Can the NHS be changed?

There have been a reasonable number of positive changes in the NHS during this crisis – although these attempts to cut through the bureaucracy have been relatively minor in the overall context of the NHS. However, one thing that has struck a few folks here is the overall resistance to change in the NHS. Many fear that any incremental improvements will simply revert back at the end of the crisis.

So being slightly simplistic here, it seemed natural to contemplate a few possible explanations.

What if the NHS is stably bad?

There are many examples of sub-optimal in the world that prove surprisingly stable. The QWERTY keyboard I am currently using is probably one of the most quoted examples. It was designed to stop the typewriter keys fouling each other at speed. Although I did a fairly good job of that on my father’s machine at low speed when I was younger. Anyone who watches their children learning to type can appreciate the high costs of switching such that alternative keyboard designs are difficult to even comprehend – can you name an alternative keyboard design? In essence, even a bad design can be remarkably persistent. No matter how bad some of the issues in the NHS the switching costs are very high - it is akin to trying to fix a car engine while driving along the highway. Hence fixing some elements of the NHS would probably require building a completely separate system and then moving everything across. Could this be an opportunity generated by all these new hospitals that the Government is proposing?

What if this is a big multiplayer game of prisoners dilemma?

I suspect most will be familiar with classic game theory. The basic idea is that although there are potentially better outcomes, this requires a level of cooperation between players that cannot be achieved due to lack of trust or knowledge. Instead, stakeholders behave in ways that are individually best for them but to the detriment of the overall system. This is a particular issue in the NHS where there are fixed budgets, since resources do not naturally follow patients without petitioning the centralised budget holder. In the absence of trust, people naturally do not take on additional work, especially if they believe that the resources do not accompany the burdens and someone else keeps the savings. This tribal behaviour is readily observable in the NHS.

What if no one actually wants to change?

In this scenario, the people who control the system do not actually want to change it no matter what the ‘customers’ actually want. There is plenty of evidence for this – many doctors and nurses will simply not countenance a discussion of change. To my ears the debate usually goes down the same line every single time: “we don’t want an American system” – as if there was only one alternative healthcare delivery system in the world and ignoring the fact that other western democracies fund and manage their healthcare systems differently to the NHS (including many not known for their unfettered capitalism). “We already have the best healthcare system,” they say despite multiple outcome measures pointing to the contrary. “Changing the system would make healthcare more expensive” as if the NHS is at capacity and that spending additional funds would simply result in cost inflation with no possible improvements. It is not hard to find a strong culture in the NHS that would frustrate change.

Maybe no one is actually really in charge?

Despite the national brand and ownership by the central government, power is much more diffuse in the NHS that one might first think. Since there is no market system to coordinate services with an ‘invisible hand’, management (usually non-clinicians) is required to centrally allocate resourcing. In practice, managers struggle to have a sufficient span of control to make more than minor changes. Since management roles often overlap, it is often difficult to make changes without the assent of multiple other managers. Moreover, since budgets are essentially fixed there are few if any incentives for service innovation. Top level managers struggle to make changes actually flow down into the patient facing services, lower level managers feel they don’t have the powers to make changes.

These possibilities are not mutually exclusive, but one has to question whether, in fact, the system is actually capable of change or indeed whether the various stakeholders really have an interest in change. It seems like a classic folie a deux between the public and the stakeholders who both have a strong interest in preserving the fantasy that we have the worlds best healthcare system. For now, the solution always seems to be shaking the magic money tree and throwing a few extra billion of someone else’s money.