“For every complex problem there is an answer that is clear, simple, and wrong.”
H L Mencken (http://www.brainyquote.com/quotes/authors/h/h_l_mencken.html )
I worked as a Non Executive Director on the boards of several NHS Trusts for about eighteen years. That association was both frustrating and educational. One thought remains with me: the NHS is one of the best innovations enacted by post-war politicians. The underlying beliefs are simple: health (like education) is a human right and a strategic national asset. It is not a commodity of choice where provision can be manipulated to suit political economic fashions. All effort must be made to extract the most out of every penny spent but beyond that citizens’ health costs what it costs. This simple fact cannot be turned into a political debating topic. Successive ‘reforms and reorganisations’ should have started at that point instead of focusing on costs, privatisation, or whatever else that came to hand at the time.
Better quality costs less (see better-value-low-cost on this website) The concept is not alien to healthcare professionals in the United Kingdom. For instance, in May 2012 a paper entitled ‘Improving Quality Reduces Costs- Quality as the Business Strategy’ was produced for NHS Wales.[i] The idea is accepted as self-evident good business practice within the public and private sectors but successive ‘reforms’ of the English NHS failed to recognise this point in practice.
The reason for this myopic viewpoint is easy to understand. The English NHS is controlled by national government in London. It is, therefore, subject to national political and economic pressures and whims as well as inflated personal ambitions. The outcomes from these factors can be seen in the high frequency of so-called reforms and reorganisations dictated by political timetables and cabinet reshuffles. They were invariably driven by top-down management dictates implemented through command-and-control. Frequent reorganisations have been disruptive, but worse they have also met with little success which explains their multiplicity and frequency.
The aim of this posting is to highlight the negative consequences of the above style of management for a key public service. This focus necessitates a closer look at the intrinsic nature of the NHS as a system. Essentially, there are two types of system: mechanistic systems and complex systems. A rocket in flight or a car assembly line are examples of the first type. On the other hand, living organisms and organisations involving large numbers of linked people are examples of complex systems. These have many internal elements that interact to produce emergent properties (such as life) that could not be ‘designed’ by simply putting the individual parts together. Predictability is in short supply under these conditions and the law of unintended consequences reigns supreme here.
The NHS is a complex system
The complex nature of healthcare is beyond dispute these days and no attempt will be made to argue this case afresh.[ii] Those occupying top levels of management within the NHS are familiar with this ‘inconvenient’ characteristic. Top-down and command-and-control styles of management are not only useless in complex situations. They are positively harmful. This conflict explains the high failure rate of NHS ‘reforms’ pushed through by governments since 1970s, and why each bout was then followed shortly thereafter by another upheaval. The nested complex systems involved in healthcare; patient, GP, social care, political system, society,… were highlighted by a document published by the NHS in 2005.[iii]
Despite the above, decision-makers continue to treat the English NHS as a mechanistic system that would respond to centrally imposed rigid planning principles. Most of what is presented below shows an effort forcefully to disaggregate components of these nested and closely linked systems in what appears to be an endless search for a setup that would quickly provide effectiveness, efficiency, and savings as well as opportunities for privatisation.
One aspect should be highlighted: every reorganisation involved the departure of many experienced staff at great cost and the promotion of others from lower ranks again at additional costs. There then followed a period of training for the new appointees who were then replaced at the next reorganisation. This would be almost comical if it were not so tragic for the NHS, its management, its finances, and above all the patients it was set up to serve.
Concepts of ‘culture’ and ‘attractor’ in complexity
These two significant features from complexity have influenced reforms considerably. As Chapman (2002:41-42) pointed out, “Severe changes to the environment may force an institution to make changes to its staffing levels and organisational tree, but it will remain recognisably the same institution. What is conserved is its internal organisation, core values, and culture.” The more politicians and senior managers sought to ‘reform’ and ‘reorganise’ the NHS the more it stayed the same, much to their irritation. In the face of that obstinate ‘resistance’ to change they sought, mostly in vain, to have their way through a succession of hard management actions conceived and applied from the top to achieve ‘culture change’.
Griffiths, charged in 1983 with the task of producing a radical reform of management in the NHS, commented in his letter to the Secretary of State: “To the outsider, it appears that when change of any kind is required, the NHS is so structured as to resemble a ‘mobile’ designed to move with any breath of air, but which in fact never changes its position and gives no clear indication of direction.” NHS culture, luckily, still manages to survive but it is under attack.
