IntroductionThe new Labour Government has said that "Our NHS is broken, but not beaten. Together we can fix it." and has launched a consultation to start the process (I would have gone with money first but that's another story).
I wanted to respond to that consultation for several reasons, notably because I have worked with business change through IT for most of my career and also I am quite involved with the NHS as a patient at the moment. The NHS matters to me and I think that my views on it are relevant.
I am putting these views in my blog so that I have a record of what I said and I can also share them easily when I want to.
The 3 shifts
The consultation covers the 3 shifts, widely trailed before, as"big changes to the way health and care services work – that doctors, nurses, patient charities, academics and politicians from all parties broadly agree are necessary to improve health and care services in England".
These are:
- moving more care from hospitals to communities
- making better use of technology in health and care
- focussing on preventing sickness, not just treating it.
The consultation then asks questions on these. I quote these questions and give my answers.
Q5. In what ways, if any, do you think that delivering more care in the community could improve health and care?
There appears to no rationale behind this idea other than the slim possibility that because more appointments are more local then fewer will be missed. Specialised services are provided through large hospitals for several good reasons from economies of scale to the frequent need to treat patients will multiple conditions.
I see no health and care benefits in doing this.
Q6. What, if anything, concerns you about the idea of delivering more care in the community in the future?
Healthcare provisions is already fragmented, e.g. dentistry and optometry, and having separate centres for other services risks further fragmentation with the need to visit several centres for one condition.
Small units are likely to be inefficient, e.g. a surgery facility at a GP surgery will either be over staffed to ensure that it meets all demand or under staffed at some times leading to more waits.
People often have multiple needs and being co-located means it is easier to address them at the same time, for example, to get an unplanned x-ray for a patient. When working on Business Transformation we called this "one and done", i.e. fix everything on one visit.
Small specialist units will focus on the one thing that they do and will lack the patient's full context to provide the best service. This happened to me when a private surgery unit missed the possibility of skin cancer and this went undiagnosed for a few years. This fragmentation may kill me.
Q7. In what ways, if any, do you think that technology could be used to improve health and care?
Again, the described benefits of this are weak at best and they are all claims made about other large IT projects that spectacularly failed to deliver. I have worked on some of these and the example of Horizon at the Post Office is fresh in our memories.
The idea that patients need only tell their story once misses two very important points, each specialist needs to hear and questions a different part of that story and that story will change over time (do you smoke, what medications are you taking, how active are you, how stable is your weight etc. etc.) and so it must be retold for accuracy.
Using AI to review scans is an obvious thing to do but it is hardly transformational. The only way that this could help significantly would be if we took lots more scans but that would be an additional cost on the NHS.
Technology is too often portrayed as a magic wand, it is not.
Q8. What, if anything, concerns you about the idea of increased use of technology in the future?
I am concerned that the benefits are overstated and could not be delivered without substantial additional investment (beyond the basic hardware, software and networks) in things like data cleaning and ID cards.
The basic technology, e.g. exchanging packets of data between systems, is easy but does not help because the data quality is pretty low and inconsistent and so sharing it will only make things worse.
I have worked on large IT systems with simpler data, e.g. spare parts held in stockrooms, and every project had to start with a large data cleaning exercise and even that does not solve all of the problems as some of the answers are unknown, e.g. a supplier code does not match any code used by any supplier. Similarly in systems involving people you will often find several dates of birth of something like 01/01/1900 where people have made up data just to get past that screen. Or, even worse, used a special data as a code for something else that has been long forgotten but which is useful.
There will be significant inconsistencies in the data between systems. To pick another example I have direct experience of, there is not a standard list of Nationality codes so things like the Census and Schools (both part of UK Government!) use different lists. These lists also change over time so while a younger person may be identified as, say, Bangladeshi their parents may be just Asian. I picked this as a simple, easy to understand example, other parts of health data are far more complex and far more prone to inconsistency. Agreeing standard lists will help but will take time and will make the data cleaning longer.
And one key part of the data is missing, a unique identifier for each person. Who remember's their NHS number or carries a card with it on? A national ID card system could help (after a lot of time and money) but there will always be gaps, e.g. recent arrivals.
I would be very surprised if you could get the data at sufficient quality to share in less than eight years and employing thousands of people for that long is expensive.
Q9. In what ways, if any, could an increased focus on prevention help people stay healthy and independent for longer?
This is where the focus should be, though not necessarily for the reasons given. We should enable people to be healthier so that they can live more fulfilling lives, not just to save the NHS money. People play sports for fun not to keep out of hospital.
The consultation gives no idea of the scale or ambition of "tackling the causes of ill health" but these need to be bold to first address recent declines in population health (e.g. obesity) and then to significantly improve them.
That means being brutal with manufacturers and retailers over things like smoking, processed foods, alcohol, etc. We know many of the major causes of ill health and should address these seriously.
Going back to school lunches for all school pupils and breakfasts too for primary pupils would be a major boost to wellness and is probably the easiest and quickest option the Government can implement.
In 2023, there were 132,977 casualties on UK roads. We must do a lot more to address this, including stricter enforcement with harsher penalties and redesigning roads to manage out traffic.
Managing out traffic is a win-win as it reduces traffic accidents and also encourages people to use other and healthier means of travel. In the early 70s I went to an edge of town secondary school and hardly anyone went there by car, we need to get back to those days.
Q10. What, if anything, concerns you about the idea of an increased focus on prevention in the future?
My concern is that the Government will back away from the big necessary changes under pressure from lobby groups claiming that it is trying to implement a "nanny state". If these measures are to work then they must be bold.