Friday, 11 October 2019
The central ethical dilemma in life is the responsible and compassionate use of power. This applies to politics, sex, religion, business, the NHS and every other hierarchy you can think of. Are those at the top of the tree using their power for the benefit of themselves, or serving those at the very bottom? In sex, the distance between top and bottom is relatively small and usually there are only two people involved. Even then, issues of consent, compassion and communication can get very muddled in the heat of the moment. So imagine how much harder it is to use power responsibly in an organisation as vast as the NHS.
Over its 71 years, most politicians have fallen into the trap of treating public services as linear systems. They like to think they can pull a lever in Downing Street and have an immediate and predictable effect on the frontline. In a linear system, if you throw a brick out of the Department of Health with a certain force and trajectory, you can predict where it will land. But healthcare is a complex adaptive system, like a pigeon. Set it free from the DH and you have no idea where it will land. If you’re clever, you can shape the NHS by letting the public and professionals in a community decide what sort of healthcare they need. It involves difficult conversations between health and social care, hospitals and GPs, local authorities, transport, education, the environment, private and charitable providers and – above all – users of the service. When you’ve had these conversations, you can collectively design the joined-up care you need and decide exactly where to put your bird seed. Or at least you could if the Health and Social Care Act hadn’t made it impossible. Any ‘pigeon of health’ you set free will have a Lansley brick tied to its foot.
Politicians aren’t stupid. They spotted the need to devolve NHS decision making downwards, to make it more responsive to local populations. When Labour were last in power, they promised to Shift the Balance of Power (or, as the cynics called it, Shift the Blame onto Patients). And when Conservatives tell you they love the NHS, what they mean is they’d love not to be responsible for it, putting services out to relentless re-tendering and outsourcing as much to the private sector as they can get away with. The fraudulent phrase that won votes for Leave EU (‘let’s take back control’) is equally attractive to NHS managers and politicians. The more control and status you have, compared to those underneath you, the more powerful you become. However, having control over something as uncontrollable as the NHS is a double-edged sword. The media stalks your every move in a crisis. The DH is keen to pass as much buck as possible to NHS England, which itself passes the buck – but not real control – down the line. Those who voted to Leave the EU hoping they will have more control over the stress in their lives are having a rude awakening.
Our obsession with Brexit has at least given NHS managers a respite from the previous media maulings. Ultimately, healthcare and politics comes down to trust. We are currently swimming in a sea of deliberate and dangerous political misinformation and game playing, and we need doctors to speak up and lead the way to an open, grown up, transparent culture where we have difficult conversations in public and, having had them, we help not just to design the best health and social care services we can but to have a say in a kinder, fairer more equal society that is vital for health. Many of you will have been doing this for years. It’s time for all of us to step up, find our voices, take back control of our NHS and rekindle our communities.