A Lost Opportunity?

Slightly of the informatics theme, but then there can’t be a successful health informatics programme, only a health transformation programme facilitated by informatics The current Government’s transformation programme is the most radical in the NHS’s history and we can not and should not try and consider health informatics issues in isolation.

My political sympathies don’t lie with the current Government, but, like many I am supportive of the key principles behind the current reforms – A greater role for clinicians; more involvement and control for patients and greater plurality in the provision of care. However, also like many I am concerned about the method and pace of the proposed changes and have some concerns about specific details.

The incoming 1997 Labour Government frittered away the very considerable support it had for The NHS Plan with a disruptive reorganisation of NHS structures – Shifting the Balance of Power – and the current coalition looks like repeating the mistake.

There is a well know quotation attributed (some say incorrectly) to the Roman General Petronius Arbiter

We trained hard . . . but it seemed that every time we were beginning to form up into teams we would be reorganized. I was to learn later in life that we tend to meet any new situation by reorganizing; and a wonderful method it can be for creating the illusion of progress while producing confusion, inefficiency, and demoralization.

Genuine or not, it also reflects my experience in the corporate world and I have concluded that while all structures can be improved by an appropriate reorganisation that the benefits rarely match the disruption involved in doing so and that it is better to evolve existing structures. Problems in all organisational structure are concentrated in the interfaces between their components and while you can move these interfaces around you can’t eliminate them, while if you leave them alone formal and informal arrangements develop to make them work, even though they may not be in the optimal place.

Keeping PCTs and SHA in place while radically but incremental reconfiguring them to be clinically led and more responsive to patients would have not created the same political splash (which in any case has nearly drowned the politicians that made it) but would have been a practical option. Similarly while I think the re-alignment of the boundaries between health and local government make sense I am not persuaded they are worth the disruption making the changes may cause.

So this was mistake number one. The second was probably not buying off the BMA soon enough. Nye Bevan said that to create the NHS he had “stuffed their [the Doctors] mouths with gold” subsequent Ministers have learn (often the hard way) that the only way to secure medical cooperation is to buy it and that doctors and GPs in particular are actually quite responsive to modest incentives (just like the rest of us) GPs I know fall in to three groups on the current reforms : Two small groups, one highly supportive and the other vehemently opposed with the vast majority in the third group who want to know “what’s in it for us?” GPs and the BMA are also properly concerned about what’s best for their patients, but I think few doubt that their patient’s best interest would be better served with greater clinician involvement and more patient control. A little less stick and a bit more carrot would probably have secured their cooperation.

The biggest problem is of course the one that’s near impossible to address and that is the difficulty of trying to implement a transformation programme at the same time as trying to achieve savings in current activity greater than that that any healthcare system anywhere has ever achieved. QIPP supported by IT and the clever use of information is the way forward, but I despair that only the bully, slash and burn approach is likely to deliver on the short-term imperatives faced by NHS managers.

Let’s hope the current pause for reflection will help us to make the reforms work. The status qou is not an option, radical change is needed, but this does not need a radical reorganisation of NHS structures.

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