too big to succeed

Too Big To Succeed (Reflections on the NHS)

The NHS is the world’s fifth largest employer. It sits behind the US and Chinese defence forces, Walmart and McDonalds. This is often trumpeted as an achievement and is certainly used a symbol of status for its senior managers. But what if it is simply too big to succeed?

As networks gets larger they reach a limit on their capacity to hold and utilise information. The inverse relationship between administrative burden and quality of care in healthcare systems has also been documented. Is the NHS just too big? Rather than quote the advantages of economy of scale maybe it might be better to look at how networked global industries work.

I’m writing this on a Mac. The screen, the chips, the case, and the power unit all come from different places. My data is stored somewhere on a cloud. We don’t have a problem with associating this product with Apple. And Apple doesn’t have a problem with sourcing the expertise necessary to build world-class products from multiple organisations or suppliers. The computer industry is a great example of utilising networks to deliver results in a complex, highly specialised and rapidly adapting environment. In this way they can localise and specialise knowledge and know-how.

So what would a networked NHS look like? This isn’t an argument about public or private or any other form of ownership. It is an inquiry as to what really would be the best way to run an operation of this scale.

We are some margin from doing this. To suggest that our ‘Foundation Trusts’ are freely networked entities would be absurd when the Secretary of State rings them regularly about their A&E waiting times. To suggest we have successfully split commissioner and provider (or even that this is a good split) is similarly bizarre. When Acute trusts are barred from sitting at strategic meetings with CCGs because of a fear of competition legislation we know this is not a process for liberating the collective intelligence in the system. ‘World Class Commissioning’ would be laughable as a misnomer if it hadn’t cost us so much.

So when respected bodies like The Kings Fund are calling for a £1.5-£2.1bn change fund that could only centralise control further and institutionalise the change architecture, perhaps it is time to think altogether differently. Could a truly networked NHS, localising its amazing knowledge and know-how provide a much better service for less?


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