The King’s Fund, a UK health charity ran a scenario essay writing competition, which I entered. I didn’t win, but here is the link and of course congratulations to the winner: (winner, runner up and other scenarios, but not mine).

Below is a  version of my submitted scenario, revised and generalised to any care system. The scenario builds on the notion of service unbundling and draws on strong and weak signals of changes likely to impact health and social care perhaps to about 2035. The scenario is written as a retrospective view from the year 2047.

Unbundling 2035

Between 2016 and 2035, the way that people worked had substantially changed by widespread digitisation of information. Smart machines and robots had moved from doing physical work to being central to much cognitive work and which led to fundamental restructuring of the economy. By 2035, taxation was changing from taxing people to taxing the work done by devices, cognologies, and robots.

The fault lines between reality and expectations were starkly evident during the 2020s, as public investment in health and social care struggled to cope with the rapidly changing world. People were becoming accustomed to flexible access to personalised services that came to them and expected the same from care provision. Rising displeasure at service decline led to middle-class flight to alternatives with rising use of private medical insurance, progressively fracturing the social contract that legitimated publicly-funded care. Indeed, by 2028, 38% of the population used private care, with over 55% amongst Millennials.

Fearful health and social executives and worried Ministers of Health had reacted to these stresses by pulling the system even more tightly together, to protect jobs and avoid the failure of publicly-funded institutions.

This fed further public displeasure by the dominant middle-aged Millennials who challenged the traditional approaches to health and social care. In the United Kingdom, for instance, this unrest led to the 2028 Referendum on their tax-funded healthcare system, leading to the replacement of this system with social insurers and personal Social and Health Care Savings Accounts.

The process of changes in health and social care around the world has become known as Unbundling. This brief historical retrospective outlines three of the key components of that unbundling.

The 1st Unbundling: of knowledge and clinical work

Professional knowledge was affected by digital technologies which had unbundled knowledge from the expert. This changed how expert knowledge was organised, used and accessed; research institutions and knowledge-based organisations were the first to feel the changes, with librarians being one of the first professions to face obsolescence. Rising under-employment, particularly in traditional male-dominated occupations was still being absorbed by the economy.

Routine cognitive work and access to information and services was increasingly provided by cognologies (intelligent technologies) or personal agents as they were called. Widely used across society, they were embedded in clinical workflow from diagnosis to autonomous minimally invasive surgery. By this time, jobs with “assistant” in the title had generally disappeared from the care system, despite having been seen as an innovative response to workforce shortages through the late 20-teens. These jobs had turned out to be uninteresting, and being highly fragmented, required time-consuming supervision.

The benefits of precision medicine were substantial by this time, enabling earlier diagnosis and simpler and less invasive treatments. Theranostics, the merging of diagnosis and therapy, unbundled the linear care pathway and the associated clinical and support work. This also led to the unbundling of specialist clinical services, laboratory testing and imaging from monopoly supply by hospitals. Indeed, the last hospital was planned in 2025, but by the time it opened in 2033, was deemed obsolete.

The 2nd Unbundling: of financing and payment

The unbearable and unsustainable rise in health and social care costs necessitated better ways to align individual behaviours and preferences with long term health and well-being. Behavioural science had shown that people did not always act in their own best interests; this meant the care system needed people to have ‘skin in the game’, best done by monetising highly salient personal risks.

Existing social insurance systems which used co-payments were more progressive in this direction, while countries with tax-funded systems were forced to reassess the use of co-payments, and financial incentives. The Millennials, having replaced the baby-boomers as the primary demographic group, were prepared to trade-off equity for more direct access to care. It also became politically difficult to advance equity as a goal against the evidence of poorer health outcomes as comparisons with peer countries drove performance improvements.

The use of medical/social savings accounts was one way that gave individuals control of their own money and building on consumerist behaviour, this directly led to improved service quality and incentivised provider performance as they could no longer hide behind the protecting veil of public funding. The social insurers were able to leverage significant reforms through novel payment systems, and influence individual health behaviours through value-based (or evidence-based) insurance not possible under a taxation system.

The 3rd Unbundling: of organisations

With people used to having their preferences met through personalised arrangements, care was organised around flexible patterns of provision able to respond easily to new models of care. This replaced the “tightly coupled” organisational approach known in the early part of the 21st century as “integration”, which we know led to constrained patient pathways, and limited patient choices unable to evolve with social, clinical and technological changes.

The big-data tipping point is reckoned to have occurred around 2025. Because the various technologies and cognologies had become ambient in care environments they were invisible to patients, informal carers, and care professionals alike; this enabled the genesis of smaller and more diverse working environments.

By 2032, medical consultants were no-longer hospital-based, having become clinical care social organisations, with their cheaper, smaller, portable, networked and intelligent clinical resources. Other care professionals had followed suit. These clinical groupings accessed additional clinical expertise on as-needed basis (known as the “Hollywood” work model); this way of organising clinical expertise helped downsize and reshape the provision of care and met patient expectations for a plurality of care experiences.

It takes time to shift from the reliance on monopoly supply of care from hospitals in those countries that continued to pursue a state monopoly role in care provision. However, most repurposed themselves quite quickly as focused factories, while the more research-oriented specialised in accelerating the translation of research into daily use, helped along by the new research discovery tools and the deepening impact of systems biology which was making clinical trials obsolete.


This Unbundling arose as a product of the evolution of social attitudes, informed by the emerging technological possibilities of the day. The period from 2016 to 2025 was a critical time for all countries, exacerbated by shortages in the workforce coupled with economic difficulties and political instability.

