Thread by @buckinghamh

.@IsabelHardman has just unleashed @nedwards_1 to give his tour de force on the root causes of the challenges facing the NHS. Strap in... #NTsummit

Is it about the level of spending? We're in the middle of the pack on % of GDP, but our GDP is low, so £ spend is low. But why? #NTsummit

Is the Treasury the blocker? Not thinking anything like long term enough. And that leads to our social care, workforce & capital issues. #NTsummit

But why that short termism? Is it about our politics & government? The decay of the civil service? #NTsummit

Pretty sure the NHS is the largest centralised health system in the developed world.

Except maybe North Korea.

Economies of scale dwarfed by the problems of complexity. #NTsummit

A punitive, upward facing culture with an anxiety problem. #NTsummit

And exacerbated by the absence of a theory of change. Seem to have tried everything in the box, including a high frequency of reorganisation. #NTsummit

Can't solve problems of relationships and culture by changing structures. #NTsummit

Over emphasis on leadership, absence of focus on basic management and administration. #NTsummit

And all this coupled with short term focus on ££ leads to inefficiency. #NTsummit

Have we got strong enough clinical engagement? Jury is out.. #NTsummit

Is the population letting us down? The evidence for that not very convincing - and ChatGPT made up a citation. #NTsummit

Having said that income inequalities pretty stark. #NTsummit

So is it the way the system is organised? Should we have more competition? #NTsummit

Just maybe, for elective care, but even there evidence pretty contested. But that's a small part of what the NHS does. #NTsummit

And anyway, competition requires spare capacity, and we haven't got that. #NTsummit

Tax funded or social insurance? Lots of tax funded systems do perform pretty well. So what's the magic ingredient? #NTsummit

Well, in most Bismarck systems the Ministry of Finance is more arms length, and there's less political interference... #NTsummit

Can't do policy pic'n'mix - US levels of taxation won't get you Scandinavian levels of social care. To get the benefits of the Dutch system maybe you have to have the Dutch culture. #NTsummit

We've never really changed our delivery model - but that's true of other countries too. Very few examples of really good structural integration. #NTsummit

So lots of hypotheses, which are right? #NTsummit

All interrelated. Can't solve by looking at one bit. No quick fixes or big bangs... #NTsummit

So focus on the basics. Good management, change management resource at the front line. Slow and boring, but maybe we've had enough excitement. Fundamentally whatever we do needs to be based in proper analysis of the problems, not leaping straight to solutions. #NTsummit