The second feature is the concept of ‘attractor’ familiar in studies of complex systems.[iv] There are obvious political, social, and economic limits that constrain the ‘shape’ the NHS could realistically assume at any point in time. Decisive politicians and managers appear and then depart throughout the history of the NHS but what they thought were radical reorganisations turned out to be variations on themes visited by past leaders. Observers are perplexed, and sometimes amused, by these repetitive bouts of reorganisation.[v] Complexity suggests that the multiplicity of so-called reforms simply cycled through a well-trodden attractor that limited what form the NHS could practically take. The length of this posting was dictated by the need to describe the various ‘reforms’ sufficiently to illustrate this point. Reforms simply meander through repetitive cycles.
The attractor within which actions were confined was in evidence for most of the history of the NHS and certainly since the 1970s. But of course each minister claimed credit for ‘fundamental reforms’. This frenzy of “redisorganization” (Oxman et.al., 2005) is not new[vi], and it has been roundly criticised. One commentator described the situation unambiguously: “Successive ‘redisorganisations’ of the NHS… have left the service seriously weakened… Apeing managerial fads and fashion in the commercial sector…over-simplifies the complexities involved in a public service with multiple, and often conflicting, objectives.” [vii] Whistle-blowers have been trying hard to say so without much success.
Essentially a straightforward system
The key elements of the healthcare system are reasonably clear. First, there is a tripartite that forms the basic building blocks of health provision; hospitals, primary care provided through doctors’ surgeries, and community health services that offer care in community settings. The debate is mostly about how these three branches are organised in relation to each other; integration under one overarching organisation or dispersal over a multiplicity of providers, public and private. Dispersal; preferred by privatisers, breaks many essential linkages and has to be approached with that risk in mind.
The second dimension relates to purchasing (also known as commissioning) and provision. The fundamental options are also readily obvious: should the two elements be undertaken by the same organisation or should they be divorced; integration or separation. A market approach requires the latter but once again imposes higher levels of cost associated with broken linkages and transaction costs. Reorganisations regularly ignore this requirement.
The third dimension is the interplay between health care and social care. This is possibly the most problematic, and one in which complexity is revealed even more plainly. The debate here centres yet again on whether to bring the two together within one authority or to separate them in more or less independent fiefdoms.
Health and social care inhabit a predominantly complex arena. It is useful to illustrate the mounting levels of complexity by the use of a Stacey diagram as shown below.[viii] The limited zone near the origin where the two axes meet offers conditions that are reasonably mechanistic and therefore amenable to universal rules and central regulation (and yes possible privatisation). Cataract operations, for instance, fit into this near-mechanistic zone.
Beyond that limited portion, a zone of complexity exists in which central regulation and universal rules become progressively less appropriate. Integration is critical here and attempts at privatisation become gradually more problematic. Many hospital activities, a larger proportion of the work undertaken by GPs, and much of that provided through community health services demonstrate this essential need for integration. Numerous enquiries convened after tragic events have concluded that ‘the victim fell between the cracks’.
If one moves further to the right of the figure and beyond the ‘zone of complexity’ one enters a near chaotic field where control and management become infinitely more difficult and costly. Older age conditions, mental health, addiction, etc. are examples of demands that would be risky to hand over to diverse operators; including of course those from the private sector. Integration is of fundamental importance here and is compromised at great risk.
Treks in search of perfection
Bevan, Minister of Health in the Labour government that came to power after the Second World War, was the architect for what was a revolution in healthcare when the NHS was created in 1948: a service free for all at the point of use and financed through taxation. Purchasers and providers were integrated and administered by one institution.
In the early years, changes took the form of adjustments as opposed to the root and branch reorganisations seen from the 1970s onwards. Gwyn Roberts, professor of Management Science at the London School of Economics suggested in 2006 that those in the NHS viewed each successive reorganisation “as having a half life of two to three years before it is either abolished or displaced by another.” (Glasby, et.al. 2007)
The three phases adopted by Gorsky (2008) in his excellent review of the history of sixty years of the NHS are generally followed here:
- First phase, ‘Foundation’ (1948 to 1979).
- Second phase, ‘Thatcherization’ (1979-1997).
- Third phase, ‘New Labour’ (1997-2008).
Another phase was added; ‘Darzification’, to bring the discussion closer to the 2013 Act.
The Health and Social Care Act that came into force; some said appropriately, on the 1st of April 2013 is not considered here, as sufficient time has not elapsed to enable the consequences to be assessed.
