The narrative around the NHS today is of angels and demons. We want to praise heroes when life is sweet and find a villain for each failure. Even more confusingly, the same person can be cast as both hero and villain: the GP who sees you through may then get blamed for overloaded chaos in an emergency department at the weekend.
The real problem is that it isn’t so black and white: it’s complex and analogies are hard to find. Imagine you are driving along a familiar road in a reliable car but round a bend the conditions suddenly become icy. Despite knowing the car, the conditions become more complex: suddenly the accelerator doesn’t speed you up nor do the brakes slow you down. Worse still, the best strategies defy your intuition, so that you are encouraged, for instance, to drive into the skid. It’s not that you’ve suddenly become a poor driver or that the car is now rubbish. But something has changed.
Of course, if you have some experience of doing it before then that helps, but what happens when the problems start piling up, one after the other: missed waiting list targets, overloaded A&E departments, cancellation of routine operations and the knock-on effects?
At one level, we understand that problems involving millions of people are often those where attempts to alleviate a problem end up making it worse. Roads clog with traffic so we widen them and then more people commute greater distances and soon the situation is back at square one – except that, by then, house prices have risen and people can no longer afford to live locally. But for most of us, our understanding of complex systems is very limited since we only see a small part of the system closest to us and most of the time things change slowly – the road-widening or the development of part of a town.
By contrast, what is happening in the NHS seems to be happening very quickly and in every quarter. Using the idea of checklists in his 2014 Reith lectures, surgeon Atul Gawande made the case that we know enough about medicine but are unable to organise ourselves well enough to ensure that the right steps are taken at the right time, every time. A checklist is a basic tool for managing a service, and in this case it is transforming the safety of surgery.
A lot of very bright, conscientious, people are working very hard in the NHS, and to solve the problems in the NHS, but they are up against the perverse behaviour of a very, very, complex system and most of the time the system will counter their best efforts. If all we do is put more effort into the problem nearest to us – more staff on A&E or more beds on the ward – the system will continue to saturate until we are back where we started. That’s what complex systems do.
Mastering complex systems
So where have we mastered complex systems? If we think again about cities, you might have predicted that it would have become impossible to feed people if transportation routes clogged up. But most people in cities dine in and out rather well. Supermarkets haven’t built larger warehouses next to their stores in order to cope with fewer deliveries – rather they have done the opposite and eliminated most of the in-store storage space. Similarly, more staff or more beds tend not to solve the problems of healthcare capacity. We need to design the system in a new way.
Supermarkets didn’t just hope for the best. They designed ways to flow groceries into their stores with extreme care, setting up advanced signalling systems to tell them exactly what was needed where and when. To do this, they’ve moved well beyond checklists, using simulation and modelling to design their logistics and advanced computing to predict what will happen next. In the same way, we need to focus on the flow of patients into and around our centres of service.
Our intuition to meet demand by creating more posts, or more beds – or to run for longer hours – is simply likely to delay the point at which demand inevitably overwhelms our ability to provide a service. We need to design and implement much deeper solutions. Just as getting rid of supermarket storage was a measure that ran counter to normal intuition, so our intuition and experience in health are unlikely to help us find the best interventions for healthcare.
Again Gawande points to something very important: start using the methods and tools that have tamed the chaos elsewhere. Beyond checklists are more advanced tools, used routinely to manage supply chains, run rescue missions, drive production, maintain the flow of petrochemicals and co-ordinate transport systems across the globe. The NHS could use these: simple strategies that have been developed to help people focus on what really matters when the crisis seems overwhelming.
Computer models, like computer games, allow you to try out tactics and strategies quickly and safely. They allow you to evaluate options: what if I route these patients this way? What if I close this ward? What if I create this new type of community service? They also allow everyone involved to see what is happening and to have a say. It is this kind of resource that could transform the ability of the NHS to design and deliver services that beat demand.
We need such resources because the solution to this crisis will look, in places, very different to anything we have seen so far. The system will always beat us if our next step is simply to try to correct the problem facing us. But there are ways to beat the system.
To read more in our A&E crisis series: Graeme Currie on why we can’t simply scapegoat hospital managers; Jonathan Shapiro on whether we all take a free NHS for granted; Anthea Wilson on how monitoring our own conditions could transform NHS care; Ron Glatter on why nothing will be fixed until politicians lose their taste for permanent revolution.