Anarchy in the UK (The NHS Remix)
Amanda Pritchard, NHS England chief executive, told local NHS leaders not long ago the economics facing the health service is a ‘f**king nightmare’, but that it was being tackled at a national level and, fingers crossed, should not prevent them from improving performance. Included in that hopeful vision is a brand new quality metric, a KPI to keep things, you know, centered on the patient with plausible numbers to provide ceremonial adequacy: Elderly people who call for help after a fall at home will no longer be left waiting for hours in agony on the floor.
Her comments, made in October last year and reported by the Daily Mail, came on the same day it was revealed that more than 7 million people in England are now waiting excessively, sometimes over a year, for routine operations at the NHS, such as cataract surgery and knee replacements.
“There are certain questions I really hope patients don’t ask me these days in general practice,” wrote Rammya Mathew, an NHS GP in an editorial in the British Medical Journal around the same time (‘Rammya Mathew: Long and uncertain wait times are leading to poorer health outcomes’). “One is, “When is my hospital appointment going to be?” Quite reasonably, patients expect that when we make a referral to secondary care we’ll have a rough idea of when they might be seen. Nine times out of 10, this just isn’t the case. Either no appointments are available when we make the referral, or internal triage at the hospital makes it almost impossible to give patients an accurate answer. Nowadays, even if I do know the answer, it’s probably not what they’re hoping to hear.”
The mind-bendingly harsh experience is even worse for those diagnosed with cancer.
In November, 2022, NHS England reported the worst ever waiting times for cancer treatment, according to a “bleak and depressing” essay in Lancet Oncology by Pat Price and colleagues. “In the past 12 months, 69,000 patients in the UK have waited longer than the recommended 62-day wait from suspected cancer referral to start of treatment (twice as many than in 2017–18), with 13 percent of patients with cancer in England waiting more than 104 days in September, 2022 — double the advised maximum waiting time. Waiting times for cancer treatment have been steadily deteriorating since 2013, but this deterioration has been exacerbated since the COVID-19 pandemic. Across all three major modalities of cure — surgery, radiotherapy, and systemic therapy — a 4-week delay in treatment increases mortality by between 6 percent and 13 percent for solid cancers, with further increases if the delay is longer.
Proportion of patients with cancer receiving first definitive treatment within 62 days of urgent referral
Communities with the largest cancer burden and suffering the strongest effects of COVID-19 are often also the communities with the least access to timely cancer care, further exacerbating the differences in cancer care throughout the UK. Despite the stated commitment of the UK Government to so-called levelling up, health inequalities in the UK continue to widen.
An accompanying editorial by Lancet Oncology editor-in-chief David Collingridge captures what can fairly be described as total system collapse: “The authors present a frank and candid assessment of cancer care in the UK over the past decade, revealing a health-care system that is nearing a cataclysmic event. A system in which health professionals are understaffed, underpaid, and at the very lowest morale. A system in which cancer outcomes are worsening, patient access to care and screening is substantially declining, and that is no longer able to meet best-practice, oncologically safe targets or provide all patients across the four nations of the UK with equitable, world-leading care."
[To avoid joining a waiting list, more and more people in the UK are paying for their own private medical care or taking out health insurance. In the second quarter of 2022, the number of patients paying directly for private hospital care increased 34 percent compared with the same period in 2019, according to the Private Healthcare Information Network, which collects data on UK private healthcare. To keep up with demand in this ‘emerging consumer market’ Cleveland Clinic plans to open its third facility in London later this year, while HCA Healthcare, another American group, has over 30 facilities.]
Meanwhile, tens of thousands of nurses and ambulance service staff walked off the job on Monday in a pay dispute, the largest ever strike in the 75-year history of the NHS. More nurses will also walk out on Tuesday, ambulance staff on Friday, and physiotherapists Thursday, making the week probably the most disruptive in NHS history, its Medical Director Stephen Powis said.
Jeremy Hunt, the UK’s Chancellor of the Exchequer (essentially the Chief Financial Officer), said he accepts “the picture that the NHS is on the brink of collapse” but warned the struggling service will also need to play its part in helping fix Britain’s broken economy. Hunt said there were “massive pressures in the NHS … with doctors, nurses on the frontline frankly under unbearable pressure”. However, he said the service received a lot of money and “we need to do everything we can to find efficiencies.”
Memo to Mr. Hunt: You can’t unf**k a strategic mess by chasing “economic efficiency.”
A Punk Rock Ethos of Disruption
There is an inherent tension between rot and genesis that all decaying systems give off. As societies pass through successive stages of development, they generate different kinds of economic systems, whose precepts are justified by the stage they are in. It all depends where you are in the continuous flow of events, and how/if/when you choose to step in with a different idea..
Something the Sex Pistols' frontman John Lydon (Johnny Rotten) understood.
