Strength through flexibility

One of the oft-used, reactionary mantras heard in the NHS is, ‘we don’t want a two-tiered healthcare system; one for the rich and one for the poor’. It’s employed by the unthinking to close down any argument, however modest, which attempts to describe the potential benefits of private investment in the NHS.

In Schein’s model of culture, it’s a level 3, ‘basic and underlying assumption’, that brooks no discussion because it’s so ‘obviously true’. It is straight out of the Socialist, totalitarian playbook, which demands implicit (sometimes even explicit) and immediate obedience. But, it beggars the NHS by denying it the additional funding that could come from allowing those who want to, to pay for ‘extras’.

Is there a better way?  We’re all familiar with airlines offering passengers wildly different prices for different experiences; from Economy through to First.  All the passengers get on the same aircraft and reach the same destination, but those who value the extras on offer, can choose to upgrade for a price.

Ironically, when I worked in France, (generally considered a much more Socialist country than the UK), I discovered that about one third of the total GDP spend on healthcare was private, compared to a mere 10% in the, ‘capitalist’, UK.  This higher, private spend largely accounts for the higher total GDP spend on healthcare in France versus the UK; a fact often conveniently overlooked by those who benchmark GDP spending on healthcare.  One could say that the French permit an à la carte menu, whilst in the UK, it is strictly, prix fixe!

The French healthcare system, by permitting greater flexibility, is stronger, on almost every outcome measure, vis-à-vis the NHS.

So, rather than advocating for a ‘two-tier’ healthcare system, (which induces an allergic reaction in many so-called defenders of the NHS), the answer is to pursue, more formally than now, an NHS that is far more flexible.  This means embracing a ‘multi-layered’ system, with different patient experiences, such as rooms, food and extras paid for either out-of-pocket or via insurance.  This type of up-selling and cross-selling could revolutionise the patient experience and at the same time generate much needed additional revenue streams for hard-pressed Trusts.  It would introduce genuine and benign competition into the system and make it much more patient-focused.  It would be like a proverbial financial tide, lifting all the boats, great and small, rich and poor, alike.

For the NHS to survive another 70 years, the key will be flexibility.  If it can’t embrace differentiation, it faces disintegration instead.






Why can’t the UK National Health Service change?

underlying-reasons-for-resistance-to-change-300x300Many within the NHS feel it is in a state of constant change, but this is an illusion.  It’s based on changing superficial things; the classic, ‘rearranging the deckchairs on the ship’.  There is an appearance of change, and when it’s your job to move the chairs, it feels like a big change-around, but the reality is that the ship ploughs on. The fundamental forces that power the ship’s direction, (the engine, propellers and rudder) remain determinedly fixed.

It’s easy to prove that this is true.  Just consider the general process of healthcare:

  • The patient thinks something is wrong
  • S/he goes to see a General Practitioner (GP)
  • The GP performs an face-to-face interview
  • The GP may or may not refer to a specialist
  • The specialist is visited by the patient and definitive treatment is eventually planned

The whole thing takes weeks.  If you went back in time a hundred years in the UK, you would see basically the same process happening.  Similarly, take a UK citizen from 1950 and show them the current UK health system, and they would understand immediately what was going on.  No real change.

As a nationalised monopoly, the NHS has no ability to change itself.  The ‘rules’, which are de facto, laws, won’t allow it.  For example,

  • No money can change hands (services are ‘free’)
  • Patients can’t access specialists without permission from a GP
  • Diagnostic services are inaccessible directly (you can’t find out what’s wrong with you on your own volition)

The insurance industry was a bit like this 30-40 years ago.  A man with a briefcase would come to your house, fill out forms, and return weeks later with an insurance policy.  Nowadays, insurance is purchased online in a matter of minutes, because the rules were changed.  The ‘man from the Pru’ has disappeared.

In order for change to occur, the ‘rules of the game’ must change.  Powerful vested interests resist this as much as possible: the medical profession, especially GPs, could easily disappear, so resist fiercely all reform.  The politicians, who are in charge, fret about re-election.  The patients, who are vulnerable, don’t know any better.

