Wednesday 11 March 2015

A glimpse at the NHS which can survive

I've told the story a number of times of the patient I met during the Barriers to Choice Review, but it looks like the right moment to tell it again.

She had muscular dystrophy and had to see her consultant every six months, which meant a two-hour round trip plus half an hour or more in the waiting room. It meant going over a large river and paying a toll, and all she said when the doctor asked her how she was doing was: “I’m fine”. What she really wanted was to check in occasionally by phone, and see him when she’s not fine. But she couldn’t because his slots were full seeing people who are also fine.

What struck me about her was that she was asking for something quite simple, though important to her as a long term patient. It was a ‘choice’ about her treatment, in a sense, but not one that is recognised currently by the system in the UK. I was particularly interested because it seemed to imply a broadening of the boundaries of choice.

Looked at like this, choice means flexibility.  That is what I said in my CentreForum essay on 'How to save public service choice for Liberalism' (well, liberalism, actually - we didn't agree about the capital L).

I mention this because it seems to me that the new NHS announcement about the pilot areas experimenting with broad service integration at local level is one of the most important steps forward for the coalition - and it is the beginning of finding ways to inject flexibility into a hideously inflexible system.

It is therefore the very beginning of an attempt to humanise the bureaucracy of the Blair/Brown years, and - by making services flexible enough to suit individuals - to bring about a major breakthrough in effectiveness and cutting costs.

Well, that's the theory and I believe it to be true.  Flexibility is the way forward now, even if it means unravelling some of the formal structures for choice, because flexibility trumps narrow choice - making any choices possible where appropriate.

Even if it means unravelling some of the formal structures designed to inject competition, because flexibility usually trumps competition too.  Because flexibility can provide for choice and competition and the reasons we might want them.

Perhaps it is premature to talk about the next steps along this road, but they need to be in preparation now.  These are they:

1. We need a general Right to Request Flexible Service Delivery. In each case, the provider would not
be obliged to provide flexibility if it is impossible, but they would be obliged to explain why in a letter, the text of which would then have to be public. It would be aimed particularly at situations where systems or bureaucratic arrangements get in the way of what people need. For example, if they want the choice of a consultant who won’t mind them asking lots of questions. Or to study Spanish at A-level when all that prevents them from doing so is their school’s timetabling system. Or to be able to go to bed later than 5pm when their carer comes round. 

2. We need to move on from the pattern of an exhausted professional class ministering to the needs of the punters, who have to stay passive to make them easier to process.  The huge resources that are available to look after people, with patients working alongside professionals to deliver services, can be tapped if we shape the institutions capable of using them.  This is the co-production agenda.

You can read how one example works in my book Give and Take (written with Sarah Bird) about time banks in healthcare.  

Put these three things together - flexible integration, a Right to Request, and co-production - and you will be able to glimpse the shape of the new NHS.

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