Heart of the Art

The NHS is alive but rather unwell. Much great work is being done and we remain the envy of many. And also we are locked in a cycle of increasing pressure. To keep the NHS functioning, as those who are in it and use it currently believe it should, is exerting huge levels of stress.

It exerts financial stress; PFI hospitals, tariffs and models of care are stretching the economic model to the limits. It exerts physical stress; high quality care and treatment is not sustainable in certain fields under this regime. It exerts mental stress; those who are treated and those who treat and manage treatment are being taken beyond reasonable levels of comfort in trying to operate in a system that is out of kilter with its environment.

The NHS is rather unwell. It has some unwelcome pathology. If we are to reduce its impact we need to understand why it arises. Like many of its patients, the NHS needs a lifestyle change if it is to address the causes of these symptoms. Instead it continues to bandage them up, or cut them out in a form of self-treatment that is rooted in the cause of the problems. It stumbles on, feeling that a better life is just around the corner if only it could find a way to break the current cycle of illness. Like some patients, it acts as if it were an expert on its own condition based on partial information and a blinkered view of its own symptoms.

Is it right to think of the NHS this way? Is it right to think of it as if it were alive? Yes, absolutely it is. The NHS is indeed alive. It is a whole ecosystem comprised of doctors and patients and families and managers. The well and the unwell, professionals, practitioners and partners. We know a huge amount about eco-systems and how they behave. And yet we continue to treat the NHS as if it was a giant machine, where levers of power connect to cogs that turn.

Command and control hierarchies and performance architecture are designed to run production systems not living things. By imposing this bizarre form of management onto something it simply doesn’t fit, we generate the stress in the NHS that makes it unwell. Even when the phrase ‘top-down’ has become so politically toxic, we still do not create the conditions by which real adaptation could emerge. We instead hide behind faux-forms of ‘bottom-up’ such as Pioneers that cannot be truly successful without looking way beyond the place they are based in. To make them work requires a fundamentally different process of change to the one currently in place.

The ‘Five-Year View’ will go the same way. At its heart there is no guiding philosophy that would determine a course of action to work with the eco-system that is the NHS. The mental model is to continue the reliance on large consultancies that have no sense of how to work in this way or any desire to do so. It breaks their business model; it does not require the hiring of a small army of very bright young people to crunch data and produce yet another expert solution, to be piloted, implemented, rolled out and delivered. So we continue, even now after so much repeated failure to make real change stick, to proceed down the same system of thought that got us into this mess.

If the NHS is alive we should consider it as an eco-system, locked in a symbiotic relationship with its environment. This environment is our country, our population, our political system. We hold certain deep and fundamental beliefs about the NHS from which emerge repeated patterns of behaviour. If we do not engage with these, try to shift them, every new change programme merely recreates a new form of what we had before. Good money if you are the consultancy hired to do the work, less good if you are the public who need a better service in return for a considerable national debt.

Working with organisations as eco-systems in relationship with their environment is not a new, novel or particularly weird idea. It is decades old as a way of considering things, some might say centuries. What is weird is to continue trying different versions of the same process in the vain hope that this time it might work out differently. Particularly when it self-evidently doesn’t.

Tinkering around with machines rarely makes them into something else, sometimes makes them run a little better as they are and often ends up with broken and disconnected parts lying all over the floor. This is no way to play with something that matters so much to us, is such a deep part of us. It is not what you do to things that are alive.

So it is now time to think altogether differently if we really want to see a different result. The question is, are we really brave enough to go outside of what we think we know? Do we really want it? Or despite the stress, are we all a little too comfortable as we are?