What if the NHS isn’t actually broken?

Principal consultant Aidan Rave believes the consensus that our health service is ‘broken’ is nothing more than a way to avoid difficult decisions

It wasn’t long after the dust had settled following the general election in July that the incoming secretary of state for health and social care was declaring that that great scion of the labour movement—the National Health Service—was broken.

In the weeks that followed, this grew to a chorus, fuelled by a withering analysis of the service’s many shortcomings in a report led by the surgeon, Lord Ara Darzi and echoed by pretty much everyone from the prime minister downwards.

Of course, some of this is pure politics; one of the main levers of influence for any incoming government is to blame the ‘other lot’ for the mess they have inherited and are now going to have to sort out. It’s also more than possible that some of the rhetoric is a precursor to and preparation for some potentially painful reform, with the Labour government perhaps adopting a variation of the ‘only Nixon can go to China’ methodology, hedging that it alone has enough trust to make the tough choices needed.

No such thing as a broken system

Whatever the politics of all of this, the ‘broken’ headline seems to have resonated with public and media alike, framing what people seem to generally accept as a system struggling under the weight of impossible expectation and insufficient funding.

But what if this diagnosis is wrong? What if the notion of ‘broken’ is actually an excuse to avoid the more difficult questions that lie at the heart of potential improvement?

In his seminal work, The practice of adaptive leadership, Ron Heifitz challenges the illusion of the broken system, arguing that there is no such thing and that, in fact, each system is carefully designed and sustained to achieve precisely the outcomes it deserves. The context here is significant. In casual terms, the word ‘broken’ might well be associated with inadvertent outcomes—something unplanned—a car breakdown for example, whereas according to Heifitz, the opposite is true, that rather than being inadvertent, the outcomes we are currently experiencing are inevitable.

Take the politics of the NHS, for example. In a public forum, politicians love talking about ‘our NHS’. They revel in assuring us that it is ‘safe in their hands’ and never an election goes past without promises of vertiginous increases in the number of nurses, doctors, hospitals and the like.

In private, many of them concede a different assessment—of an unsustainable service that simply cannot hope to live with the demand it currently faces, let alone the trajectory going forward. That’s before you get to the fireworks of amalgamating hospitals or moving an urgent care centre or frankly anything that incurs the wrath of political opposition. The result? A political narrative that day by day, week by week and month by month diverges further and further from that which is necessary to secure a sustainable health service. It’s therefore difficult not to conclude that the political stewardship of the NHS is perfectly aligned with the outcomes it currently achieves.

Culture is another interesting area. The NHS is packed with principled, committed and able staff – not all perfect, of course, but most sectors would give their right arm for a small percentage of the capacity and dedication the NHS has at its disposal. Now, let’s be really honest, is that incredible workforce focused more on treating illness or preventing it? Where should it be focused and is that focus consistent with what is required to achieve a sustainable system of healthcare? Again, it’s hard not to conclude that the culture of the NHS is perfectly aligned with the outcomes it is currently achieving.

The list goes on: money, structure, leadership, working practices and so on – all broken, or giving us precisely the results they are designed to?

Time to look afresh

Perhaps it’s time to give the ‘broken’ schtick a rest. Albert Einstein cautioned against the perils of expecting the same thinking to solve a problem that caused it in the first place, which is to some extent what the practice of fixing something that is broken encourages us to do. Better to spend some time looking afresh at the many challenges at hand, breaking matters down to first principles and building solutions based on sustainable outcomes.

The NHS faces a multitude of challenges and will take little short of the finest minds, courageous political leadership and an ambitious societal consensus to remain viable. Declaring it broken might make for good headlines in the short term, but it will do little to enable those aims to be met.