First Phase, ‘Foundation’ (1948-1979)
There were a number of minor changes but this period saw one large project; the 1962 Hospital Plan, and one major reform; the 1974 NHS Reorganisation. The aim of the 1962 Plan was to create a hierarchy of specialised Teaching Hospitals, at the top, and local District General Hospitals (DGH) and subsidiary health centres, lower down. Darzi revisited this idea as described later! Enoch Powell, Minister of Health at the time, boasted that the government was planning the hospital service on a “scale not possible this side of the Iron Curtain”[ix]. Financial and operational pressures resulted in scaling down of the project and affected its ambitious timescale; an indication of things to come.
The 1974 NHS Reorganisation created Area Health Authorities, with mostly the same boundaries as local authorities to bring health care and social care closer together; a significant move towards integration. Shared boundaries between health authorities and local authorities, however, were lost in another reorganisation in 2000 that ultimately created 303 NHS Primary Care Trusts (PCTs). Yet another reorganisation in 2006 restored the linkage when PCTs were reduced to 152 that mainly have the same boundaries as local authorities! Meandering within the ‘NHS attractor’ was in evidence then and continued thereafter!
The 1974 Reorganisation underlined the need for consensus in the management of healthcare giving all stakeholders a voice in reaching decisions. As mentioned later that approach was reversed by the 1983 Griffiths review during the Thatcher years but then in recent years a return to the need to involve stakeholders; at least in spirit, was revived once again. Difficulties experienced by some recent whistle-blowers in the NHS suggest a different story. The meandering saga continues!
The 1976 Priorities for Health and Social Services report called “for a shift away from hospital treatment to primary care, particularly for the elderly and those with long-term conditions.”[x] The most recent reforms that were started at the turn of the twenty-first century, including the Darzi plan of 2008, called for similar changes. Moreover, the newly appointed head of NHS England expressed the same viewpoint in May 2014! This cyclical process is a feature that recurs over and over again in the history of the NHS.[xi] Basically, constant repetition of the same aspirations is a clear indication of inaction and/ or failure.
Second phase, ‘Thacherization’ (1979-1997)
Walshe (2003) listed no less than eighteen major NHS “reform and restructuring” upheavals between 1980 and 2003. That level of turmoil and distraction left its mark on the NHS. The political economy shifted to the right with a move away from welfare to market norms and this change in direction was continued when New Labour came to power in 1997. The preferred approach for the NHS became increasingly focused on obsessive bouts of reorganisation aimed at treating the healthcare system as a marketable business. The new format relied heavily on powerful management from the centre. Consensus was seen as an obstacle to fast implementation of difficult ‘reforms’.
The shift was brutal and not accidental. The 1983 Griffiths management review was a key event. Significantly, it was presented in the form of a letter to the Secretary of State: “we had not been asked to prepare a report, but that we should go straight for recommendations on management action…Speed of implementation is essential.”[xii] The authors of the review made a telling observation: “In short if Florence Nightingale were carrying her lamp through the corridors of the NHS today she would almost certainly be searching for the people in charge.”[xiii] Assertive management, described by some as Stalinist in later years, remains as a preferred means to manage the NHS.[xiv] Growth of whistleblowing was and is a natural consequence of that approach.
The 1983 Griffiths review made two statements that should be highlighted as they point clearly to this persistent command-and-control mentality:
- “The Secretary of State should set up… “a full-time NHS Management Board…to plan implementation of the policies…give leadership…control performance…”
- Working “in consensus management teams where each officer has the power of veto” to be inappropriate for the business based NHS. This remains the prevailing option.
The ‘Thatcherization’ era launched another associated shift: the introduction of the internal market which sought to separate purchasing (commissioning) from provision by means of general practitioner fundholding implemented in 1991. This gave GPs (who chose to join the scheme) their own budgets from which to purchase health services for their patients from providers selected by the GPs concerned. A 1996 report, Choice and Opportunity called for more providers of primary and community care from the private sector but the Conservatives were unable to take this further when they lost power in 1997.
Third phase, ‘New Labour’ (1997-2008)
Tony Blair and his close associates changed the Labour Party almost beyond recognition. It moved substantially to the right of the political spectrum. GP fundholding was abolished a year or so after the Labour Party came to power, but that seems to have been based more on tactical grounds than anything else.[xv] The scheme was re-launched later as Practice Based Commissioning. The split between commissioning (purchasing) and provision was retained.
