My open response to the Change.NHS questions.

After last week's discussion being on Wes Streeting want to jab unemployed people in the bum (does Ozempic go in the bum?). This week we're on to the GREAT DEBATE about the future of the NHS.

Never a dull week.

So I started responding, and then a funny feeling came over me...

I realised at this moment in time either one of two things could happen: I could be witnessing the start of the future, or I could be witnessing some great content to dink out to my lovely readers - who I've downright neglected recently whilst figuratively juggling babies - for some shared debate, discussion and a little mirth.

Firstly I'd like to share my actual responses that I have duly submitted.

As you'll come to see I increasingly got a bit angry about the quality of some of the questions, but it will be pretty obvious when that's the case!

Then at the end a little bit of reflection.

Let's go.

Best things about the NHS

1. The principle of equity and fairness regardless of income. It's a social project we should treasure.

2. The clinical teams who keep battling away to care for people in such difficult conditions.

3. That lovely shade of blue [I didn't actually add this!]

In your opinion, what are the biggest challenges facing the NHS?

1. The NHS is paralysed by a culture of risk aversion and fear of doing the wrong thing, leading to nothing bold and ambitious actually happening

2. Central and political meddling, intervention and reductionism creating solutions that often create more problems, and totally disempower staff and communities.

3. The current setup totally disempowers communities, community assets, clinical staff, and arguably individuals within the population. We've totally and utterly lost sight of the fact that to get out of this we need those communities, but e.g. treat place like a bunch of groups that should fold into top down priorities, totally missing the point.

Which of these challenges do you think is most important for the 10 year health plan to address?

Waiting to access mental health services, Long wait times for a hospital procedure, Long wait times in A&E, Poor quality care, Delays in being referred for treatment, Poor co-ordination between different health and care services, Poor communication with patients from health and care services, Waiting to access community services (e.g. district nursing, community physiotherapy, community occupational therapy), Treatments or services not available on the NHS, Difficulties getting a GP appointment and of course other...

OK this is the kind of reductionist question that assumes that these manifestations of the challenges I cited above are single, individual things to be tackled and everything will be better. I'd like all of these to be solved, BECAUSE we actually looked at the root cause of why they're occurring.

Let's for example consider that we've spent decades promising that the NHS is the answer to all ills (literally and figuratively) and if "I pay my taxes" I can live unhealthy lifestyles and just demand everything from the NHS - unlimited appointments, unlimited treatments, everything catered for.

What if we actually started to think about having a proper discussion about what the contract is between citizen and service, in a hugely transparent way, that helps citizens to actually take part in that relationship other than being a consumer with a golden ticket.

So yes, please solve at least three of the above, but not by pointing at those three and letting the other areas become future priorities, because we played whack-a-mole.

Shift 1: moving more care from hospitals to communities

In what ways, if any, do you think that delivering more care in the community could improve health and care?

As far as research goes this is a pretty leading question, but I'll bite. It depends on what you actually mean by this.

Do we mean actually focusing on prevention, enabling and empowering those communities to play a more active part in solving these things, or do you mean solely shifting acute workload into settings closer to home? If the former then because it's cheaper, more likely to be effective, more likely to address marginalised groups and communities, and hopefully more likely to address risk before it happens.

But again I feel like I'm trying to answer an exam question here instead of giving my view. Interested to see how the answers to this one are spun after publication.

What, if anything, concerns you about the idea of delivering more care in the community in the future?

Solely asking GPs and community health providers (who are hugely important but you neglected to mention in the question) to do more and shifting acute into the community is a whole bundle of future problems.

As I referenced before, if we have this top-down, target driven mentality of just moving the pieces round, and push as much activity into lower skill mixes, whilst seeing as many patients within a 1 hour window, then this is not the NHS we need. GPs are slammed, pharmacies are crumbling, places groups largely system-splained to and ignored, community heath providers are buckling under the already impossible workload increases since COVID. So to get it right you need to actually get it right.

Shift 2: Making better use of technology

In what ways, if any, do you think that technology could be used to improve health and care?

