Which NHS shall we save?

Like you, I imagine, I get regular e-mails from campaigning e-petition organisations.  One such recently ran a very strong campaign around the government plan to replace the Forestry Commission and claimed the credit when this plan was withdrawn.

I had supported this campaign, but I feel obliged to replace the standard MP e-mail that I was offered.  Why, because the e-mail contained lots of assumptions about motivation – that the government was selling our forests to those who would exploit them, destroy them and deprive the owners – we, the people – of their use.

Let there be no doubt of my view – this plan needed to be withdrawn.  It was poorly presented, had not been thought through and lacked (albeit that the consultation stage was still to come) any of the safeguards that were needed.  This is why I wrote to my MP.

At the same time it was apparent to me that the government was not completely misguided.   If you live near a forest – and I am a few hundred yards from one such – you may be aware that often maintenance and management are sporadic, that the provision of recreational facilities is highly variable and that there is no mechanism for accountability to local communities for the way that our resources are managed or used.   That is to say, the current system doesn’t work, and in my view the government were quite right to propose change.

Now, fresh on the heels of this campaign success, the organisation has canvassed its members for what the next priority should be and has proudly announced its intention to “save the NHS”.   So that’s all right then.  Everything will be rosy from now on. 

I am seeing some severe limitations to this e-democracy.  So what have these tens of thousands of people actually agreed to?   Do they all have the same view of what it means to “save the NHS”?  Is there a shared vision of what the outcome is intended to be?   I doubt it.

So – hands up who thinks that the NHS is perfectly alright as it is, and needs nothing done to improve it?  Well, this is all in my imagination, but I am not seeing any hands going up.  Most specifically I am not seeing them from anyone who works in the NHS.  (Feel free to challenge this in the comments facility).  Most of us can list the well-known concerns, among them:-

  1. Those who work in it are under permanent high stress
  2. Resources are poorly managed and procurement is uncoordinated
  3. The system is over-bureaucratised, with too many managers
  4. The system suffers from high internal conflict and poor working relationships between managers, consultants and multiple other functions
  5. Governance processes (NHS Trusts) are inconsistent and not necessarily adequate
  6. The system overall results in postcode lotteries and other inconsistencies of care
  7. Societal expectations are continually growing, in the face of financial constraints and we are simply unable to afford what we are asking for.

In an earlier blog I wrote of my experience in an emergency unit dealing with people who were having heart-related scares, and was full of praise for both the quality of care and the way in which  it was delivered.  In writing as I do here, I am fully aware that there is a great deal at stake.  Nevertheless, the problems exist and must be dealt with.

Those who share a Spiral Dynamics lens will hopefully recognise the excess Blue structure build-up that has become arthritic and immobile.  You will see Orange system issues; externally the tensions around resources and expectations, internally the status and demands of consultants (possibly with Red thrown in.   You will know or be able to imagine the Values system conflicts between Green-oriented care impulses and Blue or Blue-Orange process.    And every time the National Institute for Clinical Excellence makes a decision about the cost-effectiveness of a new treatment you will see the orchestrated response from the Orange pharmaceutical lobby manipulating the media to exploit every individual case of perceived hardship.  Under all of this, you may also see a societal incapability to deal with the nature of life, that it includes pain, and death, and loss.  You might see that as a Purple failure, as well as a spiritual issue.   I do.

In the face of all this, a knee-jerk, Green-politics or left-wing knee-jerk response is emphatically not what we need.   Already there are calls for the Health Secretary to resign over the plan for GP commissioning.  No doubt there is good reason to be concerned about the preparedness for this shift.  But where is the balance?  There is legitimate concern around the need for really considered planning, the requirement for exceptionally good change management processes, and the need to address the practical concerns of such a huge change.    There is likewise an obvious risk that inertia and resistance will conspire to paralyse any forward movement.   Given the slightest glimpse of an escape route, self-interest and apathy will keep things just as the always have been.

So What Should Yellow DO?  What’s the second-tier response to this complexity?  In my view the first answer is that structures have to loosen and flexibility has to be introduced.  Command and control has to give ground to local accountability and responsiveness.  There must be a new blend of central vision and nationwide planning with devolved and accountable, customer-centred provision.   It may also be necessary for individuals in this society to recognise that we have to take more responsibility for our own well-being.   Green tends to see everyone who is obese, alcoholic, addicted to smoking, lacking in exercise as a victim, and there may be some issues around our processed food and advertised lifestyle choices which need addressing.  This is not just for governments to solve.   Society is us.  The lack of any relationship between our behaviour and our costs to society may also be part of the problem.

So when you are faced with a call to petition your MP with a call to “save the NHS” – please consider just what it is that we need to ask for.  There is a core ethic of “free to all at the point of delivery” that we abandon at our peril.   But let’s look more carefully at what that means, and at what is the best way to bring it about.

Jon

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