The process of Labour health reforms gathered momentum with a flurry of reports that were said by their authors to be ground-breaking. Shifting the Balance of Power, published in July 2001 went back to the not unexpected idea that primary care should play a bigger role. That was followed shortly thereafter by the creation of over 300 Primary Care Trusts “to improve administration and delivery of healthcare at local level.”[xvi] Inevitably, an NHS Improvement Plan published in 2004 focused on “putting people at the heart of public services.” At this point ‘patient choice’ was introduced to allow those who have waited a long time for treatment to select one of several providers; including those from the private sector. Independent Sector Treatment Centres (ISTCs) were introduced to encourage further private sector presence under the NHS umbrella. By 2011 the number of ISTCs had grown to over 150. These new private organisations remained a problematic element in the new structure despite strenuous efforts by the NHS to help them in a variety of ways including guaranteed referrals and financial incentives.[xvii]
Another feature of Labour’s agenda was the use of centrally set targets, monitored by the Healthcare Commission. The targets themselves attracted widespread criticism. Partly in response, a Standards for Better Health document was issued in 2004 with the declared aim of cutting targets. These were renamed ‘standards’ and were reduced to ‘only’ 7 domains; with 24 core standards and 37 sub-headings, coupled with 13 developmental standards; with 21 sub-headings!
A new shake-up in 2006 reduced the 303 PCTs created in 2002, Strategic Health Authorities having been reduced from 28 to 10 earlier in the same year. Management turmoil continued unabated! According to the NHS, the SHAs were set up “to manage the local NHS on behalf of the secretary of state.” Senior managers at the PCTs ignored dictates from their SHA at their peril! There was minimal local discretion. The boundaries of the new PCTs were almost identical with those of the local authorities bringing the boundary situation back to 1974! The PCTs underwent yet another major change by spinning off their provider functions to complete separation between purchasing (commissioning) and provision. The PCTs were finally abolished in 2013. NHS reorganisations continued in ever decreasing circles!
Before moving to the next phase, it is helpful to mention a joint report (‘Is the Treatment Working?’) published in June 2008 by the Audit Commission and Healthcare Commission on NHS reforms from 2000. The press release launching the report said, “…that further nationally imposed structural changes should be avoided as progress to date has been hampered by two major reorganisations since the reforms were introduced.”[xviii] It was consistent with established practice that a further reform would be published a month later.
Fourth phase, ‘Darzification’ (2007-2010)
This phase takes its name from Lord Darzi, a doctor with an excellent international reputation in the field of minimally invasive surgery, who was appointed in 2007 as Health Minister. He was brought in to initiate another radical reorganisation, possibly the most ambitious in the history of the NHS.[xix] Referring back to the concept of the ‘attractor’, however, it was inevitable that his ideas when they were published were seen as throwbacks to previous attempts at reform. It was also inevitable that they would be abolished and replaced by yet another ‘reorganisation’; see below.
It is useful to quote the words of the Secretary for Health on 4 July 2007 when he announced the project in Parliament: “Doctors, clinicians and nurses complain that they are fed up with too many top-down instructions, and they are weary of restructuring. They want a stronger focus on outcomes and patients, and less emphasis on structures and processes… If the morale and good will of the profession is dissipated, our capacity for bringing about improvement for patients diminishes.”[xx]
As happened many times before, promises not to indulge in further upheavals are routinely followed by yet more of the same. An extensive plan to reorganise services in London was developed first and that was then extended to other areas. In the Summary Letter of his interim report in October 2007; Our NHS Our Future, Lord Darzi came down firmly in favour of revolutionary change in preference to evolutionary change. He argued, the NHS “could therefore continue to make incremental improvements… It would mean accepting steady progress rather than a step-change … Alternatively we can choose to be ambitious and set out a clear vision for a world class NHS focused relentlessly on improving the quality of care. I believe that only this approach allows us fully to respond to the aspirations of patients, staff and the public.”[xxi]
The above statement expressing clear preference for revolutionary change for the NHS is of critical significance. To be fair to Darzi he did not say anything that previous ‘reformers’ would have disagreed with. However, the statement suggests that superior medical knowledge does not necessarily guarantee understanding of the complex interconnected nature of the healthcare system. Darzi, possibly influenced by his experience in operating theatres, clealry believed he was dealing with a mechanistic system that could be designed clockwork fashion from the top.
The 83-page Next Stage Review was published in mid-2008.[xxii] In line with past practice over the decades, the Prime Minister said in his preface, “As a Government the renewal of the NHS must be one of our very highest priorities and we will rise to the challenge you have set us.” It is not readily known who set the challenge as most people in the NHS have had enough of radical reforms as the Secretary of Health said only a year before (see above)! Nonetheless, the report advanced aspirations that no one could disagree with: quality care, patient-led service, clinician involvement, NHS constitution, vision, training academy, etc. However, underlying all that there was a definite structural master plan that proposed substantial changes in the buildings from which care is to be provided and the organisations, and workforce, that would provide that care in the new locations.
