“And it ought to be remembered that there is nothing more difficult to take in hand, more perilous to conduct, or more uncertain in its success, than to take the lead in the introduction of a new order of things, because the innovator has for enemies all those who have done well under the old conditions, and lukewarm defenders in those who may do well under the new. This coolness arises partly from fear of the opponents, who have the laws on their side, and partly from the incredulity of men, who do not readily believe in new things until they have had a long experience of them.”
The Prince, chapter 6, Niccolò Machiavelli, 1513
I don’t share his bleak philosophy of excusing the means so long as the ends are for the good of society. That’s not a society I would want to live in. But he did know how power and politics work. Alan Yentob’s “Imagine” programme covering the 500th anniversary of the book brought it to life, not by approval but for relevance to the way people act.
Anyone attempting change in the NHS knows it is extraordinarily difficult, no matter how good the idea. Hear the conference speeches on innovation, integration, transformation and all the other bright and happy -tions. They will be shunned again next year, you may be sure. For they can safely be ignored by the armies of the status quo, profiting from crisis, scandal and mismanagement. Monitor £43m, CQC £60m, throw another £150m at A&E after the £250m to prop up hospitals last month. The clues are in the names: never mind the speeches, follow the money, it’s all heading for inspection, regulation and preservation.
On international comparisons the NHS is not a bad health system, but it’s not a particularly good one either, and for a sector which eats 9.4% of our GDP that’s not good enough. Have you noticed how all supermarkets are almost the same? Did you know that all thermal power stations are 40% efficient, plus or minus 2%? That’s because outside such a narrow range, you can’t stay in business. Now look at variation in the NHS. From a previous blog on A&E, you can see that the time to be seen and discharged varies by a factor of 3, same again the rate of admission as an emergency. The variation in waiting time to see a GP is a factor over 10 between practices.
The NHS has been called a national religion, such is the public veneration for it. Sadly this has come to mean that it can’t be questioned, challenged or changed in any meaningful way for patients, staff or funders. The variation we find when we measure properly shows islands of excellence in a sea of mediocrity, and oh yes the occasional wrong ‘un lurking below the surface. We’ll spend uncountable sums finding those who aren’t clever enough to get away, the rest can rest. They don’t have to innovate like the high street, where 7% go bust every year. They are the special, the holy ones.
In a healthy system, the mediocre would have to emulate excellence, or face oblivion. While inspection forces compliance with a minimum, innovation, at a fraction of the cost, moves the mediocre and therefore changes the performance of the whole.
This is not a party political blog, but it’s firmly on the side of finding what works, and doing things better. Innovation means doing so on a large scale, on the basis of evidence. It’s never going to be easy, but it is worth it, for despite the dangers, we all know that in the long term institutions which don’t change will crumble. So beware, armies of the status quo, your days are numbered, the tide is against you. Good and powerful people can see that and will make it happen.
If you’ve got this far I want you to see another picture. I wonder whether Jobs copied the pose. Still not sure that innovation really can make a difference to people’s lives? How hard was it for Aneurin Bevan to create the NHS in the teeth of opposition from every pillar of the old regime? I think he succeeded because he understood Machiavelli’s next paragraph:
“It is necessary, therefore, if we desire to discuss this matter thoroughly, to inquire whether these innovators can rely on themselves or have to depend on others: that is to say, whether, to consummate their enterprise, have they to use prayers or can they use force? In the first instance they always succeed badly, and never compass anything; but when they can rely on themselves and use force, then they are rarely endangered. Hence it is that all armed prophets have conquered, and the unarmed ones have been destroyed. Besides the reasons mentioned, the nature of the people is variable, and whilst it is easy to persuade them, it is difficult to fix them in that persuasion. And thus it is necessary to take such measures that, when they believe no longer, it may be possible to make them believe by force.”