Cancer Services in the NHS are coming apart at the seams: time for a new paradigm

Measuring Up: the health of NHS Cancer Services is a report from Cancer Research UK.

I have no difficulty accepting much of what they have discovered and the report’s key points are sensible. But, two main conclusions are unsurprising and disappointing: more money and better leadership.

There will never be enough money, so we need to think differently about how we organise care itself. More leadership is a typical lament which says that the people responsible for the service haven’t done what they need to do. When I read reports such as this that call for more leadership I can only shake my head that they were not able to think further about the underlying causal landscape.

Their use of tipping point language is useful, though, as it does suggest catastrophic, rather than incremental, changes are likely. A tipping point means a move from one state to another (like tipping over the milk pitcher), where other factors come into play (otherwise it wouldn’t be tipping!). That suggests that there will be a change of state in which the old rules are unlikely to apply or be useful. After Kuhn, we call this a paradigm shift. Edward de Bono characterises two situations: one he called a problem, where you use existing rules; the other is a crisis for which you need new rules. My take is that the NHS is moving into territory where the need for different thinking is more important than problem-solving. That healthcare is a complex (wicked) and adaptive system should alert us and not surprise us that solutions create new problems and indeed crises.

Based on the report, though, we’re more likely to see hyperactive civil servants and NHS “leaders” rushing about with Powerpoint presentations full of exhortations and flow charts, accountability matrices and maps. We’ve tried that so often, one wonders if there are any other tools in the box. However, that the current state of affairs may have been caused by past reform and changes is an important insight, but to argue for essentially what is more of the same is plain silly. If past actions have destabilised cancer services and tipping is likely, then new thinking and new rules are needed. Did I miss something in the report?

If we take the simple flow of patients through the system, we are told the rate of entry is rising as GPs shift to ‘urgent’ referral, presumably the only way they know to get an oncologist’s attention, but the velocity through the system hasn’t changed. Why should that be surprising when resources are rigid and constrained by NHS structures (such as lack of effective transfer of patient information), and what appears to be performance measurement of the wrong things, creating perverse incentives.

The diagnostic phase is what appears to be rate-limiting across the patient and treatment pathway and hence is the primary blockage. While increased investment in diagnostics would be timely, how to do that is where a paradigm shift is needed. The delay in procuring proton beam equipment (so much in the news) illustrates the procurement logic that undermines service delivery. Entrepreneurial creation of free-standing diagnostic centres, providing on-demand services to oncologists and patients would be one way to deal with this. Does the NHS need to own the equipment, labs etc. or does it just need access to the service? By-passing the GP would also be another option, as the gatekeeping function appears to be another form of avoidable delay (ask women how long it took for ovarian cancer, for instance). Would it not be better for patients to access directly oncology diagnostic centres, which might also speed GP referral in turn?

The policy-down focus on leadership has clearly produced organisations of dubious purpose, but with evocative titles: Clinical Senate. Wow! But systems are judged by their performance, not what they’re called. A focus on leadership shifts cognitive priorities from a service orientation to one of lining up organisational structures, job descriptions, role definitions and mandates, meetings, minutes, but distractions if the challenge is where the rubber meets the road. The intersection of patient with system defines the leadership challenge, not the other way round.

So, what is to be done? I don’t buy the authors’ argument that change-weary people don’t need more change. They may embrace the logic of wholesale paradigm change if it got rid of the nonsense that stops them from doing what needs to be done. My take is that there is a strong case to be made for unbundling cancer services (this logic can apply in other clinical service areas, too) defined by the demands of the patient pathway. I would also look for ways to encourage entrepreneurial solutions, particularly in the form of investment in diagnostic technologies, and in enabling oncologists to work autonomously with each other and with patients. This would call time on the hospitals’ monopoly control of oncologists, cancer diagnosis, testing, and services, which is organisationally rate-limiting, and many of the identified problems are consequences of a system subjected to serious rate-limiting blockers, but lacking the ability to alter its structure to bypass, elminate, or reform those blockers.

In the end, the report is a narrative exhortation to get people to meet and plan to do what they are currently not able to do, or otherwise they would have done what needed to be done. Why not?

 

 

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