Reform Scotland

More questions than answers and a healthy dose of realism – Dr Andrew Evennett

So here we are, 75 years into the NHS’s 100 year journey from inception to centenary, faced with the seemingly Herculean task of ensuring that it reaches that venerable milestone still free at the point of need and delivering a service which is effective, cost-efficient, sustainable and valued by all of its stakeholders.

Accordingly we should acknowledge the size of this challenge and anticipate a process which will involve multiple steps, considerable sophistication, patience, diplomacy and attention to detail and foster a spirit of constructive cooperation.

I agree that at the beginning of this process it is correct to ask “what are the key questions which we should be asking?”.

In order to make lasting progress we need to set off together in the right direction.

Simplistically, one could imagine that in order to make an organisation or service work well requires an agreed vision and budget, an appropriately designed strategy, the creation of a suitable operational plan, a thorough governance framework, active stakeholder engagement, regular review and subsequent adaptation/evolution.

Yet the NHS has been doing all of this for years.

In fact the amount of political, academic, managerial, clinical and creative energy poured into the NHS has been colossal.

Over these 75 years some people have experienced interactions with the NHS which have been satisfactory, good, very good, excellent or extraordinary.

Unfortunately, others have had experiences which have been unsatisfactory, bad, very bad, dreadful or catastrophic.

The extensive systems of governance reporting and critical incident reviews have provided a vast amount of information about all of the above.

Also during this time there have been very many strategic reviews, refreshed visions for healthcare, renewed clinical strategies and public engagement exercises and yet stakeholder dissatisfaction remains very high.

So some of the ensuing questions may include:

  • Why is there still such a large gap between the intended and actual output/delivery of the NHS resulting in such a level of dissatisfaction?
  • Fundamentally, does the NHS represent the correct paradigm for healthcare delivery or are we striving for the impossible?

If Scotland is to have a mature, constructive debate aimed at building consensus around the future of health and care services, how does one satisfactorily hear the representation and meet the needs of such a large and varied group of stakeholders (patients, public/ electorate, tax payers, NHS staff, indirectly contracted staff, government,  parliament…), each with different hopes and expectations (access to excellent healthcare, value for money, good employment conditions, political ideals…) ?

Linked to this is the challenge to encourage acknowledgement of vested interests in order to allow for the most productive dialogue.

Last year I asked a number of former medical colleagues from very different roles and backgrounds to give their opinion about what should be done to improve the NHS and received dramatically different responses.

When discussing what has/has not worked well thus far, clearly there is a need to be frank, open and specific yet also to avoid causing offence to those whose contributions have turned out to be less successful or even damaging.

  • How is this going to be facilitated in order to produce the most creative framework for effective change rather than promoting defensive, obstructive or negative behaviour?

Organisational culture has the reputation of being able to confound even highly sophisticated organisational strategy, rendering it ineffective.

  • So what does a healthy organisational culture look like and how do we promote and develop this at all levels of the health and care service?
  • How do we design a service which is able to adequately cater for constantly changing societal behaviour and subsequent requirements?

The health and care sector workforce is suffering from considerable collective fatigue but also a high level of disillusionment.

  • How do we regain lost confidence in the short to medium term in order to completely overhaul the service in the medium to longer term?
  • As we seek to design a service which functions well at a national level how do we also encourage and optimise local engagement and ownership?
  •  How do we decide how to divide the use of finite resources between relatively low cost/high impact health promotion and high cost dramatic intervention?

Over the last 75 years technology has advanced at an incredible rate and undoubtedly will continue to do so even more over the next 25 years. Indeed, the development of Artificial Intelligence has been compared with that of nuclear energy, bringing both enormous opportunities as well as very real challenges.

  • How are we going to engage with science and technology to optimal effect?

 Moving on from suggested possible questions I would like to make a specific suggestion.

I have already mentioned the large number of strategic initiatives which have taken place during the life of the NHS.

In my opinion, by far the most outstanding of these has been that of Realistic Medicine, introduced by the Chief Medical Officer in 2016, conceptually relatively simple and yet profound in terms of its potential impact.

At its core is a framework for delivering dynamic, interactive healthcare capable of catering for the general and specific needs of both the population and the individual, changing as they do with time.

I would like to close this piece with the suggestion that as we proceed with the NHS 2048 project we could learn from Realistic Medicine:

We should strive to include realism in all of our discussions. Saying or planning a thing does not mean it will actually happen or succeed.

We should aspire to develop an NHS which is dynamic and interactive at every level, able to evolve rapidly as required.

Dr Andrew Evennett is a retired GP. He was a member of the NHS Highland Board, chaired the Area Clinical Forum Chairs’ Group for Scotland and served on many other health committees. He was actively involved in raising concerns about behaviour in NHS Highland and in the subsequent review processes.

If you would like to contribute to Reform Scotland’s NHS 2048 forum, please email [email protected]