Change is once again afoot in the NHS. Medical professionals, policy experts, and the closely watching general public know that our health service is no stranger to reorganisation.
But some things never seem to change. No matter what reform programme is under way, and whether or not we are in the throes of a global pandemic, some challenges seem to be perpetual. The NHS always faces staff retention and development challenges, must absorb a demand crisis every single winter, and is perpetually striving to become more internally joined-up and externally collaborative with other public services. Why?
From the outside, it at times seems that the NHS is placed in an impossible position. It must offer a universal service with fiercely protected standards and ever-improving outcomes, it must form the front line in moments of acute national emergency, and it must pay more attention than ever to the specific needs of the places and communities it serves in order to become more human, preventative, and collaborative.
Responding to all this can make healthcare seem, in financial terms, an insatiable black hole. The pursuit of doing more with less is surely unsustainable without a radical change in approach.
The most extraordinary asset at our health system’s disposal is its staff. But the NHS is so large and complex that it generates major knowledge problems. The information relevant to major decisions can be widely distributed. The specifics of different contexts often make one-size-fits-all policies untenable. So all the relevant knowledge cannot plausibly be commanded by a single centralised decision-making structure.
Rather, NHS staff all over the country are the ones who hold the individual pieces of the puzzle.
If we take this challenge seriously, what could new models for the NHS look like?
The Nobel Prize winning political economist Elinor Ostrom could offer us the key. In her ground-breaking research, she brought the idea of the commons into the policy mainstream. She proved that, at appropriate scales and with the right conditions in place, our most important assets will not be abused by the communities that depend on them but sustained and strengthened by them.
Ostrom found examples where, because the community itself has skin in the game, and incentives to work together to get the right outcomes, the commons outperforms both state monopoly and the competitive market. This holds true from irrigation systems in Nepal and lobster fisheries in Maine, to systems in Switzerland, Spain, and Japan that have functioned for hundreds of years without any external oversight whatsoever.
What if not only integrated health and care in particular places, but the time and expertise of our health system professionals themselves, could function as a self-governed commons?
Our health service already represents a very different economic sensibility than that which dominates in the private sector. And, with the emergence of integrated care systems, there now appears to be a conscious effort to escape the ‘economies-of-scale’ obsession that is the hallmark of heavily centralised systems. Rather than competing for efficiency or another central command-and-control performance drive, the NHS is looking to new models. This time, the change must be meaningful.
The Hexitime time-banking approach provides a clue as to how such new models could function in practice. It works by establishing a platform where the ‘currency’ is the precious time of all the participating professionals. The time of one participant is compensated reciprocally by ‘credit’ to make the most of another participant’s time. An hour of direct contribution to a new project might be ‘paid back’ with an hour of learning from someone in a very different role.
This suggests the potential for a genuine, self-organising community of practice for healthcare professionals. Their skills and insights are respected, and their further development facilitated. These connections are equalising, too. A senior manager can use the platform to learn from the front line, making relationships more horizontal. And as participation grows, the prospect of using this platform to strengthen place-based approaches and deepen collaboration with NHS-approximate public services is enormous.
For a vast institution in the market for new operating models, these are the kinds of approaches that can fuel internal transformation. A community of practice that can cut across the whole institution, breaking down unhelpful walls within and around the NHS, and establishing incentives for learning and leadership without fracturing its fundamental values.
In the New Local think tank’s recent analysis of Ostrom’s scholarship, her overarching insight was summarised as the capacity to ‘think big, act small’. Time banking creates the conditions for the thousands of small-scale actions that can add up to a major transformation. This approach also reflects a significant finding from the pandemic – that people will use the time available to them to mutually support one another. Not a transactional relationship, but a reciprocal one.
Perhaps by fostering its communities in a sustainable, self-governing way – the local communities needed for integrated, collaborative care, and a system-wide community of practice – the NHS can explore what a modern service can be. When must it work nationally, and when locally? How much can it afford to ‘live online’, and how much must it operate in real touching-distance of the people it helps? These are complex policy questions – and they should be considered by whole communities, not locked-away decisionmakers.
The NHS is no stranger to reorganisation. But a different model beckons: one that values the time and expertise of staff, and enables them to solve knowledge problems and collaboration challenges across the country. Learn the lessons of Elinor Ostrom, experiment with how the system works, and the next change can be truly meaningful.
Dr Simon Kaye
Dr Simon Kaye is Senior Policy Researcher at the think tank New Local. His research and commentary on politics, economics, localism, and governance have been widely published. He is the author of Think Big, Act Small: Elinor Ostrom’s Radical Vision for Community Power (2020).
Declaration of interests
I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: None.