Today, in 2047, we are well removed from those stresses that caused such great anxiety. We must marvel, though, at the courage of those who were prepared to build what today is a leaner, simpler and more plural system, removed from politicised finance and management decisions.

It is hard to imagine our familiar home-based theranostic pods emerging had this trajectory of events not happened. As our Gen-Zeds enter middle age, they will, in their turn, reshape today’s system.

Plus ça change, plus c’est la même chose.

27 December 2047


Note on the Scenario

This scenario is informed by strong and weak signals, including:

Ayers A, Miller K, Park J, Schwartz L, Antcliff R. The Hollywood model: leveraging the capabilities of freelance talent to advance innovation and reduce risk. Research-Technology Management. 2016 Sep 2;59(5):27–37.

Babraham Institute. The zero person biotech company. Drug Baron.

Cook D, Thompson JE, Habermann EB, Visscher SL, Dearani JA, Roger VL, et al. From ‘Solution Shop’ Model to ‘Focused Factory’ in hospital surgery: increasing care value and predictability. Health Affairs. 2014 May 1;33(5):746–55.

Cullis P. The personalized medicine revolution: how diagnosing and treating disease are about to change forever. Greystone Books, 2015.

Does machine learning spell the end of the data scientist? Innovation Enterprise.

Eberstadt, N. Men without work. Templeton, 2016.

Europe’s robots to become ‘electronic persons’ under draft plan. Reuters.

First 3D-printed drug just unveiled: welcome to the future of medicine.

Ford M. The rise of the robots: technology and the threat of mass unemployment. Basic Books, 2015.

Frey BC, Osborne MA. The future of employment: how susceptible are jobs to computerisation? Oxford Martin School, Oxford University, 2013.

Generation uphill. The Economist. [accessed December 2016]

Lakdawalla DN, Bhattacharya J, Goldman DP. Are the young becoming more disabled? Health Affairs, 23(1-2004):168-176.

Susskind R, Susskind D. The future of the professions: how technology will transform the work of human experts. Oxford UP, 2015.

Topol E. The creative destruction of medicine: how the digital revolution will create better health care. Basic Books, 2012.

With Samsung’s ‘Bio-Processor,’ wearable health tech is about to get weird. Motherboard.

With the release of the latest analysis from the King’s Fund (here), heightened attention is being paid to NHS performance. It may only be a coincidence that an election is looming in which the NHS may be an election puppet. The King’s Fund report includes in the title that it an assessment of the NHS under the coalition government. While to some extent this is true, the NHS performance is not really about the actions of the government, but how policy direction is implemented by NHS providers and the system for commissioning care and the role of Monitor. Gosh, so many moving parts. By the way, I have no real criticism of the methodology used in the report; it is always about what conclusions we draw that matters.

The Report takes performance since 2010 for a baseline. Any numerate person knows that choosing your starting point is important in supporting conclusions about performance. We have had a recent report on blood transfusion in the NHS in the 1970s and 1980s, which had folks then known how poorly the NHS performed would likely have led to mass emigration; at that time, many of the people now in advisory or senior roles were learning their jobs and establishing their preferences and politicians were unable to imagine alternatives.

All governments of any political persuasion have acted to protect the NHS from direct litigation; the effect of this is to indemnify managerial inaction and poor treatment of patients. For example, in the early 1990s it became known that the deaths from hospital acquired infections exceeded road traffic accidents. This produced better infection control methods but didn’t improve patient safety. Had the NHS providers been subject then to pretty standard accreditation methods used in Australia, Canada and the US, it would have likely shuttered half of the NHS hospitals as dangerous to the public.

So, one conclusion might be that the NHS isn’t doing that poorly when put against its historical legacy of significant underperformance, and inefficiencies. Despite the domestic mythology that the NHS is/was the envy of the world, it is/was the universality of it that folks admired, not its waiting lists and high clinical death rates. During the debates on the implementation of what is known loosely as Obamacare, referring to the NHS or the UK health system was avoided as a political red flag; the country that was viewed favourably was the Netherlands.

The Report usefully looks at resources available. What needs to be appreciated in understanding resource use, is whether the resources are where they need to be. NHS hospitals are monopoly suppliers of specialists, labs and imaging services and a lot of services that are run from hospitals really don’t even need to be there (think ophthalmology, diabetic care, much physiotherapy); NHS hospitals reluctantly give up clinical control of patients receiving homecare and so on.

GPs and their patients must be fitted into the hospital’s service capacity in order to receive much care. Anyone who has had to wait for a scan will wonder why. As resource utilisation dictates whether outcomes are achieved and directly impact quality of care, the bottlenecks created by monopolistic practices in the NHS will only lead to greater risk of declining performance. People who hit the 4 hour A&E target who need some imaging, will of necessity get admitted, otherwise they are on the out-patient list (which can extend into months). All this is avoidable.

So not having the right resources available at the right time isn’t a crisis of funding, it is a crisis of management and system design.

The proof is always in the pudding. The Macmillan folks released a report on cancer survival (here), with their conclusion that cancer survival in the UK is stuck in the 1990s. Despite years of extra money, what is going wrong? A paper in the International Journal of Cancer (Moller H, et al Breast cancer survival in England, Norway and Sweden: a population-based comparison, 127, 2630–2638 (2010)) concluded:

“[if cancer patients in England are presenting at more advanced stages of cancer], then the main public health implication is that any strategy for improvement should include as a primary focus symptom awareness among middle-aged and older women and their primary care professionals, with an aim to facilitate early diagnosis and treatment.”

