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.

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