The NHS: fit for 1948 but for 2014?

This past weekend I decided to spend more time reading the newspapers and leaving the do-it-yourself projects for another day. Consequently I got stuck into an article in The Observer about the NHS' funding crisis, what might happen and what the King's Fund thought should happen.

All interesting stuff, but I felt that while many of their suggestions made some sense they were missing the point about what is really going on in healthcare in the United Kingdom. Maybe they need to reflect a little using Geoffery Vickers' idea of appreciative systems.

Vickers suggested that we observe the flux of time passing as manifested by ideas and events, compare them with our internalised standards and then decide how to respond. The NHS as it currently operates is based on society's needs in 1948: a war-wracked society where infectious diseases and poor living conditions were major problems. Illnesses could be treated and the people would return home to live out the rest of their harder but shorter lives.

But the flux of time moves on and by the time we react the situation has changed: our responses are therefore always that bit too late. So it is with healthcare: we now have a relatively affluent society characterised by good general levels of health leading to an ageing population where chronic diseases of old age are much more prevalent, and one where lifestyle illnesses such as obesity and lack of general fitness are placing increasing demands on the NHS. But the standards used in the monitoring process seem to be unchanged. Organisations like the King's Fund still look for ways to make the NHS work better within the 1948 paradigm.

The rich picture below tries to capture some of the issues that are affecting health today.

The food and drinks industry encourages people to drink sugar and alcohol and eat fat, all of which when consumed to excess cause health problems. The running down of public leisure facilities through austerity programmes, selling school playing fields and minimising the importance of competitive games in schools (as just a few policies) mean that people take less exercise and keep less healthily fit. Big Pharma relies on medicalising life so that it can sell drugs and treatments to the healthcare industry, so has little interest in a healthy population.

Seen in this light, current government policies to encourage more private enterprise to run parts of the health service seem like plans to let lunatics run the asylum - it's a great business plan if one part of the corporate empire makes people sick while another makes them better so they can keep consuming. Other plans to review targets and enforce more inspections and regulation will just drive problems to another part of the system. Scandals like that in the Mid Staffordshire NHS Trust will continue to reappear in different guises.

The problem is therefore one of system boundaries. While the NHS is seen to be there to treat illness rather than to promote health neither it nor associated politicians will look to take on the real causes of poor health, the systemic ones of poor public health policies, corporate interests in promoting illness and an increasingly sedentary population. Powerful systemic factors mean that it is likely to stay as it is.

The NHS is a fantastic service we in the UK should be proud of. But perhaps its past successes are stopping us from looking at what health systems should be about in 2014?

Selling England by the pound

As the four-yearly cycle of hope and disappointment of England failing at the World Cup moves into the unpleasant memory stage it has been time for me to indulge in masochistic readings of why did it all go wrong post-mortems.

At least this time there was no ridiculous hyping of the team's chances so maybe this has made it possible for some more realistic analysis about why England's football team often does so badly in major competitions. So far reasons I have seen include:

• English players do not have enough basic skills.
• There are too many foreign players in the Premier League.
• The style of football in the Premier League does not work in international competitions.
• The players don't really care about playing for their country as they are paid too much by their clubs.
• The manager was inadequate (but not too many of those).
• English people have little sense of national identity.
• "God save the Queen" is a poor choice of national anthem for a team which only represents a quarter of the Kingdom.
• Not enough Old Etonians in the national squad.

It is good that various suspects have been arrested, but so far I have not seen much of what I would call 'systemic analysis' of drawing things together in any way. Given that England have  disappointed for many decades now it is time that people really did start to think that there is something systemic going on. Regular changes of managers has not had any real effect apart from making some people very wealthy men with no success to record.

At times like this Soft Systems Methodology calls to me, and I like to try and sketch out a rich picture to try and make some sense of my confused thoughts.

I don't want to go into the detailed process here, but just thought it might be interesting to throw out a few 'worldviews' that came to me as I drew on my whiteboard:

• The Premier League is a good commodity for rich overseas investors to buy.
• The Premier League is a good way for foreign players to learn how to beat English players.
• Temporary immigration of foreign players is a good way to stop decent English players from emerging.
• Football is mass entertainment, not a matter of life and death (thanks Bill Shankley) to particular communities any more.

The next step would be to draw up formal root definitions and conceptual models to explore these, but to be honest I'm not that desperate (however, if Greg Dyke reads this and is keen to buy some consultancy time from me, I'm available).