The implication for the NHS and belatedly recognised by NHS England, is that poor cancer outcomes come from the inability of patients to access oncologists directly in a timely manner. This arises from the hospital’s monopoly control of specialists and the inability of oncologists to establish direct access to full-service oncology services for patients when compared to access in the countries highlighted in the Macmillan report. The same can be said of many other clinical areas which hospitals monopolise. The disruptive forces at work in other sectors of our society are muted when it comes to healthcare — in part because politicians fear the failure of publicly funded institutions.

One can only be optimistic that new types of provider (such as the Vanguard sites) and other organisational redesign of clinical workflow will be successful and that the current problems are not a collective, unconscious, conspiracy of inaction within the NHS to shift responsibility onto politicians rather than taking direction action themselves.

The policy space for the NHS under the coalition government has removed considerable barriers to innovation, which should point to underperformance as a matter of design, not money.

Political manifestos that promise to spend more money are failing to grapple with the powerful underlying forces at work in healthcare. Indeed, they may be ignoring these in order to score (cheap?) political points with voters.

There is clear evidence of failure to use good practice, of time-wasting clinical workflow and excessive political and bureaucratic overhang. Granted the UK state (in its components) is justified seeking a form of accountability for the vast expenditure of public money, but this does not necessarily entail control of how the money is spent and this particular debate is questionable given the performance of other countries’ health systems (e.g. the Dalton review). Historical evidence would show that public control of expenditure in many areas leads to “rent-seeking” behaviours by public servants at the expense of service quality.

Governance arrangements such as proposed at Greater Manchester look little different from the NHS as a whole and I fear will lead to excessive wasteful bureaucracy at the expense of front-line service quality (seen from the patient’s perspective not the bureaucrats).  I wonder if they will achieve the same degree of performance as the Swedish county councils.

The power shift that is underway in healthcare, with its consumerisation through digital technology, publicly accessible performance information, and priority on value-for-money (which are not bad things) wrong-foots policy positions that seek to exert the role of the state at the expense of individual patient control and choice. And going forward, it is hard to justify disenfranchising patients from control of their healthcare when so much of their lives is under their control.

Whole Person Care as a Labour political slogan may play well in the press, but creating it requires thinking about how whole systems of care integrate and this will challenge the dysfunctional fault line running through some parties’ politics on the role of the private/independent/voluntary sectors.

This thinking is absent (at this stage) from the Greater Manchester MOU, meaning the capacity of the private and independent sectors is not included in their total health system capacity planning. But failing to grasp the needs of other than NHS organisations is not limited to this, but extends to workforce planning, which must also satisfy the needs of the private sector across a wide range of workplace settings. One may not like private healthcare, but it is irresponsible to ignore its existence.

We know that quality may be poor and performance reporting and information virtually impossible to obtain from private providers but there are reasons for this. From the position of a patient, NHS commissioners should be agnostic on the fitness of a provider and this would have the benefit of integrating care and quality across the patient treatment pathway and incorporate all possible sources of capacity and service delivery. It is the failure to normalise the role of the private and independent/volunteer sectors within total health system capacity that causes considerable fragmentation to patient care, and contributes to political posturing on the back of patient care. It would be wrong to assume failure is unique to the private sector and no political party can ignore the failures of the NHS (Bristol, Mid Staffs, and so many others).

In part this has been caused by the Department of Health traditionally insulating NHS providers from quality reporting and the consequences of failure. All governments have a problem to imagine the failure of publicly funded organisations (in any sector), but they do happen and require serious action to fix. Regretfully, there is evidence that local authorities exhibit the same behaviours.

In the end, the disinfecting light of public scrutiny is the solution, not more money. The NHS still avoids formal provider accreditation, instead opting for a (complex and troubled) inspection system through CQC which only now appears to be understanding the importance of provider failure — but failure in a complex care system is about people failing to act, of systems that are dysfunctional, and yes, driven by a focus on wrong-headed targets and a focus on pleasing political masters.

Want to know more?

On the quality of private care, this report is useful, but flawed: Centre for Health and the Public Interest, “Patient safety and private hospitals” in August 2014

The direction the NHS is now taking is evidence that some aspects of NHS performance arise from fundamental design flaws.

The mistake was likely made in 1948 to separate healthcare and social care. Today, as care processes shift into the community and the early forces of consumerisation in healthcare emerge, the underlying separation logic is unworkable.

Unfortunately, tax funded healthcare and cost-shared social care (coupled with split jurisdictional authority) have proved to be an administrative and financing nightmare, but more importantly a complex disconnected experience for patients. While Beveridge had a good idea, its execution has proved to be seriously flawed (it was even based on the unrealistic promise that costs would go down). In contrast, the social insurance model bundled health and social care from the beginning and we can see that it produces better care integration and outcomes. Indeed, countries with direct access to specialists appear to have better oncology and cardiovascular outcomes. There may even be evidence that gatekeeping may be causing access problems and delayed diagnosis (up to 1 year for ovarian cancer, and 2 years for neurological disorders, plus more….); proposed changes here are upsetting the BMA which opposes direct patient referral for oncology testing. One wonders what they fear that other countries don’t.

Patients and users of the NHS have no ‘skin the game’ because they lack the ability to exercise choice directly to influence quality. Proxy measures are used instead to achieve this and draw on the standard NHS ontology of committees and panels and senates and similar decision processes. Any student of such systems would know that such proceses are invariably excuses for inaction and may simply act to protect vested professional interest groups through those who sit on them.

