One of the most dangerous zombie ideas afflicting NHS policy is the idea that a better NHS can be built one activity silo and one improvement intervention at a time... This is a bad idea because the biggest NHS problems are not in single silos of activity but in how the silos fit together. Coordination problems between silos are far more consequential than those inside silos...

A fascinating yell of frustration from a doctor complaining about all the pressure to improve flow.

"Stop yelling at us to improve flow, we are all working as hard as we can" is an understandable response. But other views are possible...

https://twitter.com/iamlivyrose/status/1814751708112953751

To me the obvious one is that the design of the whole process of flow in her hospital is totally broken. The right place to assign blame for poor flow isn't the staff, it is the managers who haven't bothered to design a process at all...

The biggest problem with this report is the first sentence in the summary.

The real problem is the hype train of marketing bullshit on the potential of AI...

https://twitter.com/HealthFdn/status/1812034235584119187

the assumption "AI could help the huge pressures facing the NHS" conceals two big assumptions:
1. AI could help
2. we don't already know what to do about the big NHS problems.

Both are suspect...

Why do so many commentators and analysts on the NHS seem to assume that only big injections of money can create much improvement in performance when so mcu ocurrent dysfunction is caused by operational management issues? ... While performance has declined sharply, the NHS budget has not declined nor have staff numbers. But operational management and logistics capacity has been severely cut from levels that were inadequate a decade ago...

This NHS crisis is going to lead to many bad decisions. But it is worth looking back to test whether it could have been avoided.

And the root cause is hospitals recruiting more staff then they could afford...

https://twitter.com/ShaunLintern/status/1774338968294707316

There will be howls of rage that staff cuts will be needed, of course. And lots of lobbying about the consequences for safety and performance. And the rush to make cuts quickly will have bad consequences...

The idea that government have been plotting to privatise the NHS for decades has to be the least successful conspiracy in modern British history. We can tell this by reading the notorious 1982 cabinet note that is often claimed to be its origin... The original Cabinet Paper is accessible in the government archives if you want to read it here:
...discovery.nationalarchives.gov.uk/details/r/C133…

Expert consensus is often dangerous and bad for progress.

Huge medical improvement have come when iconoclasts have challenged the consensus with evidence... For example: Semmelweis on puerperal fever, John Snow on the causes of cholera, Marshall and Warren on the role of infection in stomach ulcers all used evidence to challenge the consensus...

There are two competing models of what the job of NHSE is:
1. work out the best detailed ways for hospitals to operate and tell them what to do in long detailed reports
2. Hold them to account for understanding how to achieve the big outcomes... The prevailing mode is 1. The result is long policy documents detailing how trusts ought to do stuff. These are observably ineffective for two big reasons...

The much heralded NHS Workforce Plan, whatever you think of it, can't impact the NHS much in the next 5 years (as its commitments are mostly about training which takes time). But it could have been different... If it had paid attention to the non-front-line workforce, it could have made a big impact quickly.

For example, it is worth asking which support staff do the most to release front-line time for patient care...

A key symptom of NHS problems is that doctors are overloaded with work. This is often ascribed to a fundamental shortage of doctors. But there is a huge hidden factor that also contributes to overload... Obviously fewer doctors per head compared to peer health systems is a factor in this and that is the one most often discussed. But it might not even be the largest contributor to overload...

Framing the problem wrongly and asking the wrong question often leads to the wrong answer. Nowhere more so than in NHS policy. Some examples:
... 1) "How do we reduce unnecessary attendances to A&E?" is the wrong question that already assumes the problem is attendance. But crowding and long waits are the problem and they don't depend much on attendance...

Some quick reflections on the NHS workforce plan (hardly comprehensive, but the bugger is 150 pages).

What isn't in it is more important than what is:
... It doesn't start with a clear description of what the biggest NHS challenges are (but it is a workforce plan not a whole NHS plan, so perhaps I was expecting too much)...

Who is the biggest source of bad NHS policy in the last decade?
NHSE
The Government
HM Treasury
Hospital leaders
Other service leaders
DHSC

... I'm not at all sure, for multiple reasons.

I've seen more sense from government insiders than from NHSE on some topics, for example. And some pretty terrible ideas from internal NHS leaders...

There are good ideas here, but a focus on staffing in A&Es is not one of them...

https://twitter.com/RCEMpresident/status/1634121839562706945

here is a thread explaining why staffing isn't the issue:

https://twitter.com/sib313/status/1629141391786778624?s=20

Looks like ICBs/ICSs are heading for a £6bn deficit in this year's plans. That's bad: hsj.co.uk/finance-and-ef…
... So last week's tertiation (that's a decimation three times over for pedants) of ICB management costs looks timely as a response...

How the NHS solves problems:
1. Identify the problem
2. Find someone else to blame
3. Stop. Or lobby for someone else to fix the problem. Example:
1. the problem: Many big issues are caused because too many patients are stuck in hospital beds because discharges are delayed.
2. Blame social care
3. Tell the government only they can fix this...

I complained a few days ago about this story which reports A&E performance with "headline" numbers allowing obfuscation of bad performance in major A&Es. I thought I should follow up with some numbers...
@NickTriggle

https://twitter.com/sib313/status/1625478396548349952

The major point is that using the headline number allows trusts with terrible performance in major A&Es to dilute their headline by including the (much better) performance in type 3 units (where poor performance is rare)...

Here is an experimental chart that doesn't fit well on twitter: trust type 1 A&E performance vs the national performance, monthly since 2010... Key message: for many trusts, relative performance persists over long periods...

Hugely important insight here for analysts and data scientists. It isn't enough to know the right answer: you have to persuade people to pay attention to it...

https://twitter.com/kurtstat/status/1625798624427888640

This is a big problem since the group of people who have the insights (the analysts) are often the least effective at persuading decision makers to pay attention and actually make different decisions...

Let's say an NHS hospital could achieve only one of three things by taking action right now:
1) 3% cost improvement next year
2) 5% more elective activity next year
3) 30% higher productivity in 5 years time

Which would be better? Which would NHSE want? ... The are mutually exclusive alternatives. You can only have one.

Which are they incentivised to do? ...

This story in today's Times by @eleanorhayward has the headline "GP shortage means busiest doctors look after 3,000 patients" which seriously understates the problem... The analysis averages the GP staffing across ICBs which are large regions with hundreds of GPs each. But the data exists for individual practices and the variation inside ICBs is huge...