The plan was the ultimate in clockwork reductionism. The components must come together at the same time and in the correct manner for the overall plan to work. Hospitals are redesigned, and reduced in size, to fulfil precise functions. Primary and community care are reconfigured to do much of the work previously undertaken in hospitals in addition to their traditional activities. Functionally appropriate buildings for the new plan must be ready on time to welcome the influx of new patients and, even more of a challenge, clinical and administrative staff in the exact skills and numbers must be there to treat them. There is no margin for error and no going back from the Master Plan.
Other reports followed from the centre to give more details on the implementation of the plan. In January 2009, for example, Transforming Community Services[xxiii] was published and made it clear right at the start that a quality service “requires transformational change- by clinicians and other front-line staff, by the organisations providing community services and by commissioners.” The transformation affecting both commissioners and providers was extensive and, by its very nature, disruptive when undertaken quickly. The private sector was expected to feature large in the new vision.
Lord Darzi’s reforms included a radical shake-up of hospitals as well as primary care. The reaction to the reorganisation followed similar lines in general: on their own the various ideas were good but put together as part of an integrated plan they raised serious issues of concern. Remarks made by Parliament’s Health Select Committee and the British Medical Association typify that reaction. The BMA, for instance, commented that the association “reiterates our concerns that GP-led health centres have been introduced without proper pilots or evaluation.”[xxiv] There was a clear push to attract private operators to primary care through new arrangements such as Alternative Provider Medical Services (APMS). These again were not optional extras; they were essential components of the plan. They had to be there to treat patients relocated from hospitals.
District General Hospitals (DGHs); introduced progressively from the 1962 Hospital Plan, had no place in the Darzi plan. Some would become acute major hospitals dealing with non-elective and complex care, and some would be turned into local hospitals offering non-complex care and limited accident and emergency services with some medical beds. Elective and routine surgery as well as diagnostics would be undertaken in the local polyclinics. There would be specialist hospitals at the top of the hierarchy as well as academic health and science centres of excellence. The sensible intention behind the reorganisation was to reduce the need for patients to go into a hospital (as was proposed back in 1976 and as was proposed yet again in 2014!) unless it was absolutely necessary and for hospitals to offer services that could not be provided more locally in the community. On this basis, hospitals were being redesigned or built with reduced bed numbers.[xxv] Most hospitals were expected to become independent Foundation Trusts with obvious possibilities for private sector takeover. Dispersal of provision over a wide range of organisations in competition with each other was an essential, but not a new, aim in the Darzi reforms.
The Darzi plan took past attempts at English NHS reform since 1979 to their ultimate conclusion. The inevitable was bound to happen: when a new government; a coalition between Conservative and Liberal Democrats, was formed in early May 2010 one of the first acts of the new Health Secretary, Andrew Lansley, was to call a halt to Darzi’s plan both in London and nationwide.[xxvi] Reasons given for the rethink included lack of detailed analysis of the practical aspects and associated risks of proposals put forward by Darzi. In time the new government produced its own radical reorganisation in the shape of the Health and Social Care Act of 2013. The jury is still out on this latest adventure in NHS history.
Pitfalls of revolutionary change
Misdiagnosing the NHS as a mechanistic system that could be redesigned and managed from the top in a command-and-control fashion has caused no end of trouble, expense, and misery to patients. Darzi’s Plan simply took this clockwork approach to its extreme. There are obvious reasons why such an approach was doomed to failure. The following pitfalls are presented simply to indicate the most elementary risks:
1) An efficient market could not operate without reliable information. In the reorganised public/ private NHS this was an urgent requirement and a major hurdle. The days when the patient was known to the doctor were virtually over.[xxvii] The NHS launched the National Programme for IT (NPfIT) in 2002 to hold, among other things, records on millions of people that doctors anywhere could access. The cost was put at that time at about £2.5 billion; not unreasonable for “the biggest civil information technology programme in the world.”[xxviii] Costs soon soared to £20 billion. The new IT system diverted money and staff resources from healthcare![xxix] NPfIT was finally abandoned.[xxx]
2) Workforce for a “step-change” plan proved to be another insurmountable problem. The NHS provided for decades an integrated organisation that allowed clinicians to work, and be trained, at different locations as part of their normal working life. Separation into independent silos meant that such movement would be difficult if not impossible. A study in orthopaedics revealed serious concerns expressed by patients, GPs and surgeons.[xxxi] Where competent clinicians, radiologists, and surgeons would come from, and in the right numbers, was unclear. Just as important how would the next generation of surgeons and doctors with special interest (GPSI) be trained? Staff shortages are now an endemic feature of the ‘reorganised’ NHS, but much more was needed for the intricate plans to work.