The Greater Manchester approach is in the spirit of service integration and could lead to better quality and care, but I fear it will simply replicate the complex administrative and bureaucratic overhang that bedevils the NHS itself. In the end, it may only be redistributing resources without real service delivery innovation. Of course, if they were to replicate the Swedish approach, then perhaps there might be light at the end of the tunnel, but the funding model is wrong for that.  Simply lumping things together requires the creation of coordination systems, which will, in the end, direct managerial attention to the performance of the coordination system, and not on quality, service delivery and patient care. Keep in mind that only the patient has direct experience of the care pathway, and where it fails to integrate.

However, I have no problem with decentralising and localising services and doubt the word “National” also meant uniform services at the lowest common standard; such thinking has led to mediocre service quality, unacceptable waiting, delay and political confusion. Excellence should be allowed to flourish as evidence of how good care can be; unfortunately, localised excellence is often rubbished and characterised as post-code lotteries and multi-tierism, and ends up being used as political hay to undermine innovation.

English: British National Insurance stamp.

Skin in the game? British National Insurance stamp. (Photo credit: Wikipedia)


NHS England and other English health organisations have produced a five year ‘forward view’ [here]. The refreshingly short and precise document establishes a new approach to the English health service, something political reform has failed to achieve since perhaps the beginning in 1948, namely the realisation that top-down reform really doesn’t work. This is a bit surprising given how often

NHS folk have travelled, particularly to the US, and other places, where the notion of a top-down approach is anathema. All these visits, reports and breathless commentary on lessons learned has really, it now seems, to have been for nought.

We also now have some explanation why the attempts to adapt lessons and approaches from other countries has failed — the heavy overarching deadweight of central control has stifled innovation. Given the additional volumes of studies of the NHS, think tank policy papers, round-table discussions and consultation, researchers, in the UK at least, seem to have been trapped within their own paradigm and failed to see the internal fault lines that pointed to this blind-spot.

Anyway, that said, we now see that Simon Stevens, head of NHS England, has not wasted his time in the US, as not only does the report quote Lincoln’s Gettysburg Address, but tacitly acknowledges that the US (and other countries, but not in the UK) favour decentralised experimentalisation with payer and service delivery flexibility.

Lawton Burns in his important book on healthcare innovation [The Business of Healthcare Innovation, 2005, @Amazon] notes that one reason the US dominates the health technology innovation space is precisely because of the flexibility to experiment, try new things in healthcare service development.

This report, together with the other surprising ‘discovery’ that the funding of healthcare and social care are also part of the problem, after decades of dysfunction, shows that there is now a window within which major changes can be achieved to remove perverse policy incentives, drop barriers to change and get rid of the zombie administriative rules that kill off good ideas.

So where might this all go? Yes there are some very good examples already in place and one hopes more to come. But putting the cat amongst the pigeons may have other rather interesting consequences.

If we see increased power shifting to cities, will we see Swedish-style county-council run healthcare? Such an approach has the merits of democratic accountability, and challengingly, puts funding options within local taxation strategies. Given years ago I advocated with the other big city in the UK a local-council run NHS which caused no end of criticism, I would be surprised if this doesn’t come back on the agenda.

The rising priority of prevention also highlights one weakness of the NHS.  Dating back to 1819, employers had legal duties imposed on them for the health and safety of their workers, a responsibility which the creation of the NHS in effect removed at least in respect of health.  The report notes that employers pay National Insurance as though that were sufficient motivation. What the report fails to add is that NI employer contributions are not experience-rated in terms of the health of the workers themselves. The NHS has flirted with workplace healthcare in the past, but the concept of “primary care in the workplace” has failed. Stevens will know (and others should) how many countries separate workplace health from general health. Some places call it “workers compensation” and it involves risk-based employer premiums, adjusted for actual workplace health, injuries and accidents. Countries with such systems include the USA, Canada, Australia, Japan, and others.  What taxation does is risk-pool, but that means it is hard to link individual behaviour to risk.

American Accountable Care Organisations and other similar approaches in other countries of long-standing, only work when organisations are free to associate in ways that make financial and healthcare sense. US ACOs are forming partly in response to the financial signals in healthcare legislation there, but these signals, coupled with systems of rigourous inspection (and a failure regime), focuses minds. Vertical or horizontal integration in the NHS is needed, and would serve to remove at a stroke the barriers that bedevil patients. I’ve seen how building primary care onto the ‘front’ of the hospital enabled speedy patient access to specialists (they simply came down from the wards) and avoided inappropriate admissions. Buying a nursing home added a step-down into the coummenity releasing pressure on in-patient beds. GP integration toward secondary care pulls diagnostic imaging and laboratory technologies toward the patient, and removes hospital monopoly control of what is the major cause of delayed diagnosis.

But, the end result is in the UK, consumers, patients, employers, have no real skin in the game, which in these days of behavioural economics means that it is additionally challenging in the NHS to activate the essential incentives to align patients around their care, or employers around healthy workplaces other than through moral suasion.

We may need to revisit how to use the NI contributions as co-payments to create the necessary financial incentives that serve to quantify risk to both patients and employers.

Of course, one should be grateful for small miracles, which is why this report is welcomed.

P.S. I suspect this can be done without new money.


Ebola  is really quite a horrible little bit of DNA. Its route to humans is via the fruit bat and between humans through body fluids. So much for the public health model.

The virus is taking advantage of humans with poor lifestyle, illiteracy, folk medicine, weak healthcare systems and lack of awareness. If it is true a 2 year old is person zero, how did that come to be? The public health model wants to find the person, but what we really need to understand are the conditions for zero to become infected. That means mapping the ecology within which the virus operates.

We’re in the middle in the countries at risk of the Ebola outbread, and at the beginning everywhere else (even a case or two does not a crisis make). Nigeria may now be coming out the other end. The key is to build into our response an anticipatory and first response capacity throughout.

The real test of how these three countries will emerge from the Ebola crisis depends on what they are now putting in place for the Post-infection phase. Typically, events such as these emerge, get dealt with quite quickly (as in the case of other Ebola outbreaks), but building in anticipatory and response capacity is not a resulting priority. Better organised healthcare systems will handle situations like this better.

The three at-risk countries have weak governance, score low on Transparency International’s corruption scale, and low on WHO’s Human Development Scale, all characteristics of failing states.  It is not inconceivable that these countries could collapse; the historical record shows that other civilisations have collapsed from disease.

Since weak healthcare systems are contributive to the problem, improving access to care and reducing the cash component would require improving the economic performance of the country itself. That comes with greater trust in government and confidence in the future. So there are tools and techniques that can be deployed to help.

Consideration should also be given to more integrated, ecological models of how viruses and infections work, what some call “conservation medicine”. Many of the problems of pandemics arise from unnecessarily narrow specialised focus and adoption of particular disease transmission paradigms that marginalise knowledge in related areas.

Without being too draconian in this respect, some rethink is appropriate of the prevailing public health driven model, characterised by high degrees of alarmist rhetoric and hyperactivity, to achieve a measure of integration particularly around pinch points in the flow of information for effective decision-making.  A ‘systems model’ would start with the likely inaccuracy of diagnostic tools (which both over- and under-report). There is also a general weakness in animal and human disease surveillance and corresponding weaknesses in subsequent information management.  What we know from thinking like a virus is that humans can be just as dangerous as the bats that originate the virus, but we use different logic when dealing with humans as with the bats.

Compounding he problem with Ebola and other zoonoses of that type is that our ability to collect information and act is slower than the pace of spread.

Obviously screening people at airports makes sense within the public health model, but makes little sense from the point of view of the virus itself. Regretfully, quarantining whole countries may need to contemplated. Screening at airports does little when the origin is people arising from stricken regions. What do they say about closing the barn doors after the cows have left?

But we must learn how to think more like the virus, so we react more quickly, and ensure the virus will not have the opportunity to spread.  After all, that is what the virus wants to do.

About the three most at-risk countries

The countries that are the core to the current Ebola crisis are Guinea, Sierra Leone and Liberia. Using WHO Human Development data (from here), we learn that these three countries are classified as low development countries: Liberia is ranked 175, Guinea 179 and Sierra Leone 183; there are 187 countries on the list. They spend less than 3.0% of GDP on education (closer to 5% is associated with higher education attainment levels) and with literacy levels below 50%. Expenditure on health as a percentage of GDP shows they are essentially cash-based systems, which given the relative poor human development means access to healthcare will be income rather than need linked — they have health systems for those who can afford it. Transparency International ranks these countries toward the bottom (more rather than less corrupt) with scores below 30 (see here). All very worrisome but indicative of national priorities at odds with the needs of the country. Many are more prone to conflict than care.

From the point of view of a virus, these are excellent conditions for transmission: illiteracy, poverty, unhealthy population with low life expectancies (under 50 years or so), internal strife and conflict.

Guinea: spends 6% of GDP on health, of which 67.4% is cash

Sierra Leone: spends 18.8% on health, of which 74.9% is cash

Liberia: spends 19.5% on health of which 17.7% is cash (best of the three in that respect)

Want to know more?Laurie Garrett’s The Coming Plague, 1994. See here at Garrett’s website. And they say prophecy is dead.

Right now, there is the proposed NHS Reinstatement Bill, a lobby document which lays out a way to reverse many NHS reforms.

Rescue is on the way; thank goodness for the superhero to save us. (DC Comics) (Photo credit: Wikipedia)

Rescue is on the way; thank goodness for the superhero to save us. (DC Comics) (Photo credit: Wikipedia)

This lobby document, which is what is it, is familiar reading, and brings back various structures that in the past have failed. You can find information on it at this link.

What is interesting about this approach is the aura of respectability that it wraps itself in, by proposing the changes as a legislative draft, almost as though it were ready to go to committee.  This is, obviously, an influencing tactic designed to force debate onto the topics covered in the proposed bill, and disarm critics who don’t agree that the points in the lobby document are the right starting points. In that respect, the lobby document polarises positions, particularly against current policy direction.

The whole lobby document’s comments and notes identifies proposed changes to a variety of existing legilsation. What we don’t find, though is any evidence that the authors were in any way persuasive  or influential during public consultations at the time. We call that ‘sour grapes’.

Approaches such as this suffer from the following:

  1.  a belief that the fundamental values underpinning the health service can only be protected in a particular way and these are the ways things used to be.
  2. a belief that the changes that have been made have violated these values; moreover, that the solutions have made things ‘worse’ as they see it.
  3. selective use of academic research to support the positions that one wishes to avoid changing.

New PublicManagement as reform of government itself must sit uncomfortably with this regressive thinking.

For the authors, they would no doubt point to market failure logic to prove that the NHS should not be ‘marketised’ as they put it, forgetting that a greater fear is ‘government failure’, for which there is ample evidence, not just with the NHS but a whole host of other public initiatives and legislation that has wasted public money.

Healthcare systems are complex and by trying to overlay what they see as simple solutions to the problems they claim arise from the reform agenda of past years, they misrepresent what the actual problems are. As messy, or complex/wicked, challenges, the authors believe that by taking away that messiness, they’ll also take away the problems. But they know just as well as anyone, that their solutions will only create, perhaps even recreate, the very problems that led to reform in the first place, except now they will be today’s problems, not yesterday’s.

