The Decline and Fall of the NHS
I have no doubt that the NHS is in the middle of failing. It has done remarkably well, and it will do remarkably badly. The whole of the UK will suffer as a result. We will suffer in our health, in our politics, in our education, in our economy, in our international reputation. We are in the process of throwing away what we learned over 70 years and we are throwing it away because we cannot see what was good and great, and what was dogma and dross that would sink us.
In rehearsing how all this works I would like to avoid the conventional political arguments: about funding, about control, about the undeclared ambitions of dark money from across the Atlantic. Those things are real and important, but it is even more important to understand the dynamics of internal decay and destruction, more akin to the fall of Rome than to a Turkish coup.
We can argue about Rome but the point is to notice a dynamic that goes inexorably to completion. Indeed the fall of all empires seems to happen swiftly and surely once the process of disintegration starts to happen. It is part of their way of being. What is the way of being of the NHS?
The three dynamics of failure
These three dynamics of failure necessarily overlap and intertwine. They are the same collapse described from different vantage points.
The institutionalisation of the NHS has happened alongside the development of a massive epidemic of long term health conditions. People are MUCH sicker than they were 40 years ago. Therefore, there has to be one question at the centre of our concern: has the NHS itself been part of the development of that tidal wave of ill-health? Or since readers of this blog know what I think of official dietary guidelines: is the NHS as an institution capable of determining its own role in this decline?
Dynamic 1 therefore is a perceived inability of the NHS to self-stabilise or self-correct its course at the level of the nation’s health. The NHS is veering off course without any steering mechanism that works to bring it back.
The great advantage the NHS has over other health systems in other countries is that it is properly universal. I keep bleating that the world is not flat. There are health issues that are foundational and there are ingrown toe-nails. If you want to promote the nation’s health and limit the cost of doing so, it is imperative to deal with the foundational issues: indeed it is worth spending whatever it takes to make an impact where it matters.
Dynamic 2 therefore is the perceived inability of the NHS to focus on what matters when it matters, to use its universal coverage to understand where to intervene in the health of the nation. The dynamic is to pay attention to a thousand things and miss the ones that directly affect survival.
The NHS has been completely colonised by Big Pharma who show every intention to bleed it dry. The ability of the NHS to defend its borders has been fatally breached by its choice of friends. The industrialisation of healthcare is far advanced and probably irreversible. The rate of overtreatment and over-prescribing is huge. Patients know this is not about them.
Dynamic 3 therefore is an inability to distinguish friend and foe leading to a race to gouge NHS resources before they run out. The dynamic is to lose management control to giant corporations with quite distinct interests, in a way that naturally escalates.
Another way to say all that would be to say that the NHS has no meaningful strategy for its universal coverage beyond drumming up political support for its begging bowl. And of course when I try to engage anyone in the questions that these dynamics pose, and the lack of response to those questions, nobody wants to know.
In economic terms, the ballooning costs of the NHS are held to require cost-cutting and efficiency. We have a text-book example, if anyone could see it, of how a focus on budgets and financial accounting in the many parts of the NHS empire only leads to overall cost escalation.
Questions of demand
The chief element of the begging bowl is to point to rising demand and equate it with needing more money. Let me tell a parallel story. I did some work (in a small social enterprise start-up) on helping people who owned their own home but could not afford to maintain it, quite a common situation. We were concerned about people’s home being stolen by the banks via unfair equity release schemes and shared appreciation mortgages. There were days when you could get a council grant in such circumstances.
We worked with various London Boroughs to find people who needed help and to coach local residents and signpost them as safely as we could. But the question arose inevitably about how may houses were in disrepair. There is a National Housing Survey that estimates these things which gave us a figure of tens of thousands of houses in Greater London. Finding them was more problematical and both working with historic applications for grants and visiting likely areas door-to-door produced only tens of properties.
Having approached the Housing Minister at a conference I went to see her and her civil servants to ask about this situation. She was sharp, asked good questions. I kid you not I was referred to an independent consultant who knew about these things and who turned out to want a job with us.
Having sucked my teeth a while I decided that it suited everyone to have a huge figure for houses in disrepair, whether it mapped to anything in reality or not. Reading across to health it suits everyone to have a picture showing high and rising demand. The notion that high and rising demand must illustrate NHS strategic failure is absent from the debate.
Demand is what any reasonable national health service would be focussed on managing. Everyone apart from some very hard to reach groups comes through the door. The question should be how to stay in touch without those people needing to consume expensive services. Or in English, with them staying healthy and independent.
Many managers think that if the area of healthcare that they manage becomes more efficient, then they have done their bit towards the whole health service becoming more efficient. This is simply not systemic: it doesn’t work like that. Probably the easiest way to become more efficient is to hive off your expensive cases to somewhere else: like the GP to A&E shuffle. But there are many ways of choking off “demand” so that it (yes, people) goes elsewhere. And in a universal service “elsewhere” is still in the overall cost base and is likely to be more expensive that the first port of call.