The solution of the NHS’s problems are the same as those that have worked in other service industries, namely, change the rules.  This is known as ‘deregulation’; it’s not rocket-science.

Productivity in the NHS


Some doctors seem to be confused by productivity. It is the ratio of outputs to inputs. Output per hour is, more properly, a partial productivity measure. When I was a registrar in anaesthesia, I did more than 1000 anaesthetic procedures a year; nowadays a registrar is lucky to do 400. This means less output per doctor, but the cause is working fewer hours, so output per hour is similar. Twenty five years ago, my department did 21 000 anaesthetic procedures a year with six consultants, four registrars, and four senior house officers. Now, we do 25 000 with more than 30 consultants, eight registrars, and eight senior house officers; do the maths.

John Appleby, Chief Economist at the Kings Fund, rightly emphasises the productivity problem in the NHS—it is the crucial “missing piece” that few will talk about.1 Most self interest groups, such as political parties and trade unions (including the BMA and royal colleges), prefer to stress inputs, rather than outputs.

This navel gazing stops us learning from other systems, such as many European health systems (none of the top 10 European systems are tax-funded). When I worked in France, it was normal to work on Saturdays, cases at the end of lists were never cancelled through “running out of time,” and orthopaedic surgeons performed 500 primary joint replacements a year, compared with about 250 in the NHS.

The solution to the productivity problem includes the following: adoption of new technology, deregulation of restrictive practices, and changes to the way clinicians work. All these are frequently and effectively blocked by complacent and self- serving special interest groups.

1  Appleby J. UK NHS: Less money (but more bangs per buck)? BMJ2015;350:h1037. (10 March.)

Do you know about Action Learning?

Action Learning is a methodology for solving the intractable problems that keep the CXO’s awake at night!

In brief, it is ‘learning through doing and doing through learning’. The basic premise is that those closest to the problem are best able to solve it. It is summed up by the equation: L = f(P + Q)

where L = learning, P = programmed knowledge, (in other words, what we already know and carry around in our brains) and Q = questioning, (to gain insight into how people think, feel and preceive).

If the rate of learning exceeds the rate of change in the environment then individuals/organisations can thrive. If learning is less than the rate of change, then failiure is likely.

Reg Revans, a physicist, who worked at the Cavendish Laboratories in Cambridge, came up with the idea when wrestling with the structure of the atom in the 40’s!

I came across action learning a few years ago, and now see it as an extremely powerful methodology for organisational improvement. Business-driven action learning is a variant that aims to focus action learning on the busienss objectives of organisations. The Singapore conference I’ve just come from brings together best practice, and many organisastions similar to CSC have found it useful (e.g. Siemens, GE, Intel, etc).

When ‘operations’ doesn’t mean surgery

It took me a little while to understand that we were talking about different things.  I thought ‘operations’ meant surgical procedures; managers thought it meant ‘everything’, i.e. how we do what we do. 

If you’re not sure what the ‘operations’ of your organisation is, ask yourself, why does this organisation exist?  What does it do?  What is its purpose, its raison d’être?   This is its operations function.  It should also be what most of the organisation’s resources are spent on. 

You can quantify it by the 4 ‘Vs’: 

  • 1. Volume: how much?
  • 2. Variety: what type?
  • 3. Variation: when?
  • 4. Visibility: Who sees what we do? 

How do we arrange our resources?  In most hospitals, the patient has to fit in around the staff (lots of patients moving around between areas).  This shows that the process is more important than the patient.  On the other hand, if patients are too sick to be moved, ‘Safari’ ward rounds occur, with groups of doctors journeying through the hospital in search of ‘their’ patients!  Sometimes, specific areas deal with specific patients (Cell Layout); rarely, an idealised pathway of care is followed (Product Layout). 

For as long as I can remember, the central issue in the NHS has been how much money to spend on it.  In other words, the focus has been on inputs.  However, due to the lack of dramatic improvement in the service despite year-on-year increases in funding, there is a growing realisation that scrutiny of outputs may be more enlightening.  Thus, not so much asking “How much are we spending?” but rather, “How well are we performing?”  This would be a great ‘operations philosophy’!