The importance of the sounds of silence.

Some months ago I warned readers that at some point I might begin posting again.

Given the current amount of discussion and debate about the NHS and social care reform, I think June 2023 is the right time.

For the last few years, I have had a monthly virtual breakfast with my friend Victor Adebowale. Well-known in health circles you may know him as being, amongst other things, Chair of the NHS Confederation (aka the Confed). During one of these conversations recently he commented that some things in the NHS were talked about a lot – and some things barely mentioned. He summed up the impact of this state of affairs with the remark that, “History is shaped by the issues we don’t talk about more than the issues we do talk about”.

I think this is a really important insight into how both history and the NHS have evolved. On June 14th Victor, as Confed Chair, will begin his speech with this thought.

And for my blog it’s this thought that drives its renaissance. Life is too short to churn out a series of posts which don’t really add anything new. There are better things I can do with my life.

But since, by definition, important things are not being talked about, finding them is a difficult piece of detective work.

Given so much debate currently rages within social care and the NHS, what are the things that people are not talking about. And how is the silence about them likely to make history?

In discussions about the NHS 20 years ago, virtually nothing was being said about health and everyone (very much including me) was concentrating on health care. The current strong debate on the importance of developing health in all policies demonstrates how important it is. Yet 20 years ago this was one of the sounds of silence that really made history – with all the poor health that surrounded us.

So how to find today’s silences? One way of finding them is to focus on an area of loud policy agreement and listen carefully to what is not being said.

In June 2023 there are many loud debates and two of them are amongst the loudest. The first is taking place in health care and the other across the whole of society.

In health care (when the Government gets round to publishing its work force plan) there is agreement that there needs to be a big increase in doctors and nurses planned and delivered both now and over the next 20-30 years.

On the other hand, most of the media is very worried about how AI will change everything. There seems a lot of agreement that with AI nearly every job will change, and some will simply go.

However, what there is not much talk about is if AI is going to change ‘everything’ why does the concept of ‘everything’ not include the nature of the doctors and nurses that we will need in 20 years’ time?

The problem with the ‘need for more doctors and nurses’ (which in 2023 is absolutely true – and let’s face it, it would have been very useful if 12 years ago there had been a workforce plan for the future) – is that it takes so long to train them (especially doctors). Over the next 20 years the nature of medicine and health care will change radically – perhaps several times over. Some of that change will be caused by AI, some by genomics and some by pharmaceuticals. Taken together the changes will be enormous.

Currently the nature of medicine and health care is at the mercy of several powerful sciences. It is certain that in the 12 years we spend training a doctor that what they do, and how they do it, will be transformed.  I have no doubt that we will still need people to carry out health care work in 12 years from now, but could I tell you what they will be doing in 12 years? No, I don’t think I could.

Will they be the same people as do it now? No. Will some of it be similar? Yes. Will AI be doing some of it? Yes. Will AI be doing a lot of it? Probably. Will AI be doing all of it? No.

Today our method of training doctors is drawn from an age where knowledge was owned by one group of people (those who had been trained) and passed onto another through the process of training. The fact that the machine on which I am writing this potentially gives me access to all the knowledge in the world, changes what needs to happen with training. The only knowledge this machine doesn’t give me is the new knowledge that doctors will actually be using in the five years after they finish training. We know that we can’t train them with that knowledge because we don’t yet know what it is.

This probably means that for the modern doctor initial training is only a part of 35 years of work.

Equally technology will change the way in which training takes place. University lecturers are already very worried about AI’s ability to provide such good answers to essays that they don’t know whether to grade the student or the machine. Perhaps that means using the essay as a means of assessment – in addition to the memory exam – may not be all that useful.

Let’s double the numbers of doctors and nurses in training, but understand that they will not be doing the same thing as they are now.

If AI is going to change ‘everything’ NHS exceptionalism will not exempt the NHS from that ‘everything’.