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The System

Tom Fogden The Point of Care Foundation 16 October 2015

Tom Fogden, communications and admin intern for The Point of Care Foundation, asks why changing the NHS often appears to be a futile task.


I spend a lot of time reading NHS-related news articles, blogs, Tweets and op-eds. Most of these pieces, regardless of audience or exposure, are addressing present problems within the health service and most seek a solution to these problems. And many of the pieces present the idea that they have it all cracked. Literally, the entire NHS can be made good again in one 800-or-so word blog. Except for one thing.

“The System.”

Consensus is, naturally, rare in a service that employs nearly one in every fifty members of the English population alone, but The System seems to create allies – even in a “the enemy of my enemy is my friend” kind of way – whenever, or wherever it is mentioned.

The System, in case you’re wondering is not an Orwellian-government department, but is the thing that most people hold as responsible for creating barriers to organisational and individual development, improvement and change in the NHS.

It’s not a physical presence, but the actions of The System certainly manifest themselves in physical ways.  It’s why compassion towards patients goes missing; it’s why new ideas get left behind on the desk at home – not even making it to the drawing board; it’s why thirty per cent of staff strongly disagree that their workplace is open, honest and challenging.

It’s more a cultural issue than anything else. Imagine a football club sitting relatively happily in a mid-table position but with a troop of stern-faced accountants always looming over them, pointing at balance and cash flow sheets showing the club is destined for bankruptcy. There’s a nagging sense of doubt and fear.

That doubt and fear is The System.

I think it is, therefore it is

Except, while everyone agrees that The System exists, no one is entirely sure how The System actually works or why it has emerged.

Some believe that The System is a nefarious, bureaucratic guillotine hanging over everyone in the NHS with good intentions. It’s the paperwork, administration and finance that stops good things happening.

Others believe that change has become impossible because the NHS is so large and complex. It’s because there are so many overlapping networks, processes and mechanisms all working within the NHS that accessing any areas for change has become impossible.

Others are convinced that The System is the sum of the NHS’ parts, and therefore it can only be destroyed by a dissolution of the NHS’ present organisational state. It’s the large, cumbersome and complicated organisations that kill this sort of change. Even having a complete top-down reorganisation of the NHS would fail to stop The System.

Many believe that the NHS’ current political-football status has created a feeling of anxiety and uncertainty for staff and potential change-makers. The NHS, they believe has actually ceased to become an entity due to the different ways in which different aspects of the service function. It’s become so bad, that the NHS is now a set of values and principles more than an actual health service.

Whatever you want

Destroying The System, or any noun for that matter is hard work. And, when working with organisations like the NHS it gets harder the further you travel up the chain of command.

But a good place to start is making change directly where people work – and then pushing these changes upwards. It won’t be easy, but if it was easy everyone would be doing it. Targeted interventions for change, across disciplines and hierarchies, which focus on how people feel when they work would help to create better working environments, which lead to better patient experiences.

Innovations which change the way patients feel are largely determined by what staff do – and the actions of staff are largely determined by how they feel. If staff experiences are improved, patient experiences will also improve, and vice versa. Patients would receive better outcomes, their families wouldn’t be worrying, staff wouldn’t be scared when the inspectorate(s) come.

William Edwards Deming said that “A system is a network of interdependent components that work together to try to accomplish the aim of the system. A system must have an aim. Without an aim there is no system. The aim of the system must be clear to everyone in the system. The aim must include plans for the future.”

To improve its system, the NHS needs to work out what it wants to be. Does it want to deliver integrated care? When we hear talk of innovation, what is it in aid of? Does it want to be a world-leader in pioneering medicine, or does it want to sort you out with a cold? Does it want to be both? Does it need to be paperless, or does it just need to get a handle on what it’s doing at the moment?

Being free at the point of access, isn’t the aim of the NHS, because it already is (mostly). Being free is the method. The aim should be making sure that patients are treated, whether their conditions are episodic or chronic and are treated by staff who are compassionate, caring and happy. It’s only when the NHS works out what it wants to be, which won’t be easy either, that it be able to push on and really become the world-beating system we all know it can be.

Look on the bright side

There are, in spite of The System, examples of people creating change around the service. Over 95 NHS organisations are now running Schwartz Rounds to help improve culture, the #Hellomynameis campaign has become enormously successful, and Salford Royal, along with other trusts, continue to lead the way in re-designing care around patients whilst maintaining a supportive and open culture for staff.

Change can be made, it will often be hard, but that does not mean we should give up in the face of The System.