Why don't we get the care we deserve?

26 Green and White Papers, 14 Acts, a doubling of funding, more doctors and nurses, and better buildings.    Competition, choice, increased regulation, world class commissioning, benchmarking, consultant contract, GP contract, dental contracts, Agenda for Change, Map of Medicine, turnaround, demand management, the improvement movement, National Service Frameworks, Evidence Based Medicine, guidelines, clinical pathways, personal budgets, Essence of Care, Energising for Excellence, Safeguarding, Monitor, PFI, AQP, HAI, NPfIT, FTs, PCTs, PBC, BCBV, PROMS, CNST, PbR, CQC, NSFs, EWTD, QIPP, QoF, targets.  From Our Health, Our Care, Our Say to From Good to Great and any number in between via untold numbers of consultations on all sorts of ideas.

All this since 1997 and still we have the Chair of the CQC, Dame Jo Williams saying; "Too often our inspectors saw the delivery of care treated as a task that needed to be completed. Those responsible for the training and development of staff, particularly in nursing, need to look long and hard at why the focus has become the unit of work rather than the person who needs to be looked after – and how this can be changed. Task-focused care is not person-centred care. Often what is needed is kindness and compassion, which cost nothing." The entire NHS needed to ensure that it made big improvements to end the scandal of poor care", she added.


But it's ok because patient satisfaction levels are at a record high and at least you can get through your A&E in 4 hours....


The reason given for this outrage?  Well Janet Davies of the Royal College of Nursing thought it was because in a time of a "squeeze on finances" it is difficult to maintain standards of care.  If only we could get the numbers of nurses right.  So there you have it, the RCN representative saying its about money and numbers.  I can't remember the reasons that were given for appalling levels of care when money wasn't an issue.  I should be shocked by what she said, but right now I feel exasperated.


The real outrage is that we have squandered billions of pounds over decades designing a system that doesn't care.  And it doesn't care because it is focussed on the wrong things.   The list of "stuff" we have done at the start of this blog is not exhaustive.  With each iteration it has removed people who do the work further away from doing good work.  Goodness, it seems, happens in spite, not because, of the system.  But who will conclude that this way of viewing the world has not worked?  More likely people who believe in the current conventional management paradigm will argue that we haven't gone far enough, or didn't implement them well enough.  Some will even say its a people problem.  After all, how difficult can it be to just be courteous and polite to someone.  I couldn't disagree more.


The fundamental issue is that the NHS is systemically incapable of understanding people and creating people shaped solutions for them.  Our leaders have industrialised our public services and commoditised our relationships to such an extent that people are units of activity, not human beings who need understanding in order to help them.  


We don't understand demand.  That it is person, not service shaped, so needs person not service shaped solutions.  We don't train against demand so we end up with staff unable to carry out simple duties.


We believe that we need to ration and prioritise but we are completely blind to the monumental levels of waste in the system.  And not waste from a lean perspective, that we have too many steps in any given process, but waste from a systems thinking perspective, that we do not create value from a person point of view, end-to-end over time.


We have lost sight of purpose from a users perspective, seduced by the lure of an economic view of the world that makes performance worse not better.  And in doing so we have not only let down the people who depend on us but the staff who work in the NHS too. 


The bad news is, the system isn't working and the Bill will not help.  It's the wrong thing wronger.  The good news is there is a cure. You just need to be prepared to change your thinking.