Filed Under (Healthcare delivery, Patient involvement, Reform of the NHS) by Paul on 27-03-2014
All this week I am trying to unpick the five major arguments being made about the overwhelming pressures that challenge the NHS. I am trying to uncover why the way in which these arguments are made is, rather than unlocking and forcing change, making that necessary radical change more difficult.
My overarching point is that it is the posing of these arguments as a set of challenges that are in fact overwhelming the NHS. What I am trying to is to demonstrate that each challenge presents opportunities for the NHS to adapt rather than being overwhelmed.
Today I want to discuss what is seen as the problem of rising expectations.
I started working in public services, in London local government, in 1984. From the start, and continuously over the last 13 years of working in the NHS, I have heard leading public servants complain about the rising expectations of the public.
The argument is straightforward. If the public expect more, we can’t deliver it and it makes out job harder. So ‘rising public expectations’ over the last 30 years have consistently made our job harder.
In its own terms you know what people mean when they say this. If the public don’t complain and fit in with how we organise ourselves, (for example by not getting sick between Friday afternoon and Monday morning when we aren’t there) then the work of a health service is a lot easier.
If people are prepared to travel a few miles to what we refer to as an “outpatient clinic” (but which is in fact inside the hospital so should be called an “in-patient clinic”) and turn up with a crowd of other people at 0900 to be seen at 1215 then our organisational ability will likely meet their low expectations.
But over the last 30 years more and more people have found that in the rest of their lives they can make an appointment with, say, their hairdresser – near their home, at a set time and will probably receive a text reminder beforehand. And on nearly every occasion there will be someone ready to cut your hair at the appointed place and time.
Given that a hairdresser can organise this, the problem for the NHS is that now they now expect it to do the same.
A coda here about class.
Amongst the top 10% of the population I am not sure that expectations of public services have increased in the last 30 years. In the mid-1980s the top 10% expected to get respect, courtesy and convenience for all the services they used – public and private. And when they didn’t get it from the NHS they made a fuss.
For them expectations have always been high.
No the problem of rising expectations for the NHS is caused by the fact that ordinary people now have greater expectations of it than they had 30 years ago. From amongst a class of people who were once simply grateful more and more people have emerged with higher expectations.
This means that more and more people expect services to be organised around their lives – and not around the needs of the organisation .The main problem is not the rising expectations, the problem is that we now need to confront the way in which many of our organisations work for their own convenience.
And it’s true that people are more informed and inquiring. They are demanding a greater say. Ordinary people are getting a taste for greater power and control in their lives.
One of the main political points I want to make is that the very existence of mass public services raises expectations.
Expectations of what the NHS would be had been raised, from its very creation, by the public’s experience of World War II. That generation expected more from life and from Government. (It was just as well that that generation also had the courage to hold high expectations about beating the Nazis).
The point of mass secondary schooling was to raise the next couple of generations to want to attend university.
If people involved in a large scale public service complain that the public want more then they don’t “get” the movement of history of which created their service in the first place.
Now there is apparently a problem because too many people are getting too much information about health and health care.
In the past people would talk to their immediate family before a visit to their GP. Now more and more will consult the internet and walk in to see their GP with printouts. In the past they would come in with bits and pieces of knowledge from their parents and grandparents, now they come in with bits and pieces of knowledge from the World Wide Web.
Of course this knowledge is not ‘correct’ but it’s there – and it’s there to be referred to when the patient has had their consultation. The doctor can’t say “don’t go on the internet” in much the same way as in the past he couldn’t say “don’t talk to your grandmother”.
So rising public expectation is seen as a problem across the whole service, from consulting room to boardroom.
Yet in other industries and services, there are attempts to raise expectations and organise to meet them.
In the hotel industry for example one can imagine that a hotel manager may feel that Trip Advisor makes their life a lot harder. I can imagine them moaning to themselves about the latest complaint on the website. But what I can’t imagine them doing is talking to their staff in their morning meeting and complaining about rising public expectations of the hotel.
Nor can I imagine a similar discussion taking place in the boardroom of the hotel chain.
In the hotel industry, and in most other services, the role of the leader of an organisation is to use those higher expectations to drive improvement. The problem for leaders in other industries is constructing a service when the public doesn’t know or demand what it wants.
The same is true for the NHS. The problem for the health service is caused by people putting up with fragmented services that don’t help their recovery.
To create a really successful health service we need, both in the consulting room and among the public, much more active engagement and we need to use that activity and demand for better health and healthcare as an asset.
This week I gave a talk at a mental health trust about these issues. I just caught the end of a patient’s story when she said that the pivotal moment for her had been when a member of staff had said to her that one day she, the patient, would get a job and go back to work. At that moment it was not imaginable, but slowly that hope of a better outcome raised her own expectation. She was then able to use that raised expectation to recover.
Recovery in mental and physical health is assisted by the raised expectation of recovery. Good medicine works with not against that expectation.