One might argue that the authors are committing a type 3 error, of unintentionally solving the wrong problem well, but that would assume that they have are not clear in their minds what they are proposing. Therefore, it appears they are do know better and are committing a type 4 error, of intentially solving the wrong problem well because that fits with their policy preferences, or prejudices.

That’s why this is a lobby document, designed to intensionally convince, (is mislead too strong?) others of their definition of what the NHS problem is.

Regardless, the lobby document and the authors are caught by a fundament policy trap: of solving the wrong problem.

Want to know more?

Government failure in the UK is examined in Anthony King and Ivor Crewe, The Blunders of Our Governments, 2013 (@Amazon) and in Richard Bacon and Christopher Hope, Conundrum: Why every government gets things wrong and what we can do about it, 2013. (@Amazon)

New Public Management was originally conceptualised by Christopher Hood, in 1991, A Public Management for All Seasons. Public Administration, 69 (Spring), 3-19. Some (Dunlevey et al) argue that New Public Management is dead and that governance in the digital era requires greater, not less, government. That may be the case for some, but if you actually look at the tools that are available to government in a digital world, you’d find that there is little reason for government to own or run very much. See Christopher Hood and Helen Margetts, The Tools of Government in the Digital Age, 2007. (@Amazon)

I have found Leslie David Simon’s book, (Woodrow Willson Centre, 2000) an early, and compelling way of laying out the digital agenda in a policy context really well. (@Amazon)

I would also recommend Vito Tanzi, Government versus Markets: the changing economic role of the state, 2011. (@Amazon)


Measuring Up: the health of NHS Cancer Services is a report from Cancer Research UK.

I have no difficulty accepting much of what they have discovered and the report’s key points are sensible. But, two main conclusions are unsurprising and disappointing: more money and better leadership.

Paradigm Shift: If it sounds like a duck, it’s a duck. English: A male Freckled Duck (Stictonetta naevosa) (Photo credit: Wikipedia)

Paradigm Shift: If it sounds like a duck, it’s a duck. English: A male Freckled Duck (Stictonetta naevosa) (Photo credit: Wikipedia)

There will never be enough money, so we need to think differently about how we organise care itself. More leadership is a typical lament which says that the people responsible for the service haven’t done what they need to do. When I read reports such as this that call for more leadership I can only shake my head that they were not able to think further about the underlying causal landscape.

Their use of tipping point language is useful, though, as it does suggest catastrophic, rather than incremental, changes are likely. A tipping point means a move from one state to another (like tipping over the milk pitcher), where other factors come into play (otherwise it wouldn’t be tipping!). That suggests that there will be a change of state in which the old rules are unlikely to apply or be useful. After Kuhn, we call this a paradigm shift. Edward de Bono characterises two situations: one he called a problem, where you use existing rules; the other is a crisis for which you need new rules. My take is that the NHS is moving into territory where the need for different thinking is more important than problem-solving. That healthcare is a complex (wicked) and adaptive system should alert us and not surprise us that solutions create new problems and indeed crises.

Based on the report, though, we’re more likely to see hyperactive civil servants and NHS “leaders” rushing about with Powerpoint presentations full of exhortations and flow charts, accountability matrices and maps. We’ve tried that so often, one wonders if there are any other tools in the box. However, that the current state of affairs may have been caused by past reform and changes is an important insight, but to argue for essentially what is more of the same is plain silly. If past actions have destabilised cancer services and tipping is likely, then new thinking and new rules are needed. Did I miss something in the report?

If we take the simple flow of patients through the system, we are told the rate of entry is rising as GPs shift to ‘urgent’ referral, presumably the only way they know to get an oncologist’s attention, but the velocity through the system hasn’t changed. Why should that be surprising when resources are rigid and constrained by NHS structures (such as lack of effective transfer of patient information), and what appears to be performance measurement of the wrong things, creating perverse incentives.

The diagnostic phase is what appears to be rate-limiting across the patient and treatment pathway and hence is the primary blockage. While increased investment in diagnostics would be timely, how to do that is where a paradigm shift is needed. The delay in procuring proton beam equipment (so much in the news) illustrates the procurement logic that undermines service delivery. Entrepreneurial creation of free-standing diagnostic centres, providing on-demand services to oncologists and patients would be one way to deal with this. Does the NHS need to own the equipment, labs etc. or does it just need access to the service? By-passing the GP would also be another option, as the gatekeeping function appears to be another form of avoidable delay (ask women how long it took for ovarian cancer, for instance). Would it not be better for patients to access directly oncology diagnostic centres, which might also speed GP referral in turn?

The policy-down focus on leadership has clearly produced organisations of dubious purpose, but with evocative titles: Clinical Senate. Wow! But systems are judged by their performance, not what they’re called. A focus on leadership shifts cognitive priorities from a service orientation to one of lining up organisational structures, job descriptions, role definitions and mandates, meetings, minutes, but distractions if the challenge is where the rubber meets the road. The intersection of patient with system defines the leadership challenge, not the other way round.

So, what is to be done? I don’t buy the authors’ argument that change-weary people don’t need more change. They may embrace the logic of wholesale paradigm change if it got rid of the nonsense that stops them from doing what needs to be done. My take is that there is a strong case to be made for unbundling cancer services (this logic can apply in other clinical service areas, too) defined by the demands of the patient pathway. I would also look for ways to encourage entrepreneurial solutions, particularly in the form of investment in diagnostic technologies, and in enabling oncologists to work autonomously with each other and with patients. This would call time on the hospitals’ monopoly control of oncologists, cancer diagnosis, testing, and services, which is organisationally rate-limiting, and many of the identified problems are consequences of a system subjected to serious rate-limiting blockers, but lacking the ability to alter its structure to bypass, elminate, or reform those blockers.

