The only way to change the NHS fast enough to thrive is to have powerful argument not only for the new – but against the old.

My last two posts have explored some of the current problems about   the development of associates’ roles. I want to continue with that issue, but I want to work with another theme of my blog – to bring about real change in the NHS and social care, you need to have a good, sustained argument in favour of that change. Above all you need to be capable of deploying that argument over and over again, and for some time.

Over the next decade, nearly every change that the NHS needs to enact will entail important technical activities, a moral debate about the change and, usually, an impact on patients and their care.  If, in bringing about any particular change, you restrict yourself to arguing for its technical advantages you may have some impact, but to fully succeed you will have to overcome not only technical, but crucially moral arguments against it.

If the only argument for change is technical, it will be beaten by a moral argument against it. Of course, the NHS as a health care system is an complex bundle of very technical issues that need to work well if it going to deliver any services at all. But there are also moral issues. Health care in general involves moral arguments and the NHS in particular means a great deal to people in their hearts and souls, in addition to their worries about their health.

Consequentially, if you want to change anything about the NHS you need a strong moral argument for that change. And you need to go on making that moral argument every day.  Many people arguing for change often find this puzzling. They want to know why the NHS won’t just do what’s right?  “Just get on with it” – rather than hanging on to the past.

The reason why the politics of change is so difficult was probably best explained 500+ years ago – when, at a time of great change in Europe, Machiavelli write a primer of advice to the prince who wanted to bring about change.

“It must be considered that there is nothing more difficult to carry out nor more doubtful of success nor more dangerous to handle than to initiate a new order of things; for the reformer has enemies in all those who profit by the old order, and only lukewarm defenders in all those who would profit by the new order; this lukewarmness arising partly from the incredulity of mankind who does not truly believe in anything new until they actually have experience of it.

Nicolo Machiavelli The Prince Chapter 6

Some big themes for NHS reform here,

“The reformer has enemies in all those who profit by the old order

Changing the skill mix of those who provide the public with NHS Health care will disrupt the old order. Those who live in that old order will resist that change. That does not make them bad people. And whilst those who have new skills and new jobs in health care will profit from the new order they are ‘lukewarm’ about the change because not many of them are yet in post.

And above all,

‘…the incredulity of mankind who does not truly believe in anything new until they actually have experience of it”.

Before it happens, do people really believe than an AI machine can read their MRI scans better than a trained doctor? Before I experience it, if I have had a long-term condition for a decade, do I really believe 30 minutes with a health trainer will be more useful to me than 7 minutes with a GP? Do I really believe, before it has happened, that 20 minutes with a Physician Associate tomorrow will be more beneficial than 7 minutes with a GP in two weeks’ time?

Before I ‘actually experience it’ it’s difficult to believe, and simultaneously some who believe in the old order will say machines, health trainers and physicians’ associates are, compared to a doctor, dangerous. The new order will make some mistakes, which will automatically be laid at the door of its newness rather than the fact that every order new and old makes mistakes.

What lessons can we learn from this?

It looks to me (and quite a few others) that in terms of its skill mix the NHS has to become a “new order” in the next decade.

So first, let’s not be at all surprised that the ‘old order’ fights hard against the new. It’s not because the old order is full of bad people. They genuinely believe that the old order is better and safer. And they will argue and mobilise to defend what they believe is right.

Second, they will argue their case with the public. Of course, there will be private arguments about change, but it is with the public that the argument will be strongest – and that is where it will be settled. To make their case they will raise, amongst other things, issues of safety. They will argue that the problem with the new is that it is dangerous. – because it is disturbing when what has been the right order of things for some time to introduce novelty. “Look what happened to poor Mr Smith who was misdiagnosed because he put his health care in the hands of someone not as qualified as the old order”. This moral argument in favour of safety and against the new order has already been heard and will be again many times over, now and in the future.

To counter this powerful argument, those in favour of change are going to have to deploy a moral argument about safety against the old order. Because the old order also makes mistakes.

I was at a party the other day where, because we are now of a certain age, there were a number of people who had been quite ill in the last year. Some of them they had been misdiagnosed for months and months by the old order. Each had a particular story about how they had to find novel ways of circumventing the old order to get the correct diagnosis.

These are indeed sad mistakes.

But if the moral argument for the new is going to prevail against this old order, patient safety, argument they will have to mobilise their own moral argument about problems of safety with the old order.

To bring about change we will have to point out that the old order has problems with safe decision making – not just the new. Because if the old order persuades us all to cling to the past, we will be hanging onto a system which cannot cope with the issue of health and provision of heath care now – let alone in the future.

That’s why the arguments for change, the arguments for a different skill mix, will need to tackle both moral and technical issues.

And those arguments will, if the NHS is to make the changes it needs at the speed that it needs them, have to be deployed again and again, and again.

Next week I’ll explore how to utilise these lessons when I return to the issue of public involvement in developing the next NHS Plan.