Cowper’s Cut: The fear, the network and the path

In last week’s column, I wrote that “the government and its special advisors and supplicants are very, very scared about the NHS and they don’t know what to do”.

It remains blatantly true, but they are not the only people who are afraid.

The leaders of the NHS are afraid. They know that they have been – let’s say “encouraged” – to accept system control totals whose hallmark is heroic optimism, if not downright comic fiction of a kind to make the late Terry Pratchett come back to life with envy.

The money is going to go wrong. It is going wrong already in commissioning-land as the latest NHS England board finance paper noted. The interesting question is how quickly the desire for a more reality-based finance provider sector will dawn. First-mover advantage is A Thing.

Clinicians and their non-clinical colleagues are afraid. They know that the system is not any significant distance from an unmistakable and widespread care quality crisis. And winter has not yet hit.

Fear is a pretty terrible motivation. It’s also ugly mood music. Why does a safety-critical industry such as the NHS – healthcare – have the level of bullying and fear running through it at so many levels?

I wonder whether the uncertainty about effective improvement and management techniques in healthcare is part of this problem. Specifically, error in healthcare is obviously high risk, yet designing out failure and the acceptance of the importance of human factors is still in its infancy in the NHS.

Oderint, dum metuant

Lucius Accius, a tragic poet of ancient Rome, first came up with the tyrant’s refrain “oderint, dum metuant” – “let them hate me, so long as they fear me”.

The NHS was created to supply universal healthcare, and also to give the right answer to the centre.

Bullies have gone unchallenged and unsacked

I’m grateful for Ben Chu’s latest Independent column for reminding me of the useful concepts of network effects and path dependency.

The network effect is also known as “demand side economies of scale” – where a thing is more useful the more people who take part in it. Network effects can lead to bandwagon effects.

I think fear, and bullying, in the NHS has become a network effect among poor managers – and indeed sometimes among poor staff in clinical and non-clinical jobs. Bullies have gone unchallenged and unsacked.

It’s interesting to borrow my former colleague Mark Redhead’s observation on Twitter that “I hear a lot of people in the wider NHS say that they heart the NHS, but also go on to say that they are working in a toxic environment. To me this takes a lot of mental gymnastics”. Indeed.

Investopedia defines “path dependency” as ”an idea that tries to explain the continued use of a product or practice based on historical preference or use. This holds true even if newer, more efficient products or practices are available due to the previous commitment made. Path dependency occurs because it is often easier or more cost effective to simply continue along an already set path than to create an entirely new one”.

Unhealthy culture

A culture that has decided that to kiss up and kick down represents an effective management strategy is, to put it mildly, not a healthy culture.

Into this situation we will now introduce a fight between NHS England and the Department of Health and ministers (and possibly Parliament) over the mandate. NHS England’s board paper “to set out the results and implications of the 2018-19 Budget, and next steps”, was quite explicit that trade-offs will have to be made. NHS Commissioning Board’s CEO, Skipton House Sun King Simon Stevens listed the priorities as accident and emergency, mental health and primary care.

NHS leaders are used to listening to the order in which priorities are stated with care.

So what happens next? Mandate targets for cancer and A&E waiting time haven’t been met in A Very Long Time: just saying. Referral to Treatment waiting targets are the subject of big misses already at “Portsmouth, St George’s, Imperial, Barts, London North West, Kettering, Royal Orthopaedic” as my smart colleague Ben Clover noted.

Meanwhile, another smart colleague Lawrence Dunhill got the DH official response to the NHS England board meeting’s decisions, which is that “we are supporting the NHS with an extra £2.8bn by 2019-20 to make progress on A&E and waiting time performance, including £335m this year to help with winter pressures. We expect NHS England will use that money to make sure every patient gets the treatment they require in a timely way”.

Mmmm. It’s almost as if Simon Stevens has longstanding form for ignoring the shit out of things that won’t work.

Like dear old Lord Lansley’s 2012 Act, they may (as Hamlet put it of drinking culture) be honoured more in the breach than the observance.

Oh, and weren’t Chairman Mal’s comments about the NHS Commissioning Board being a non-partisan non-political organisation at the board meeting interesting?

I wonder at whom they might possibly have been aimed?