In the end, the report is a narrative exhortation to get people to meet and plan to do what they are currently not able to do, or otherwise they would have done what needed to be done. Why not?



Sir Andrew Dillon, the erstwhile leader of NICE as said that it is irrational for the Cancer Drug Fund to pay for drugs that NICE has turned down.

He’s right of course, it is irrational. But only if NICE’s logic is compelling.

When rules don't work [Conceptual work by Yves Klein at Rue Gentil-Bernard, Fontenay-aux-Roses, October 1960, photo by Harry Shunk. Le Saut dans le Vide (Leap into the Void) (Photo credit: Wikipedia)]

When rules don’t work [Conceptual work by Yves Klein at Rue Gentil-Bernard, Fontenay-aux-Roses, October 1960, photo by Harry Shunk. Le Saut dans le Vide (Leap into the Void) (Photo credit: Wikipedia)]

The problem for Sir Andrew, and likemined people, is that there is another logic that trumps NICE’s rational world. Don’t get me wrong. NICE performs a useful, but technocratic, function with analytical assessments that any rational person would indeed want to know. Where we part company is believing that NICE’s logic is the final word on the matter. Which it isn’t.

Tasked, perhaps unenviably, with parsing the performance of medicines and clinical practice, cannot also mean that they are above challenge. Many of NICE’s rulings fly in the face, not of logic, but of our beliefs as humans. It is why we do things when the odds are against us, because not to do so would be wrong. If we think of the challenges NICE faces as wicked problems, that is complex problems with a multiplicity of solutions, it becomes self-evident that their logic is just one way of deciding and choosing. We could use other rules, other criteria. The Cancer Drug Fund is just such an approach. It is another matter whether we should have in place alternative funding approaches that individuals can avail themselves of (such as co-payments or co-insurance); for extraordinarily costly therapies, co-funding would not apply, so we’ll back to the problem anyway.

NICE has a troublesome relationship with the notion of ‘rule of rescue’ and so has decided to ignore it. There replacement, the “end-of-life premium” is really just a reweighting of the logic they use.

You see, the rule of rescue is what we might call a meta-rule — it is a rule that tells us if other rules are working properly, and importantly, as a moral imperative which tells us what to do. The rule is often invoked in a particular form: that people facing death should be treated regardless of cost. The rule as originally formulated is really about assisting identifiable individuals facing avoidable death (Jonson, 1986); the bioethicists and economists have shifted this to a cost-effectiveness approach, making it one about trade-offs instead.

The problem for healthcare systems is that all patients are becoming identifiable as medicines become personalised (medicines may become orphan drugs). The problem for the NHS is that it does not allow such people to rescue themselves because it prohibits any sort of co-funding or other arrangements. The only option is an opt-out (and private medical insurance has rules about pre-existing conditions). Given the funding priorities of the NHS, we should be reflecting not so much on how to make the pot bigger, but on using the money that is available better (there will never be enough money), and ways to introduce practical co-funding.

Since individuals have no other options in the NHS, the rule of rescue as a moral imperative will be violated and we will act, not out of analytical error (i.e. make a technical mistake), but unethically. You see, the NHS must be the healthcare system of last resort and therefore of rescue, otherwise, identified individuals are destined to a death sanctioned by public policy and is that a policy or healthcare system worth having?

We have seen a similar challenge to NHS/NICE logic recently with the King family and proton beam therapy, and the NHS will also use NICE logic to determine access. Whether beams or drugs, it is the same argument.

But why cancer? The main public policy question is why should cancer patients be given preferential treatment as against any other deserving group? This may in part be driven by the often astronomical costs of new cancer therapies themselves, which demarcate cancer patients decisively from equally deserving patients with less cost-contentious therapies. I have just finished some work on motor neuron disease, for which there is one specific medicine and life expectancy from diagnosis is 3 to 5 years, with median survival rates that are measured in months. NICE reportedly is developing guidelines for this disease. Costs are considerable, and at least in the UK, highlight the bureaucratic illogic of separate healthcare and social care, but that is another story.

The moral dilemma that the economists at NICE are trying to reduce to an equation is whether a new therapy is extending life, or delaying death. The Oregon approach collapsed when the hard choices emerged and people were unable to resolve this dilemma, which is not a quantitative issue, but one of how we value our humanity. Kierkegaard’s Concluding Unscientific Postscript speaks of the leap to faith as involving self-reflection and the emergence of scepticism. It is worrisome that NICE is so confident.

Further reading

Cookson R, McCabe C, Tsuchiya A. Public healthcare resource allocation and the Rule of Rescue. J Med Ethics. 2008 Jan 7 [cited 2014 Sep 4];34(7):540–4.
Jonsen, AR 1986, Bentham in a box: technology assessment and health care allocation, Law, Medicine and Health Care, Vol 14, pp172–4.
Richardson J, McKie J. The rule of rescue, working paper 112, Centre for Health Program Evaluation, Monash University

This report on the regulation of private hospitals in England from the Centre for Health and the Public Interest is important, but 15 years too late.

The UK has had and continues to have a love/hate relationship with the private (or independent as it is termed) healthcare sector. This has created a significant fault line across all reform and policy making on the NHS for at least 15 years. Reluctance to create a level regulatory playing field has been evident for years, despite the obvious need for one. I think part of the reason is that creating a level regulatory playing field so that the NHS and private hospitals had to meet common standards would legitimate the private sector itself.

However, when I first worked with a colleague to suggest, around the early 1990s, that the NHS hospitals should undergo some sort of accreditation, resistance was clear. At the time, I noted to others that there were more deaths in NHS hospitals arising from substandard care than from road traffic accidents.

