There is a need for solutions based on a full understanding of the reasons behind the variation and complexity in service delivery, writes Alastair Beattie
In 1981, when I started working in the Statistics Section at the Regional Health Authority in Newcastle upon Tyne, every health authority had its own logo.
Yet by 1991 when Margaret Thatcher introduced the purchaser-provider split, every purchaser and every provider developed their own; so there were hundreds. They reflected and encouraged variation between different NHS organisations, for example, in management cultures and computer systems.
It wasn’t until 1999 that the now familiar blue and white NHS logo was even introduced.
But: the providers and commissioners still have their own cultures, care pathways and a great diversity of computer systems.
The starry-eyed question
In the 1990’s, now working in a hospital, I asked a colleague: “why isn’t the health service more like M&S”.
I really was naive!
Since then my job has evolved from producing statistics to understanding how data is collected. To how care pathways are organised and how this knowledge needs to inform informatics, and (finally) the safe implementation of clinical computer systems. And so I can now answer my own question:
Because the NHS may be nationally funded but never has been integrated.
Before this can we first need to understand the local and national history of the last 70 years, so we can fully appreciate what needs to be overcome.
A catastrophic combination
So: What if Marks & Spencer was run like the NHS?
Staff in one store would not know how the others worked – for example, the till systems would be different. There could also be several different computer systems in every store, and they wouldn’t easily be able to talk to each other.
Terminology would be different too. A pie in one store would be called a flan in another, and their contents would differ too! The people at head office would not understand the extent of this variation, and may conclude falsely that one store was not providing enough pies!
The branches would be deluged with data requests, but the findings would often not make sense because the questions would be interpreted differently by each store
For example: hand surgery in one trust is done by orthopaedic surgeons, but by plastic surgeons in the next. An electronic referral from a GP for a suspected basal cell carcinoma will need to be made to the dermatology department in one trust but to the plastic surgery department in another.
As “M&S” would be publicly funded, with no charging, there would be great public scrutiny, and “M&S” would regularly be the leading news item.
The branches would be deluged with data requests, but the findings would often not make sense because the questions would be interpreted differently by each store. Not that this would stop them being used to generate media stories, which may then lead to new policies for the stores to implement!
There wouldn’t be a “store card” as there wouldn’t be a central function to coordinate it. Each store could run its own system, without any of them being interoperable. The customer would have to identify themselves to the cashier and hope that the points were allocated to the correct record. The electronic records of the goods received may contain details of another customer with the same name, and parts of the record may be held on paper.
Race of larger and smaller stores
The larger stores (aka hospitals) would need to regularly supply lots of data to head office, with staff on the shop floor expected to collect detailed statistical data about each customer. Smaller stores (aka GPs) would not have to shoulder so great a burden. They would have till systems that worked well operationally for them because their business is less complicated, and had not had several years of data requests.
There would be M&S stores in many locations, but the quality of the service, the staff cultures and the range of items on sale would vary greatly
Head office would have to accept that it did not understand much about the small stores, in comparison to what it knew (or thought it knew) about the larger ones. Frontline staff would be under pressure not to get the statistical data wrong, because of the implication for the funding and reputation of the stores.
There would be “M&S” stores in many locations, but the quality of the service, the staff cultures and the range of items on sale would vary greatly, and there would be no easy way for the customer to know what each store offered.
If the people at head office had never worked in one of the stores then they would find it incredibly frustrating!
Never about ‘plug and play’
There would be a conflict between doing what’s best for the customer and what’s best for the shareholder; just as in the NHS the conflict is between doing what’s best for the patient and what’s best for the taxpayer.
People who have worked a long time in the NHS implicitly understand the complexity and its reasons, but it’s not easy to communicate why and how “the NHS is different” to new people. Perhaps this analogy will help!
Once we all appreciate all of this we should be better equipped to ask the right questions and work on solutions and they won’t be ideal to the complex system and integration problems we face. It’s never going to be about “plug and play”.
Finding even partial solutions to make an improvement means that we will have better served our two customers – the patient and the taxpayer.