3) There was hardly any appreciation of the additional costs imposed by a dispersed market led healthcare system. A vast amount of information has to be collected, verified, stored, and transmitted by one party and then received, checked, stored and then responded to by the other party. The process never stops. Because of the temptation to cut corners the information has to be checked against actual delivery through more time-consuming verification activity. In the health service, information security in storage and transmission is a high-risk issue that puts further demands on all involved. All this comes on top of the need for service specification, invitations to tender, preparation of bids, assessment of bids, selection of best provider, contract negotiation, and then monitoring of delivery.
Transaction costs and their association with a dispersed market-based healthcare system is seen best in the US system where the “proportion of health funds devoted to administration… has risen 50% in the past 30 years and now stands at31% of total health spending…” (Woodlander and Himmelstein, 2007) [xxxii] Tudor Hart (2006) suggested that in the past administration, transactions, legal support and profits for contractors accounted for less than six per cent of total spending on health care. This grew to about 12 per cent by 2004 and was approaching 20 per cent in 2006. Other figures have been given in answers to Parliamentary question but it is self evident that administrative costs would increase in step with the move to a fragmented market-based healthcare setup.[xxxiii]
4) Professor Eric Wolstenholme and Liz Wolstenholme described another key risk of dispersed patterns of health care; disruption caused to the care pathways patients have to negotiate when organisational boundaries multiplied. “The more autonomous boundaries patients cross the greater the number of disconnects and duplication of activity. The resultant bottlenecks can seriously affect the achievement of performance targets and stretch managerial resources to the extreme in a search for ways of coping. Many of these measures led to cost escalation that the changes were intended to reduce.”[xxxiv]
This is possibly the most frequently criticised aspect of recent reforms by clinicians and health workers. Three emeritus professors of general practice addressed the issue when they considered the unintended consequences of ‘reforms’, and market-led fragmentation of NHS services. They wrote that the “most serious consequences of the current reforms arise fromthe tinkering with the model of patient led personal care givenby a known GP in favour of episodic delivery of a top-down agendaby any of a variety of healthcare workers in a variety of sites.The best of the past is in danger of being lost without sufficientproved benefit in return. Our conversations with doctors inpractice suggest that many share our concerns; so too do manypatients.”[xxxv]
The above examples were given to highlight one specific point: in complex situations self-evident ideas that seem reasonable and attractive when viewed in isolation quickly generate a multiplicity of serious risks when they are grafted onto the system. There is a vast difference between an industrial assembly line and managing a healthcare system.
Public finances are currently under the microscope and the amounts available to healthcare might well be affected negatively. Similarly, the demands for healthcare are certain to increase. Commentators agree that billions made available to rescue the economy at home and abroad will have to be paid for in future through higher taxes and reductions in public spending. Private Finance Initiatives (PFI) have been exposed as very costly expedients to bury the facts for a while. The consequences are now emerging with a vengeance.[xxxvi]
The pitfalls mentioned above might seem all too obvious at a time when so much is known about complex systems and the ‘soft’ management needs they impose. And yet, reforms within the English NHS over the years suggest that those in charge consistently, and apparently illogically, adopted inappropriate ‘hard’ mechanistic management styles. Those involved in healthcare pride themselves on evidence-based decision making, but when it comes to the most fundamental changes imposed from the top on the NHS this principle is suspended for some reason. This raises a key question: why do they do it?
Is it because they do not understand the nature of the healthcare system? This possibility is easy to reject. Many eminent clinicians and academics have written about complexity in healthcare and their publications are widely available. The British Medical Journal has also published several well-research papers on the subject.[xxxvii] The King’s Fund, Nuffield Institute and NHS Leadership Centre held a conference as far back as January 2003, ‘Forward Thinking’ on the same theme. A couple of months later, in March 2003, the Mayo Clinic in the USA organised an event on ‘Complexity Science in Practice’.
The NHS Modernisation Agency published ‘Working with Systems’ in 2005 that described in detail the appropriate way to manage complex situations. On page 29 it presented the chart below (based on an American publication) which outlined a reiterative management format that is often quoted within the NHS: Plan, Do, Study, Act.
In October 2008, the NHS Institute for Innovation and Improvement announced the launch of an Academy for Large Scale Change following Lord Darzi’s review. The link to complexity is evident: Paul Plsek, known for his valuable contributions in that field, was appointed as Academy Director. Moreover, lean technology is known and practiced within the NHS.[xxxviii] In short, one could not suggest that the NHS is unaware of the close association between complexity and healthcare.