But the view at the time was to ring-fence the NHS from that sort of performance and quality scrutiny at an institutional level. Based on some of the work I was doing at the time, and my own experience with accreditation systems, I felt that the negative reaction reflected a fear that NHS hospitals would fail; using pretty standard accreditation standards from the US, Canada and Australia at the time, I perceived that many NHS trusts would indeed fail. Mainly on safety and quality control grounds (I was teaching NHS managers about quality and quantitative methods in healthcare at the time). Many hospitals lacked any quantitative analytical or operations management capabilities within their organisation and had rather weak data for quality control and performance management purposes. The Department of Health, it must be said, had such expertise on contract but that was to inform their own policy making, not to improve operational performance. I would suggest that such quantitative expertise for quality is still missing at the hospital level.

The consequence has been years of fiddling with quality assurance and inspection regimes. Government has been advised, I think badly, by people who also shared the operative underlying assumption that a single regulatory and inspection system for both the NHS and private hospitals would be politically a step too far. Consequently, the private sector and the NHS have moved in different directions. The private sector has been both an opt-out for patients through private insurance arrangements, and an overflow supplier to the NHS when it ran into capacity constraints. Only more recently, has it been a direct and core supplier of services.

The UK situation constrasts wildly with practices in other countries where ownership of the hospital does not exempt the organisation from regulatory oversight. Indeed, many European hospitals seek out US-based Joint Commission International accreditation, a very high standard. Interestingly, there are no private providers in the UK that have achieved this standard, while (with any type of accreditation) there are 26 in Ireland, 3 in Belgium, 2 in Netherlands, 4 in Germany, 26 in Italy, 15 in Portugal, 23 in Spain, 13 in Malaysia and so on. Perhaps they know something?

I agree with the report’s sentiments, though perhaps not so much how it characterises the private sector as exceptionally risky. Indeed, the past years have demonstrated that NHS hospitals can be exceedingly risky. For instance, the report notes the 6000 admissions per year to the NHS from independent hospitals, while also noting that such hospitals do not have emergency facilities. One might ask whether a common regulatory environment would have led some independent hospitals to invest in such facilities? But such a figure should not be a surprise any more than transfer between NHS secondary hospitals of patients who need more complex tertiary and quaternary care; not every organisation can do everything. In respect of equipment, NHS equipment, too, has failed, gone missing or not worked properly (I have had personal experience of a nurse using equipment that lacked recent calibation); so before we cast the net, let’s make sure we know what we’re fishing for.

The report notes that the private hospitals do not directly employ their doctors, as though this were a problem. Many countries do not directly employ doctors, using fee-for-service type arrangements for compensation. What the report failed to note is that the private hospitals in the UK employ a system called “privileges”, which requires doctors to prove competency in areas for which the hospital in turn grants them privileges to offer that service in the hospital; NHS hospitals do not use a comparable system. I have argued that the NHS should introduce a privileges system, which would bring a more rigourous standard of clinical performance management than the NHS consultant employment contract does and would have the additional benefit of increasing flexibility in the supply of doctors, and perhaps importantly, keep doctors within their scope of primary competency.

A few other points that struck me:

1. Clinical risk does not transfer to the private provider when treating an NHS-funded patient. I’m not sure how this is a useful restriction, especially if the patient chose the private hospital. It seems to me that part of a level playing field would ensure that clinical risk transferred, too. The report addresses this obliquely in terms of whether the NHS is the provider of last resort.

2. The observation that clinical workflow is different is interesting, but it does appear somewhat anecdotal. The private sector is excluded from the requirement to take trainees, and that may contribute to the lack of depth, but I doubt the public would feel reassured that the clinical depth the authors referred to was reliance on trainees! We know what that looked like with registrars. The solution is to ensure the private hospitals are included in the system for training the health professions as a consequence of a common regulatory regime. By the way, I’ve looked at the supervision and training of junior doctors and other health professions and one should not be complacent that it is done well. However, I share the authors’ concerns over the organisation of clinical work, but would not single out the private sector on this point.

3. The volume of work in specific areas is a point well taken. However, I would again suggest that is an artefact of the regulatory system, and lack of effective use of the clinical resources themselves. Proper contracts for suitable volume, rather than handling overflow, would shift workload closer to levels where higher quality standards apply. It might also enable the consultant, for instance, to integrate their clinical workloads, rather than adding the private patients on at the end of an already busy day. Again, organisation of work arises from the current rules and may perhaps be causative of may of the identified problems.

4. I note that only one of the two authors is a specialist in healthcare or health policy, particularly patient safety with grounded expertise.

Many of the report’s comments, with which I broadly agree can seem quite disturbing, really arise from the regulatory box that the private sector has been put in. Given that private hospitals use the same doctors in the main as practise in the NHS, do these doctors lose their minds when they practice privately, or something else is certainly wrong at a system level. My guess is that the box is the problem, and the private hospitals are quite capable of meeting care standards, given a level playing field.

My remarks are meant to focus attention on the important distinction between the NHS as an organising principle for ensuring (and assuring) healthcare to people and the mechanisms used to identify and engage providers who meet the requisite standards. Focusing on the latter, would necessite doing what the report recommends, but ’tis a shame it has taken this long, to say once again, what has been said for years.

Is now any different?

Further reading: Vito Tanzi’s excellent book, Government versus Markets The Changing Economic Role of the State. Then think again about this



1. I don’t have private health insurance.

2. I have received NHS-funded care in a private hospital.

3. My NHS trust has recently been reviewed as overall inadequate by CQC.

4. I know something about the issues I am writing about.