We Don’t Know What the NHS is For

Pritpal S Tamber

March 11, 2013

Is it about the delivery of clinical services or the collective ego of a place?

Last week the people of Leeds successfully halted the NHS’ plans to reform children’s heart services, which included moving surgery to a neighbouring city. It was a great victory for the citizenry. According to the High Court, the campaign group, Save Our Surgery (SOS), raised legitimate concerns about the decision-making process by which the NHS had decided to move surgery. It was democracy in action.

The problem is their “victory” has probably doomed local children to poorer outcomes. For some time now it’s been known that specialist surgery needs to be done in dedicated sites to increase the likelihood of better outcomes. So how is it that good democracy appears to be incompatible with good clinical outcomes?

To my mind, there are two answers: one about how NHS England goes about reforming services, and the other about the context in which such reform is being conducted.

The “how” answer is simple. The NHS was effectively telling local communities how their services should look. It completely failed to miss the fact that the community pays their salaries through taxation so, at best, all the NHS is set up to do is advise local communities what the right services might be. I’ve written in the past about how poorly my GP practice and local Clinical Commissioning Group engages its citizens so none of this was a surprise to me. It is, in fact, a manifestation of the kind of patriarchy that we like to think is a thing of the past but remains not only rife but the modus operandi of care planning and delivery.

The “context” answer is more complex. It’s easy to suggest that SOS simply did not understand the evidence on the impact on outcomes. While this may be true it clearly did not matter to them as much as having local services. In essence, to them providing local services is what the NHS is for.

The technocrats behind the reforms clearly have a different understanding of what the NHS is for. They probably believe it should provide the best outcomes possible for the local community, even if it means people having to travel to a neighbouring city for surgery. It’s easy to see, then, that citizens and providers have a different understanding of what the NHS is for. They’re operating from different contexts.

Most large organisations work hard to understand what they’re for. They develop a clear sense of purpose, often defined as vision, mission, and values, to underpin their every decision. While the High Court battle went on last week I was reminded of this when I met a business consultant who specialises in helping organisations define and communicate their purpose. He’s formerly of the theatre and his key skill is in helping organisations authentically narrate their purpose in ways that engage multiple audiences, whether inside (staff) or outside an organisation (customers).

SOS knew their purpose – to keep services local. Simple. But what does the NHS think it’s for? I would argue that as a tax-funded system the core purpose of the NHS is to inform citizens about best practice and then participate in developing a shared understanding of what services are right for a community (within the budget available). This is a fundamental shift. I’m suggesting that the NHS’ main purpose is not about providing care but providing information in order to discuss and agree what care to provide.

All this might feel insubstantial but let’s consider examples from the real world. Most people think Coca-Cola and Tesco simply exist to make money. Making money is, indeed, an important part of what they do, but Coca-Cola actually wants to “refresh the world”, “inspire moments of optimism and happiness”, and “make a difference”. Meanwhile Tesco uses its slogan, “every little helps”, as a guiding philosophy in everything they do and have applied it to all aspects of their business through what they call their “steering wheel”. Both organisations strive to be internally and externally consistent.

I realise that both companies have their critics so I am not specifically defending their business practices. All I’m saying is they understand what they’re for and are brave enough to openly declare it on their websites (Coca-Cola even let people comment). It is from this clear understanding of their purpose that they make decisions.

So what is the NHS for?

I believe last week’s ruling was a defining moment in the history of the NHS (and note that it’s one delivered by citizens, not bureaucrats or politicians). It illustrated the disconnect that exists between providers of care and the citizens they serve. The response to the High Court ruling from the Chairman of the Committee proposing the reforms says it all:

“The pressing need to reform children’s heart services is long overdue and experts have cautioned that further delay in achieving the necessary change would be a major setback in improving outcomes for children with heart disease.”

He reverts to telling local communities how their services should look. What he should have done was take a step back and realise that the experts were making recommendations based on what they assume the NHS is for rather than understanding what local citizens believe it is for. And let’s not forget it’s the citizens that actually pay for it.

The citizens of Leeds have challenged the NHS to define its purpose. Whether NHS England is sufficiently well led to rise to the challenge is yet to be seen.

Competing interests: I do not have any competing interests in relation to this post. The business consultant mentioned will not benefit from this post.

This post was first published on my original blog, Optimising Clinical Knowledge, and co-posted on BMJ Blogs.

Pritpal S Tamber

I’m a doctor who trained as a medical editor and publisher and now researches and consults on the link between community power and health equity. My interest in community power started when I was the Physician Editor of TEDMED and is explained in My Perspective. I also work as a freelance medical editor and publisher for organisations that want to write high-quality articles and a strategy for their publishing and promotion. Find out more on my About page.

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