For about the last 10 years the garden at our house has not been an object of pleasure. It had been a chore, and something that we put up with for the various well-known reasons people put up with something, namely money, imagination, time, lack of a plan, and procrastination. While we were not making the necessary changes the mature shrubs overgrew, and ivy covered every wall. The roof of the shed fell in. Robin the gardener tried to make it look a bit better but by the end the garden was still a garden, but it was useless to the family. Slugs and snails loved it, but little else flourished in it. Any new plants quickly died, or were eaten by the slugs.
In 2008 my wife and I got around to thinking about what we wanted in a garden. We didn't start from the existing model or layout, we started from function.
So we decided that we wanted a decent seating and dining area. We wanted a dry area for hanging out washing, a shed, and a canopy to cover the bins and recycling. We wanted a gentle sloping path so that we could allow easy access for older relatives or for prams in place of our old and very steep grit stone steps. With Charlotte having arrived in February 2008 we wanted a decent open play area for her. We wanted some flower beds as well, but they fitted in around the edges of the functions.
We talked to our builder and over a few iterations a workable plan emerged. The builder did the work over the winter of 2008 and since then the family and several visitors have been enjoying our new garden which now does what a garden should do — it allows people to flow and mix in pleasant surroundings. It also houses a good selection of plants, and this year we have seen more insects and birds than we have had in many years.
A dysfunctional overgrown mess has become an elegant functional integrated whole that can meet the differing needs and wants of everyone.
To my mind the NHS is like an overgrown garden. Yes it's a health service, but everything is just that bit rough, there isn't space for new specimens, and it's easy to get wet as you walk past the overgrown shrubs. The creeping ivy is provided by the acres of government publications and other glossy brochures that litter the shelves in offices. The weeds are the multiple meetings and other distractions that reduce hours to minutes, consume enthusiasm and fail to replenish it. The garden does not flow from one area to another and so you have to climb a steep staircase to get from primary into secondary care, and jump into the information void as you return to the primary area. No one has cut back the hardy perennials. Quangos of uncertain provenance and function grow in neglected corners of the garden and spread their tendrils inwards. The management consultants do to money what slugs do to plants. The whole is severely overgrown, disorganised, messy, uncoordinated and dysfunctional. Yes it works to some extent, and in some parts, but that's hardly good enough given the amount spent on the upkeep of this morass of complexity and dysfunction.
The fundamentals of health care are actually simple. The job of the health service is to treat people who are ill. Illness can strike us whether we are rich or poor- which is why a pooled risk scheme such as the NHS makes financial sense for us personally, and as a country collectively.
Illness treatment comes basically under three headings which are medical, surgical, and rehabilitation. To do this the service needs to provide the space and time in which doctors, nurses, and other clinicians can meet and talk to patients. That doesn't mean overbooked clinics and 10-minute consultations.
The NHS has been tasked with many other functions which actually are nothing to do with its core function of providing a good remedial service to people who are ill. The NHS has been criticised for being ‘an illness service’ but actually this is just what the NHS is meant to be!
These other functions are distracting, and could well be done better by bodies outside the NHS, or not at all.
The NHS has grown complex and expensive accretions as ministers have not told it to focus on it's basic role which is diagnosis and treatment of sickness, and instead, have given it targets and agendas in areas only tenuously connected to its basic function: reducing health inequalities, ethnicity monitoring, and meeting government targets. Even in areas where it has recognised that a problem needs sorting out, the government has tinkered uselessly, and corrected parts of the system rather than thought of the overall flows of patients through the system. And no, I do not have any belief that practice-based commissioning is any sort of mechanism that can help here.
What we see in the current NHS is a complex mess of confused functions, and parts not integrated with wholes. We see arguments between and within the various parts of the system, but we don't seem to have people asking ‘how could the overall system work better here?’ Even if people share these thoughts the incentives of extra activity equalling extra cash for hospitals under payment by results, and the misplaced machismo of ‘we'll do it in primary care and save money from the rapacious, dirty, resource-hungry, inefficient hospital’ of some leading PBC enthusiasts will ensure that the solution will be in terms of ‘a win for primary care’ or ‘a win for secondary care’, and not ‘a win for the system as a whole.’
The most liberating thing any SOS for health could do would be to specify the function they want the NHS to deliver on, and then leave the NHS to work out how to do this. The NHS silos and quangos need destroying, and we need to move to systems thinking in which we recognise the continuity of the patient as they progress through different parts of the NHS system.
‘The secret of caring for the patient is to care for the patient’. These words, burned indelibly into the minds of generations of medical students, closed a lecture given by Francis W Peabody to Harvard students on 21 October, 1925. Given the billions invested in the NHS it wouldn't be too hard for us to deliver this, would it?
- © British Journal of General Practice, 2010.