Or do the problems of the English NHS stem from the close association between national politics and healthcare in England? Walshe (2003) put this succinctly: “No other national public service in the UK is so directly managed from Whitehall (except, perhaps, the armed forces), and none is subject to such detailed and continuous political intervention. No other comparable European country has a health service run by central government, even in countries where the state plays just as large a role in funding healthcare through taxation.”
A new party coming to power after an election feel obliged to show that the previous administration was at fault in what it did to the NHS and then move on to suggest how the this will be rectified by the new administration. The process seems unstoppable. The next trigger for NHS ‘reform’ on this basis will follow the general election in 2015.
A change of party is not the only trigger for the next wave of reform. Each individual prime minster, secretary of state for health and their senior civil servants feel obliged to ‘leave their imprint’ on the NHS. This is not theory. Lord Darzi’s review was announced shortly after Gordon Brown became prime minster. Successive reorganisations can be synchronised with the comings and goings of politicians and their senior civil servants.
Sadly the revolving door between business and politics (see Hertz: 2001) is another trigger these days. There is a natural tendency for those who come fresh from the private sector to view healthcare in more mechanistic terms than those who have worked in the NHS for some time. The period of involvement of the newcomers is relatively brief. They do not stay long enough to cycle through planning, implementation and review. Hence, their contributions often prove to be inappropriate but by that time they had gone elsewhere.
A number of ideas have been put forward to provide a higher degree of independence for the NHS.[xxxix]Interestingly, David Cameron, when he was leader of the Conservative opposition, announced in a speech to the King’s Fund on 9 October 2006 that he would promote a bill to give the NHS greater independence by taking politics out of the NHS. Previously two minsters in the Labour government also proposed giving a charter to the NHS similar to that enjoyed by the British Broadcasting Corporation (BBC).[xl] Unfortunately, these proposals remain unfulfilled.
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Harle, D. et.al. (2009), ‘Community-based orthopaedic follow-up: is it what the doctors and patients want?’ Annals of the Royal College of Surgeons of England, 2009; 91: 66-70.
Gorsky, M. (2008), ‘The British National Health Service 1948-2008: A Review of Historiography’, Social History of Medicine, 21(3): 437-460, Oxford University Press.
Hart, J. T. (2006), The Political Economy of Health Care, Bristol: Policy Press.
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[i] MacArthur, H., Phillips, C. & Simpson, H. (2012) Improving Quality Reduces Costs – _Quality as the Business Strategy, Cardiff: 1000 Lives Plus
[ii] See for instance Holt (2004),Sweeny and Grffiths (2002) and Plsek and Greenhalgh (2001).
[iii] Working in Systems, published by the NHS Modernisation Agency in April 2005.
[iv] The most straightforward description of an attractor, given by several authors, is an air-conditioning system which allows the actual temperature of the room to vary continuously but only within preset limits.
[v] See for instance ‘Ten years of going round in circles’, The Sunday Telegraph: 25 February 2007, and ‘NHS reforms- a case of déjà-vu?’ http://news.bbc.co.uk/1/hi/health/4603740.stm .
[vi] Listing of the ‘reforms’ applied to health services in Britain up to 2008 are available in http://www.sochealth.co.uk/news/NHSreform.htm .
[vii] Professor David Hunter – head of the Centre for Public Policy and Health, Durham University and chair of the UK Public Health Association in a lecture at Birmingham University on 22 September 2005.
[viii] See also Sweeney and Griffiths (2002:65).
[ix] John Mohan, http://www.historyandpolicy.org/papers/policy-paper-14.html accessed on 2 February 2009.
[x] See Trggle (2006), ‘NHS reforms- a case of déjà-vu?’, http://news.bbc.co.uk/1/hi/health/4603740.stm accessed on 22 February 2009.
[xi] Public health, community health services, and primary care are repeatedly highlighted as though they are ideas recently discovered. The Report of the Sanitary Commission of Massachusetts submitted in 1850 to the state legislature left no doubt about what needs to be done in these fields (Evans, et. al., 1981)! These areas of work are still being rediscovered and advocated within the NHS.
[xii] Note from E. R. Griffiths to Secretary of State for Social Services, http://www.sochealth.co.uk/history/griffiths.htm , accessed on 18 February 2009.