Co-creation
Actually the schemes that make a difference to the overall viability of healthcare are generally co-created. I hate the language. What it means at best is that people come to understand for themselves what support they need from healthcare professionals and work with those professionals to develop the best ways for professionals and others to meet those needs. This is the opposite dynamic of any professionally-led initiative. There are precious few examples.
David Graeber and David Wengrow recently published a wonderful article called How to Change the Course of Human History. By chance I did discuss with them some of the background evidence they use in the article (they are an anthropologist and an archaeologist respectively.) The important point is that over history, societies have experimented with many, many forms of organisation. And in many cases societies adopted very different forms of organisation at different times of year, to meet the changing requirements of the seasons. Our point for this blog, is that such experimentation involving repeated trials of organisational forms involving whole societies is the only way to find out what works. Letting an institution develop and then pretending it works, and is the only thing that works, is just not credible. It is not evidence-based in the slightest, and cannot be evidence-based.
We have lost the imagination to see this. There is another wonderful study from more recent times in James Scott’s The Art of Not Being Governed: An Anarchist History of Upland Southeast Asia. In that story the developing city states of Southeast Asia are subject to a strange (to us) continuous migration of peoples. People can live free in the mountains where they cannot be found or they can live as slaves in the cities. There are advantages to both and a continual traffic of people making different choices at different times and circumstances of their lives. This is the way for people to understand existentially how they want to live their lives. We desperately need people to be able to find out for themselves what they need from a national health service in order to be, well, healthy.
Reform anyone?
We have had enough reforms of the NHS to last several lifetimes of a sane person. And they promise radical change and it all looks much the same but a little bit shabbier and more cynical.
Let me sketch a story I was close to at one point, that is not part of national reforms directly. There was a senior consultant called Steve Allder and he would reform the stroke pathway at his Acute Trust. He said he first spent some years getting the trust of senior management at his Trust because he needed them not to interfere. Then he spent five years building collaboration and understanding the changes that would work for everyone involved — a lots of people across many departments. To name just one issue because it pertains to the story, he found that places in the rehab clinic were constraining throughput and that they needed to negotiate daily with families of elderly, frail, stroke patients about what rehab meant for them. Anyway having got a stunning result — much better care for much less resources and everyone happy — the rehab clinic was turned into a social enterprise led by a member of the great and the good who proceeded to turn the clock back on the changes so nothing worked anymore. Ten years of creative work versus one precious ego? No contest.
But if you would care the review the three dynamics that I started of with against the notion of free-flowing and imaginative co-creation, I think you will agree that there is every chance that these massive management challenges will be met by people voting with their feet. What I like to call the East German solution: you can govern the country all you like but there won’t be any people in it. The only reason informed people put up with the behaviour of the NHS is that it’s the only one we have and we have already paid for our care.
Before I started on this journey, Nora Bateson, in oracular mode, said that it was impossible to reform healthcare except by changing what people demanded of it. That is, there are no internal routes to meaningful change. I have been on a long journey, including a personal health journey, to come to the same conclusion. The David Graeber story says that probably we all need go on that journey and it is much better if we go together!
Who knows best?
If you will forgive me and if you have the stamina, I would like to do one more read across from something entirely different. There is a stunningly beautiful book entitled The Archipelago of Hope by Gleb Raygorodetsky. (And yes, I did have to use a map to remind myself where Kamchatka is, where he grew up). The subtitle is Wisdom and Resilience from the Edge of Climate Change.
The book tries to get some perspective on the big science version of climate change, just as we are trying to get some perspective on the autocratic NHS. The thesis as I understand it is that they are indigenous people still in many places around the world, and that as indigenous people they are closely integrated with the local ecological systems. Because of the that close integration and bodily understanding, they understand better than any conceivable scientist both what climate change means locally, and what can be done to adapt to what is happening. Even for frighteningly green climate professionals, that is a challenge and the book starts with an Oxford conference on that very subject where they forgot to invite the indigenous people themselves!
So who are the equivalent groups of people in this abductive reasoning from climate to healthcare? I think that question bears more thinking about than I have space for here, but here is a candidate. There is a wonderful Moroccan woman, Samira ben Omar who does work sometime within and sometimes just outside the NHS with hard to reach minority communities. These communities in the nature of things are largely self-sufficient and look after themselves. I worked for a while with a group of Yemeni Somalis in North London who doubly a minority: at home in Somalia and then as refugees in London. The were really lovely people.
These minority groups are often off the radar of the NHS: totally unreasonable and illiterate people who won’t come to the doctor. However because they are tight-knit and self-sufficient communities they do understand in their own terms what their healthcare needs are. Put the other way round there is no way to tell them what their healthcare needs are. Handled sensitively, this is a source of huge insight: cynically this is what off the radar means.
I’ll do one more group. Richard Tomlins is a Professor of Race and Equality at Coventry University. I am chuckling as I write. If you meet him in London the standard attire is a pin stripe suit with a t-shirt underneath and a swag bag with his yoga kit in it. He is a Coventry supporter and in our work together on health clinics, we discussed the culture of football supporters, a subject that I am virginal about. I understand, however, that male football supporters as a group disdain health services which they understand are not for them. It would be quite wonderful to take an anthropological approach to understanding what health services co-created by football supporters would look like!
