Grenfell Tower
The Challenge of reforming the NHS – The Issue of Reputational Risk
The NHS has a rather mixed reputation. Seen by many, even most, as a jewel in the crown of the UK, but it has also been described recently as ‘broken’[1].
Long waiting lists, relatively poor health outcomes, failing hospital buildings, overstretched GP practices, blocked beds – these are just some of the observations made, and not really disputed, of this lauded UK institution.
Given this state of affairs, it seems that, surely, any reform will make things better. But, from evidence of the NHS itself and other similarly large and complex organisational systems, improvements of entities like the NHS come only slowly and typically follow a ‘hockey stick curve’. i.e. they tend to get worse before they get better[2]. Moreover, reform means change, and how do we separate change for the good from change for the sake of change? Sceptics and those with vested interests in not changing will point to the dip in the hockey stick and will counsel for the return to the status quo. The challenge to ‘fix’ the NHS is, therefore, going to be hard, but it seems clear that we cannot continue on the path we are on, so what can be done?
Many things have the potential to generate improvements and, broadly, these can be divided into three general categories:
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Deploy more resources (more: doctors, nurses, hospitals, equipment,…)
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Improve the systems (doing things more efficiently, better communications, involve Artifical Intelligence, …)
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Improve the culture (challenge and correct traditional demarcated jobsworth thinking, passing the buck, arbitrarily protecting budgets, …).
The government is currently looking at a combination of the first two (with an emphasis on the second before deploying the first. This appears to be a common viewpoint applied in many areas including, recently, the rail sector). The expectation being that if the pressure can be reduced, the third will follow.
However, in the crisis that the NHS is described as being in, it’s important that the third area of improvement comes first. Once we’ve accepted the magnitude of the problem – which is where we nearly are – then ‘we’re all in it together’ can take hold. As the NASA cleaner said during the Apollo program when asked what her job was, ‘I’m helping put a man on the Moon’[3].
With this as the contextual backdrop, we can start to look at the challenge of change/reform through the lens of risk management. But risk comes in a variety of forms, so let’s start by looking here at ‘Reputational Risk’.
As we have noted, if the ‘hockey-stick’ proves to be in-play then the NHS will appear to get worse before it gets better, and its reputation will suffer and be damaged further. But this need not be the case. While output metrics may indicate increased waiting times for instance, we can also choose to judge the NHS in the short term not so much by the current score, but rather by its adherence to a change programme. For example, are we following the anticipated hockey-stick profile, if a doctor says to you or me, ‘the treatment will cause a lot of discomfort for a few weeks but then you’ll see an improvement’. Knowing that the discomfort will be both limited in time and necessary for the longer-term benefit makes the discomfort much less distressing. When it does get better you’ll have praise for the doctor.
Such dramatic change programmes are never going to be cheap, quick, or easy. Given this, politics are almost bound to get in the way. Improvement will be on the timescale of years and so in the interim, the NHS performance can easily become politicized, especially around the time of General Elections. How do we separate the inevitable positioning of governments regarding election popularity from the genuine programme of improvement that the NHS is undergoing? This is a conundrum that we have yet to solve yet solve we must if we want the NHS to continue.
We can think of specific risks within the category of ‘Reputational Risk’, and in particular their likelihood and impact. If the reputation of the NHS collapses to a point that there is a popular perception that the NHS is a failed concept and must be replaced, presumably by something involving private medical insurance and provision, then the impact is the ‘end of the NHS as we know it’. While the likelihood is hard to judge and may seem extremely remote, we still have to face the possibility. Ultimately, if we all deem the NHS to have failed to the point where it is replaced, then it will be reputational damage that kills it since this will turn its replacement into a political necessity implemented through a national political mandate, and potentially a referendum.
So, what can we learn from pondering the plight of the NHS through this first risk management lens? We start by appreciating that any reform process needs to deal clearly and squarly with expectations up front. While honesty is surely essential, communication of strategy, objectives and real progress is vital to keep everyone on board. We need to be warned clearly about how uncomfortable some of the ‘bumps in the road’ will be and we have to believe that short-term suffering is worth it for long-term gain. Hyperbole and sensationalist reporting leads to mistrust when exposed and not countered. Loss of trust can in itself lead to, even if perhaps misplaced, reputational damage. Moreover, such transparency demands that the reforms are both appropriate (i.e. they make things better) and consensual (i.e. there is buy-in by the majority concerned in its implementation).
Setting out the plan for reform clearly, explaining ahead of time that it isn’t going to be quick, easy, or cheap to sort out, and preparing the steps carefully ahead of taking actions – i.e. conducting due diligence in a timely manner will all be key. The alternative is a series of hockey sticks, each abandonned at its lowest point with, consequentially, decline and chaos.
[1] Speech made by the Secretary of State for Health and Social Care, July 2024, see: https://www.gov.uk/government/speeches/statement-from-the-secretary-of-state-for-health-and-social-care. Accessed September 2024.
[2] See for example The Book “Evaluating the NHS Reforms, (1994) Edited by Robinson, R. and Le Grand, J, accessible from: https://books.google.co.uk/books?id=lUcKxyVMkOIC&lpg=PA1&ots=HqadsRxznf&dq=nhs%20reform&lr&pg=PA1#v=onepage&q=nhs%20reform&f=false
[3] There are many references to this well-noted incident, see for example this one (from an NHS source): chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.dbth.nhs.uk/wp-content/uploads/2018/11/ManontheMoon.pdf, accessed September 2024