Many. If we use the right technology and in the right way.

Let's be honest, the whole of civilisation is going through a digital industrial revolution with huge benefits, and healthcare is expected to benefit the most, or see the most transformation.

We need to start to imagine an NHS that is shifting to make use of evolving digital infrastructure, evolving over and over again. Because if we don't the NHS is probably toast as the fundamentals just won't add up.

But please don't just point to more scanners and EPRs because that will hardly be a revolution in care. I could point to many examples but again I don't see the value in answering an exam question here.

What, if anything, concerns you about the idea of increased use of technology in the future?

Where to begin. Firstly, if we are blindly led into tech-for-tech's sake by technophiliacs driving a philosophy that tech will save the NHS then we're likely to sleepwalk into a low quality automated healthcare system treating people like cattle that misses the point that health and healthcare is about humanity.

I'm not advocating that we should not use technology - quite the opposite, but we need better thinking about what the actual vision for technology is - who are we empowering to do what? what is the best impact of automation (intelligent and process)? are we empowering our workforce or replacing and phasing out tasks, then jobs, then services?

Where is the sophisticated moral discussion about the future of care with technology as I've seen literally zero emerge from political, national and local leaders to date.

Otherwise my concerns are that we create an algorithm driven dystopia that micro-manages our population in order to reduce risk.

Where is the sophisticated moral discussion about the future of care with technology as I've seen literally zero emerge from political, national and local leaders to date.

Shift 3: Focussing on preventing sickness not just treating it

In what ways, if any, could an increased focus on prevention help people stay healthy and independent for longer?

This is a stupid obvious leading question and I'm not going to answer it. Kind of like asking my 8 year old son if an increased focus on being able to read and write is going to help him pass exams in the future.

What, if anything, concerns you about the idea of an increased focus on prevention in the future?

Obviously I have few concerns about actually trying to prevent people getting ill and pick up chronic diseases. My concerns would again be grounded in HOW this is driven.

Firstly - is this solely in the context of the NHS? Why is the NHS being seen as the sole answer to prevention? of course it has a role, but we're all getting fat and sick because we live in an environment that makes us sick - including hospitals with Burger Kings in them! - we simply cannot add such a complex societal ambition as 'prevention' to the TO DO list of the NHS because that will fail.

What is the holistic, joined up vision that includes investment in, and empowerment of, communities?

As per a previous answer the biggest concern and risk is that we continue to expand the medicalised interventionist view of society driven by institutions.

So yes, let's focus on prevention but as a wider contract between the government, industry, care services and the citizen and citizen collectives.

All in all, how satisfied or dissatisfied would you say you are with the way in which the National Health Service runs nowadays?

Very dissatisfied (surprise!)

Then there's a bunch of personal questions that you can't have dear reader!

Reflections

Firstly, on a serious note it's great that we have a government who is actually bothering to ask questions even if some of them are dumb, blatantly leading and obviously political.

But my concern is that these questions fall far short of the 'great national discussion' that's being promised.

More importantly my concerns around 'which three of these would you like to fix' is hugely reductionist and feels like a national exercise in picking whether you'd like the lamb or the fish on a tasting menu.

This in itself is the problem we have in the NHS, and wider society. We're just not having the discussions we need to have.

For example if the two questions around technology are the sum total, as I noted, where is the sophisticated moral discussion about the future of care with technology as I've seen literally zero emerge from political, national and local leaders to date.

Are we not able to actually have a macro discussion around the role of tech in healthcare? If not then why not?

Sadly, my hopes of seeing the materials that could underpin the great debate, has led me to a feeling of a great deflate.

Liam Cahill is a trusted adviser to frontline providers and national bodies on all things digital, with nearly two decades experience of doing tech stuff in the NHS. He has mentored and advised some of the best known names in Healthtech, and they've usually said some nice things about his work. He has also released a comprehensive course on how to understand and respond to the intricacies of the NHS when trying to work with it.

Some rabbit holes for you to go down below: