Chris Lancelot: Let the NHS evolve to become better and brighter

I've been reading Tim Harford's new book Adapt: why success always starts with failure. It's an eye-opener, with massive implications for healthcare.

The GP Record, by Fran Orford
The GP Record, by Fran Orford

Harford, an economist, applies both evolutionary theory and psychology to economics and decision-making. His conclusions make for stunning reading - but, like all good science, it all looks so obvious once it has been pointed out.

His thesis involves two major insights. The first is that companies and organisations evolve - and, as with species, they mainly do it by tiny steps, mostly randomly. What works is kept, what doesn't is eradicated - in the case of companies, by being taken over or going bankrupt. Economic evolution happens best where there are many different opportunities for variation; where the survival of the fittest is accepted; and - crucially - the weakest are allowed to fail.

His second point is about accurate feedback. Evidence-based decision-making is vital in a healthy organisation. It is all too easy for those in charge to be cocooned from reality if the information they receive is inappropriately filtered - often by subordinates who don't want to be the bearers of bad news.

Although Harford doesn't specifically mention the NHS, the implications for it are clear. The NHS is a classic contender for an inefficient and non-adaptable organisation: it has many layers of bureaucracy which interfere with accurate feedback, it is centrally driven and it tries to be uniform.

If it is to evolve, to adapt, to become more cost-effective, it must be prepared to allow local variation and to assess the results objectively.

We all talk about the 'postcode lottery' as if it were a bad thing: it doesn't have to be. A specific local change may be the prelude to a massive improvement in the quality of healthcare nationwide - but we won't know until we take the risk and let it happen.

An NHS which is totally homogeneous cannot spontaneously evolve. It needs to adopt evolution's tactics: to allow - indeed, encourage - local variation and local experimentation, but like evolution, to be prepared ruthlessly to cull those many variations that don't deliver. Propping up failures isn't an option.

Do read the book: it is well written, evidence-based and mind-blowing.

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