsoever.
Is this somewhat brutal, uncertain and amoral world an environment we think would best suit the delivery of health care? One lesson from Harford’s principles would be that if such an environment proved too tough and the NHS starts to fail, then first spot that failure is happening and second adapt to deal with it. This (almost) fits the evolution of the Health and Social Care Bill since its publication in 2010. It’s an open question still whether the ‘adaptations’ (aka amendments) will ensure its survival.
An important question arising from Harford’s principles is the degree to which the NHS or health care in general - from the system as a whole through to hospitals and down to individual health professionals - can afford to take risks with failure. The price of failure could be measured in unnecessary death and pain. But the flip side is that leaving unchanged things that need changing - from a treatment regime, or the location of a hospital, to the organisation of a stroke service - also has a price.
As ever, perhaps, improving things, making progress, requires the freedom to experiment and make mistakes. Which means that top-down imposed command and control is out and decentralisation is in. But not always. Always well to remember a fourth principle: ‘Horses for courses’ .