But what suddenly stood out to me is how football has just become another English business that can be bought, exploited and traded like anything else (e.g. AstraZeneca, Cadbury's, etc.). The influence of the City is here: who cares what it is as long as there is profit to be made. This is perhaps the fundamental reason why it has all gone wrong; sell kids Xboxes and get them to watch football onTV so they are protected from the dangers out there. More money to be made from that than from watching little kids run around football pitches. No wonder the numbers of people actually playing football is steadily declining, and we need foreign players to make up the numbers. To paraphrase Oscar Wilde, the people who really run football (Sky, the Premier League, to name a few) know the price of everything but the value of nothing. As long as the money rolls in nobody really cares about the England football team.

This is what I like about systems thinking: after days of trying to deal with the complexities I had a moment of clarity. I can deal with my disappointment: I've had a season ticket with Sheffield Wednesday for 10 years and know all about the systemic pain of football.

Playing the (non-systemic) blame game

I have listened to a number of radio interviews in recent days talking about the Iraq crisis, and one of the themes has been playing the blame game.

It is always interesting listening to radio interviews with politicians. The politicians always try to blame somebody else and the radio interviewers almost always try to boil down a complex situation into a two-minute explanation: asking things like, "So who is to blame for the current situation in Iraq?"

So amongst others we have had:

• Tony Blair saying the 2003 invasion of Iraq had nothing to do with the current situation.
• Unidentified person on the BBC saying that Nouri al Maliki is to blame for having misused the democratic process (discussed in this Guardian article). 
• Paul Bremer saying that the US and British troops pulled out of the occupation too early

Now, I know that you can find more nuanced discussions in the quality newspapers and online, but it always irritates me when the news sources that reach most people offer such simplistic analyses. In a time when fewer and fewer people are buying print newspapers and are relying on rolling radio and TV news sources it is disappointing and somewhat alarming when the analyses that most people have ready access to are so reductionist.

It is also dispiriting (although admittedly not surprising) to hear politicians coming out with comments which are (to my ears at least) one-dimensional and self-serving. Systems practitioners know quite well that in a wicked problem (such as Iraq) everything has an impact, and to say that the 2003 invasion is not to blame in any way for the current crisis is breathtaking. Commenting that had American and British troops stayed in Iraq longer would have prevented the current situation is based on an assumption that the Iraqi people would have been happy to see occupying troops in the country for all of this time. The notion that a prolonged occupation could have fuelled resentment leading to violent unrest, changing the dynamics of the situation in that way, does not seem to be considered, or at least articulated.

The art of being a successful politician is to deny systemic effects, to make other people believe that nothing that you do ever has any negative impact and that when things go wrong it is because of what other people have done. Of course, being able to do this well is what helps politicians have glittering careers in democracy, so maybe we should question whether or not democracy is something that should be imposed on countries around the world. It is pertinent to remember the title of Ken Livingstone's 1988 the biography, "If Voting Changed Anything They'd Abolish It".

Iraq - mission accomplished? I think not

The current alarming situation in Iraq is a classic example of what systems thinkers see as unintended consequences of acting in a wicked problem.

Back in the early 2000s great thinkers in the United States and United Kingdom presented a scenario whereby as soon as the dictator Saddam Hussein was removed there would be a linear progression of events embracing democracy, which would lead to peace and stability in the country. Of course, this has not happened, and it may be difficult to imagine that anyone would have really thought that it would.

Democracy takes many generations to take effective root in a society, and the typical pattern when dropped onto a non-democratic society emerging from a dictatorship is that political structures organise around ethnic or religious divides, and that a winner-takes-all mentality ensues, as everyone has learnt from the previous dictator.

One of the characteristics of wicked problems is that they are symptoms of other interrelated problems, and this is very clear in Iraq. The destabilisation of Syria has led to roaming, somewhat disorganised bands of militant groups, the tensions between Sunni and Shia Islam in the region plays out regionally and within Iraq's democratic processes, the massive amount of weaponry and trained personnel available as a result of the instability in the whole region, and of course there is the Israel question.

All of these factors and more are interacting to produce non-linear effects, and it is hard to see how this will all pan out. However, what is fairly certain is that democracy will not be a winner in the Iraq the near future.

