One of the main purposes of this blog is to question some of the established orthodoxies of the NHS and how we think about it. By definition that means that I raise questions all the time about how the NHS thinks about the main issues it faces.
For the last five posts during this month of my return to the fray I want to develop a different set of arguments. These will question why so many leaders and commentators in the NHS seem to need to passionately portray the organisation as being mired deep in a many faceted crisis.
There is constant talk about ‘the graph of doom’ which has demography rising and resources flat lining.
I want to explore the nature of the psychological need that is being met by this constant return to viewing the world in this way.
Because, from the outside, all this talk of doom seems to make the job of actually achieving anything very hard indeed.
One way of looking at this is that if there are…
- too many old people
- too many sick people (who are also apparently the wrong sort of sick),
- too many changes in technology
- sky-high rising public expectations and
- no new money
…then don’t all of these external factors create a set of drivers which argue relentlessly for the necessity of radical change?
One would think so. But then in the real world where these arguments are being made by and large radical changes of scale are not being made.
So I think we need to think of another purpose that this way of looking at things serves. If all of these external factors are coming together to create pressure for change isn’t it also the case that change on this scale can’t be achieved? So, the argument goes, this is all so overwhelming that nothing can be achieved – so let’s carry on much as we are already.
So the paradox of this week’s posts is that what should be powerful arguments leading to change have in fact become OVERWHELMING arguments resulting in people not knowing where to turn.
I am grateful to my old boss Alan Milburn for showing me how these arguments need to be turned on their head. A few weeks ago at the Guy’s and St Thomas’ Charity he gave a lecture on how all of this overpowering doom could be a set of opportunities for the service potentially leading to very different leadership activities.
Because, as with so many things, this is all about leadership. The framing of the argument is a matter for the leadership of the system. And at the moment that argument is being framed to be so overwhelming that everybody is being frightened back to the status quo.
This week I want to spend a day on each of the five areas which have been portrayed as overwhelming challenges and see what possibilities they provide the NHS.
- The nature of disease
- The nature of technology
- Public expectations
- The money
On demography I need declare an important interest. I am 65 – the same age as the NHS – and therefore part of the age group and generation that are being seen as the burden that will destroy it.
Personally I don’t quite see myself as a burden but I sort of get the point.
However, my generation – colloquially referred to as the “baby boomers” – has, until now, more often been seen as a generation causing problems because of too much activity – not too much passivity.
We were – just – young mods and rockers (in my case a failed rocker as I never mastered riding a motorbike); we developed and sustained several parts of pop culture; we were the first major wave of student unrest; we were an early part of the property boom; we rode a tide of divorces and changed jobs far more often than previous generations.
All of this seems very active. (For our parents, much too active.)
Apparently now that we are entering retirement we are going – for the first time in our lives – to become a passive burden, rack up several co-morbidities and spend the last 30 years of our lives bothering doctors.
Old people are not just often referred to as a ‘burden’ but we also seem to feature in a lot of ‘drowning analogies’. There is, and will be, a flood of demand which will lead to the NHS drowning under it. All of this becomes a tsunami of need.
One of the statistics used to make this case is that by 2030 a third of the population will be elderly. This is assumed to clinch the whole argument since a problem that big must be insuperable. Personally I would be 82 and be part of this flood by being ill, and passive.
I think it’s certain many of us will be ill. My aches and pains will develop into arthritis and I am pretty sure that my blood pressure will be too high. Almost certainly I will also have another morbidity.
So it’s true that there will be more of us and that many of us will be ill in complex ways.
But will we be ill in the same way as today’s 82 year olds?
When I read the Saturday and Sunday supplements many of them treat me as a very active consumer for the rest of my life. I read them as appeals to me and older generations to become ever more active. There are a whole host of organisations that are looking to me to be very active indeed when I am in my 80s.
Private sector organisations assume I will be very active.
The NHS assumes I will be very passive.
Voluntary sector organisations see me as active.
The NHS sees me as passive.
The NHS assumes that its burden (and the problem of their increasing activity) is caused in part by my passivity.
But what will be the characteristics of my activity that the NHS, if it understood me in that way, could work with?
How might my GP be encouraged to view the next 30 years of my life as a set of assets with which the NHS can work?
One of those assets would be my wish for my home to be the established and clear locus of health care. I do not want care closer to home. I want care at home.
Our care will be centred on our experience of our own homes and not designed for the convenience of the organisations that will deliver it. My generation will expect much more high acuity care in the comfort of our own homes.
This will be a challenge to the current way of working. The new generation of the old will not tolerate a system of care that tells us what to do. We will want to tell it what to do.
But for the NHS this is also a very considerable opportunity. It will require a shift in the way in which the NHS delivers care but that shift would be based upon a recognition of our capacity to play a much bigger and active role in our own health care.
The opportunity is to re-fashion care so that it is aligned with the mind-set of this century rather than the last.