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Double-digging the NHS. Again.

Not content with having delivered the fourth highest covid-19 cases per million people in the world and a Brexit deal that stifles half of UK exports to the EU, Boris Johnson's government is so flushed with planning and decision-making success, and feels so validated in its policy of ignoring expert advice, that it now intends to restructure the NHS. Despite all warnings to the contrary. Again.


Large-scale disruption to the NHS has a track record of unmitigated disaster. The noughties saw the National Programme for IT, which wasted £6.4bn of public money and has been described as the "biggest IT failure ever seen" - which isn't surprising, since it ignored well-known modern IT development practices, and was described even by the government itself in a 2011 Press Release as "the type of unpopular top-down programme that has been imposed on front-line NHS staff in the past". Despite this frank acknowledgement that top-down overhaul is not the best way to improve healthcare, only a year later in 2012 the government tried again, with a massive restructuring that immediately undermined efforts to cut spending and make the health service more efficient.


The UK's failure to address covid-19 in a methodical manner is inseparable from the legacy of such disruption. The NHS is a system - an organisation of organisations - and it delivers its services using a multitude of complex collaborative processes. These processes are of the kind best described by the theory of Human Interaction Management, not by flowcharts - they are what we described in NHS GATHER, the Web platform for replicating healthcare innovations that was loved by NHS staff but swept away with so much else of value in the last round of NHS restructuring. And as any management consultant worth their salt knows, it is processes that deliver outcomes, not organisation charts.


While it is great to hear the Conservative party finally recognising that it is better to join up services at community level than to outsource them to rapacious multinational corporations, why not simply empower existing local NHS, council, and third sector organisations to adopt the Supercommunities model? If you want to improve performance, you have to get down and dirty with the details of what is happening on the ground, and improve the way people work - and to be effective, do it in an Agile, iterative manner. By contrast, sweep everything away in order to start again from scratch, and you throw the baby out with the bathwater. Patient outcomes are delivered via a network of close-knit, effective collaboration between NHS staff and their colleagues, both inside and outside healthcare, which takes years to build but can be disrupted in an instant by dunder-headed government intervention from the top.

Unfortunately, UK ministers seem reluctant to trust expert advice. Perhaps they should spend more time in the garden. With the rise of the permaculture movement, vegetable growers learned that the traditional method of preparing soil for the Spring - double-digging, which loosens up the soil to the depth of two spades - is only warranted in special cases. Generally, it is better neither to dig nor till, since this leaves intact the deep but tenuous structures that make soil productive. However many buckets of nutrients you add to your garden, the benefits won't be available to plants or other organisms if you disrupt the almost invisible networks of hyphae that run throughout the earth - the numerous, fine threads of mycorrhizal fungi which help plants to find nutrients and moisture, reaching into tiny soil cavities that roots cannot enter.


Inevitably, the latest double-digging of the NHS by a Conservative UK government will sunder yet again the vital but fragile relationships of goodwill and trust which have been carefully built up by professionals over many years, and on which healthcare outcomes depend. How many more decades will have to start with restructuring of the NHS before lessons are finally learned?

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