Tragedy in Nigeria

Boko Haram is in the news again today for killing about 45 people in north eastern Nigeria. This organisation has been making the international news for several years now, even though they have apparently been in existence since 2002.

News reporting of Boko Haram tends to follow the same reductionist principles of most non-UK bad news events, focusing on specific details and ignoring context. It is possible to find out more about the history and politics of the organisation, but to the casual news reader they probably just come across as a crazy, murderous band. When seen in that light the response that seems logical for the authorities to take is to do whatever they can to crush and imprison its members, so that the problem will go away. However, further reflection suggests that this approach might not be so effective in the longer term.

Systems concepts can help to throw some light on why Boko Haram are operating. First, we can think about it as a 'wicked' problem. For example:

• We cannot produce a single definition of the problem; are they terrorists, gangsters or just religious fundamentalists who are really troubled by the world that they see?
• The current situation is shaped by its history, and will continue to evolve. Every intervention will cause a change in the situation, for better or worse.
• What is the endpoint? Boko Haram ceases to exist, its members are dead, fundamentalist Islam is no longer a significant force in the region, or what?
• It is not an isolated problem, and is deeply connected with other problems regionally and internationally.

The last issue is interesting and particularly relates to the systems idea of a boundary. News reporting, as described above, draws a tightly-defined boundary around Boko Haram, separating it from other issues. This gives the idea that we can simply solve the problem by eliminating it (i.e. killing or imprisoning them all). However, if we loosen the boundary other, very significant factors become apparent:

• The western involvement in destabilising Libya unintentionally created to the availability of large numbers of fighting personnel and heavy weaponry.
• For centuries there have been tensions between Islamic and Christian communities in sub-Saharan Africa.
• Nigeria is potentially a very wealthy country due to the oil, but this wealth is concentrated in the Christian south. Endemic corruption means that wealth from the oil does not really benefit people in the Islamic north (nor many in the Christian south).
• Western (which can be seen as Christian) oil companies are implicit in supporting corrupt government regimes and oil company practices.
• Fundamentalist Islam has been growing in importance for several decades globally, and has been characterised by violent clashes and demonisation in the West.

The list could go on. Each of these is a major problem in its own right, which is feeding into the north-east Nigerian context. A causal flow diagram would show a number of positive feedback loops all coming together to make the situation worse.

From this analysis Boko Haram is just a symptom of huge regional and international forces, and crushing it will not in the long-term solve any problems, but could arguably add a further twist to the feedback loops driving Christian and Islamic peoples apart everywhere in the world.

Biomass issues

As a vaguely environmentally-minded person I have been aware of some time about the apparent benefits of burning biomass for energy.

Cultivating quick growing vegetation which can then be burnt is a relatively carbon-neutral way of generating energy, and so would seem to be attractive from a renewable energy perspective.  As a result the UK Government has set targets for generating energy from burning biomass.

Ah, targets. One of the things you learn when studying systems is that targets have a funny way of distorting what happens. In order to meet the targets people will do all sorts of crazy things, and in the case of biomass they have started importing timber from the United States (http://www.bbc.co.uk/news/science-environment-22630815).  So the timber is transported within the USA to a port, is then put on a ship which burns diesel fuel to cross the Atlantic, and is then transported from the docks to a power station.

Now, I don't know what the energy cost for doing this is, but I wouldn't mind betting that the whole biomass system is far from carbon-neutral. 

Again, yesterday morning I heard a news item which said that subsidies for producing biomass were diverted land from food production, which was pushing up prices. Unfortunately the radio item did not go into detail and I have not been able to explore this further in order to fully understand the problem. But again, we see systemic issues kicking in.

Why systemic stories?

Since I started studying towards a Master's degree in systems thinking (the Open University Systems Thinking in Practice) I have started to become much more of a 'systems thinker'.

To me that means that I have become much more adept at spotting how single events or stories are part of a bigger picture, that there are connections and dynamic relationships, and that we are often looking at things with very narrow boundaries which make it difficult to actually realise why something is happening or how it can be resolved in some way.

This often happens when I am listening to the radio news in the mornings, and hear some expert talking about a current issue and they say something like, "It's a systemic problem." Ding ding. I might think about it for a while but then forget about it as the rest of the day overwhelms me.

But I thought it might be a useful exercise to try and capture these stories, and do some simple first-level thinking about why they are systemic and what the issues are.

And so this blog was born.