Appearing live on the British Today show at the supper hour in December 1976, Lydon responded to interviewer Bill Grundy’s command, “Say something outrageous,” by calling him a “dirty fucker” and a “fucking rotter.” The newspapers put the Sex Pistols on the front page for a week with screaming headlines like “TV Fury Over Rock Cult Filth” and “Punk? Call It Filthy Lucre”. Members of Parliament denounced them.
“Anarchy in the U.K.” entered the charts at Number 43, but record company executives refused to handle it as EMI was fast buckling under the public pressure. The Pistols added to the outrage by refusing to apologize, and by doing long interviews in which they denounced the entrenched system of music ratings and sacred luminaries like Mick Jagger and Rod Stewart. They went on tour, traveling around the United Kingdom in a bus, arriving at gigs only to discover that they had been banned in the township. Out of twenty-one scheduled dates, the Sex Pistols played three.
So incendiary was their impact at the time that in their native England, the Houses of Parliament questioned whether they violated the Traitors and Treasons Act, a crime that carries the death penalty to this day. The Pistols would inspire the formation of numerous other groundbreaking groups, and Lydon would become the unlikely champion of a generation clamoring for change.
“No regrets,” proclaimed Malcolm McLaren, the Sex Pistols’ infamous manager, after the swearing-on-TV incident. “These lads … want a change of scene. What they did was quite genuine.” Here’s the clip:
There are as many theories about why punk rock came to be as there are punk-rock progenitors, but like all good revolutions, this one was born out of deep discontent with the times. It was propelled by technical accessibility and entrepreneurship: it was simple and easy to pull off by pretty much anyone. In December 1976, the English fanzine Sideburns published a now-famous illustration of three chords, captioned "This is a chord, this is another, this is a third. Now form a band."
Punk was hardcore Zen, a completely different operating philosophy that undermined the integrity of the culture in which it was introduced. It altered what was meant by a 'new industry model', changing those deeply embedded habits of thought which give a system its sense of what is the natural order of things.
Or to frame it in terms of today's lexicon, punk was...innovative...disruptive....transformative. Nothing was sacred. You could lose yourself in a reactionary had-it-up-to-here fury while also fully savoring the rupture, the novelty of the moment as a cathartic split from convention and cliche.
Punk was a completely different wattage.
Healthcare is the Economy
It is hard to avoid the impression that, in confronting the need for "disruption" by the healthcare-industrial complex as a whole, we are enacting a historical pantomime in which, rather than aiming for new storylines, the actors perform similar roles with exaggerated gestures and the audience knows ahead of time at which points to boo and when to cheer. And so we stay kinetically-trapped in a massive feedback loop, trying to fit the future onto the past, conceptually bound by the Standard Model of thought and inaction.
We have become comfortable with the ‘organized irresponsibility’ of a massive flywheel, one that's powered by legacy concepts, deep technical debt and obsolete narrative framings; it incessantly spins around itself as an infinitely recursive problem, the writing being overwritten by the same arrangement of pieces. Healthcare has been stuck for decades in stasis, governed by the veto power of legacy expert knowledge and culture, moving only in cautious increments.
We’re in a different era.
“The world is getting weirder and weirder. Huge things are happening at speeds to high to measure, or even fathom, in the brain of a normal human. We are like moths in a blizzard” — Hunter S. Thompson
The next cycle of evolution in the business and economics of healthcare starts with a different operating theory for the economics, one that positions ‘the production of affordable health’ as an economic objective, not “cost” and/or “price” of a piece in isolation from its context. The roadmap starts with an integrative vision, not just the 'right analysis' of the economic problem, but the right synthesis. It will also take a strong social imagination born from creative leadership.
This is a different value equation altogether, a view of market innovation through the lens of strategy for market interoperability: life sciences market + healthcare market + government market = new industry ecosystems as the locus for competition.
Public health is not separate and distinct from economic health. Healthcare is the economy; it is one thought. (For deeper analysis on this theme, I suggest exploring WifOR Institute, an independent economic research institute developing new economic concepts and practices; or the New Approaches to Economic Challenges team at the OECD.)
The skill that "government" worldwide will need to develop is a striking the right balance in what Arthur Schlesinger defined as a ‘political economy cycle,’ the “continuing shift in national involvement between public purpose and private interest.” This means market innovation born from collaboration with industry -- how to restructure markets and shape individual choices within those markets as an embedded economic system.
Because by the time you get to this kind of epic fail, the feedback loops are running the show, and the search for "efficiencies" to “fix” with bureaucratic routine is strategy by mental fantasy 🤘
/ jgs
John G. Singer is executive director of Blue Spoon Consulting, a global leader in ecosystem-centered market strategies. Blue Spoon was the first to apply systems theory to solve complex market access and integration challenges in the pharmaceutical industry.
Image: The Sex Pistols perform live onstage at Baton Rouge's Kingfisher Club, Louisiana, on their final tour on January 09 1978 L-R Johnny Rotten (John Lydon) Steve Jones, Sid Vicious (Photo by Richard E. Aaron/Redferns)