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Just one thing after another

Richard Taunt, Director of Policy at the Health Foundation, reflects upon the history of health policy reform.

London. A government building. A group of health care staff arrive with a proposal: only those with certain qualifications should be able to do their job. The powers that be listen. They have sympathy for the cause but also misgivings: how could it be made to work? Did they have enough qualified staff to make it work? With regret, the proposal is turned down. The group leave empty-handed.

This happened in 2011 with repeated calls for the government to regulate health care assistants. It also happened 600 years previously, when Henry V refused petitions to regulate physicians largely due to the lack of infrastructure to implement it. Funnily enough, Shakespeare decided to leave this feature of Henry’s reign out of his play.

Interesting. A nice anecdote to use at a party (perhaps, you may not have friends as geeky as mine). But it’s also fundamentally important. The circularity of health policy is increasingly well understood as bodies are abolished and then established under a new name soon after. However, the extent of this cyclical nature is I fear woefully underestimated, as is how amazingly rich a resource past history can be to policymakers. Today’s issues are all too frequently the issues we considered yesterday too (and probably the day before).

Integration? ‘There is a need for far more ... services that support people outside hospital. Often what there is could achieve more if it were better co-ordinated with other services in and out of hospital’. Liberal Democrat manifesto perhaps? Not quite, the NHS Reorganisation White Paper of August (who publishes a White Paper in August?) 1972.

Long-term sustainability of the NHS? In early September 1982 the Cabinet discussed options for long-term funding of the NHS and other public services. The paper before them included options not light on controversy: ‘Even though a free state service would be retained for the uninsured and possibly for the non-working population, for the majority the change would represent the abolition of the NHS’.

The need to transform services? You could be forgiven for thinking the following comes from a Simon Stevens speech yesterday rather than Enoch Powell 54 years ago: ‘We have to get the idea into our heads that a hospital is a shell, a framework, however complex, to contain certain processes, and when the processes change or are superseded, then the shell must most probably be scrapped’.

I worked at the Department of Health for the best part of a decade. Those working there today form part of a line stretching back to those who worked with Bevan in crafting the NHS in the 1940s, back to those who met with Florence Nightingale in the 1860s, back to those listening to the petitioning physicians in 1421.

I was aware of this heritage; the Department’s head office at 79 Whitehall has a book of remembrance for those in its predecessor organisations who died during the two world wars. However, I struggle to think of any occasion when I started a new policy by forensically looking at the past, nor any particular appetite of Ministers to learn why their brilliant new idea wasn’t so new (an understanding of which might have taught them it was unlikely to be brilliant either).

Part of the problem is the lack of time available to policymakers to do the necessary archive searching. Hopefully this is where we can help. In setting out health and care policy by six key themes (choice and competition, commissioning, public health, adult social care and integration, providers, and regulation), the Policy Navigator aims to make it easier than ever to learn what has gone before and how that relates to today’s issues.

However, we’re not quite naïve enough to think a new website will revolutionise the world (a lesson we could have learnt from one of several policy initiatives). The reason why health policy goes round and round - and the reason why Henry V is relevant today - is that many of the issues we debate have no obvious right answer, if they have a right answer at all. As such, we try one thing, it doesn’t work perfectly, so we try the opposite, which doesn’t work so well either, and on we go.

We need a shift in thinking: away from trying to ‘solve’ these issues towards a focus on how we can learn from how they have previously been addressed. Such a willingness to learn and improve forms a cornerstone of quality improvement in health care. Viewed in this way, every policy U-turn of history can form a mega-PDSA cycle from which to improve policymaking.

All being well, in 600 years there will still be health policy debates raging fiercely in government buildings, most likely being pretty similar to what we debate today. In working out how to control the health care costs of 2615, let’s hope our policymaking successors are digging out the Five Year Forward View and reflecting on its great success/tragic shortcomings [note to future self: delete as applicable].