[xiii] See http://www.bristol-inquiry.org.uk/final_report/report/sec1_chap_4_7.htm
[xiv] Sir Peter Dixon, chair of University College Hospital Trust in London said for instance: “I think there’s a Stalinist culture among SHAs [Strategic Health Authorities] that isn’t helpful.” Health Service Journal, 12 February 2009.
[xv] See Kay (2002), ‘The abolition of the GP fundholding scheme’, The British Journal of Medicine General Practice, 52(475): 141–144
[xvi] http://www.nhs.uk/Tools/Pages/NHSTimeline.aspx accessed on 20 February 2009.
[xvii] For further details on ISTC see Player and Leys (2008).
[xviii] See http://www.healthcarecommission.org.uk/_db/_documents/Is_the_Treatment_Working_Progress_with_the_NHS_System_Reform_Programme.pdf
[xix] See for example The Guardian, ‘Starting From Scratch’ 11 July 2007 and The Times, ‘Can Lord Ara Darzi Reform the NHS?’ 1 April 2008.
[xxiii] Transforming Community Services: Enabling New Patterns of Provision, Department of Health, Gateway Reference 10850.
[xxiv] BMA, Government must address flaws in its health reforms, 13 January 2009, http://web.bma.org.uk/pressrel.nsf/wlu/SGOY-7N8L2M?OpenDocument&vw=wfmms
[xxv] The process started some years ago. The UK has only 389 hospital beds per 100,000 inhabitants, even when taking into account both private and NHS beds. Denmark, Sweden and Spain have even less. This is fine provided services in primary care are geared to take the load. The Mail 12 January 2009. http://www.dailymail.co.uk/news/article-1113660/Were-worse-hospital-beds-Macedonia.html
[xxvi] ‘Lansley calls halt to Darzi in London’, S. Gainbury and D. West, Helath Service Journal, 19 May 2010. See also ‘Lansley orders halt to all Darzi plans nationwide’, I. Quinn, Pulse, 21 May 2010.
[xxvii] See ‘Personal touch lost in ‘pass-the-patient’, John Black, President, Royal College of Surgeons, http://news.bbc.co.uk/1/hi/health/7839235.stm
[xxviii] Nic Flemming, The Telegraph, 12 October 2004.
[xxxi] Harle, D. et.al. (2009).
[xxxii] http://www.theatlantic.com/business/archive/2013/03/why-is-american-health-care-so-ridiculously-expensive/274425/ accessed on 14 July 2014.
[xxxiii] Ashby’s cybernetic Law of Requisite Variety explains this feature clearly.
[xxxiv] E and L Wolstenholme, A Systems View of NHS reorganisations: the pain and cost of boldly going where we have been before, http://www.symmetricsd.co.uk/files/NHS_Reorganisation_-_A_Systems_View.pdf
[xxxv] ‘The state of general practice—not all for the better’,BMJ 2008;336:1310 (7 June), doi:10.1136/bmj.a172.
[xxxvi] The UK government treasury announced on 4 March 2009 that the government will lend money to Private Finance Initiative companies to continue to build projects for the public sector. In effect the government will become the lender as well as the purchase of the project which poses quite a challenge to the idea of PFI! See Nicholas Timmins, ‘Taxpayer set to fund fully PFI projects’, Financial Times, http://www.ft.com/cms/s/0/aeb2ccf6-085c-11de-8a33-0000779fd2ac.html accessed 5 March 2009. See also Nicholas Watt, ‘Hospital projects at risk in PFI credit crisis, warns leaked memo’, The Guardian 26 January 2009.
[xxxvii] A series of papers were published in 2001. The BMJ’s ‘editor’s choice’ in the 7 June 2008 issue was ‘Complexity theory’ and this referred to other recent papers on the same topic. See http://www.bmj.com/cgi/content/full/336/7656/0 See also A. Shiell, et.al. Complex interventions or complex systems? Implications for health economic evaluation http://www.bmj.com/cgi/content/full/336/7656/1281
[xxxviii] The NHS Institute of Innovation and Improvement published ‘Productive Series’ based essentially on small-scale application by local staff of lean technology to various healthcare situations including productive wards, productive community hospitals, productive operating theatres, etc.
[xxxix] See for instance, J. Glasby, E. Peck, C. Ham and H. Dickinson, ‘Things can only get better?- the argument for NHS independence’, Health Services Management Centre, School of Public Policy, University of Birmingham. http://www.newscentre.bham.ac.uk/documents/Things_can_only_get_better__the_argument_for_NHS_independence.pdf
[xl] http://www.guardian.co.uk/politics/2006/oct/09/conservatives.uk1 accessed 3 March 2009.