Our health service presents wicked problems

The Nuffield Trust’s new NHS reform timeline is a salutary reminder that the NHS, and health services internationally, teem with ‘wicked problems’.

A phrase originally used in social planning, this describes problems difficult or impossible to solve because of incomplete, contradictory, and changing requirements, often hard to define. Sometimes those seeking to solve the problems are also causing them. Often one wicked problem is merely a symptom of another one.

Solutions to wicked problems are better or worse, not right or wrong.

For example, how does one encourage patient choice – often to be treated near home – with the better outcomes that come from centralising expert staff? Or provide equivalent services everywhere, while encouraging local decision making?

Mitigating the resource allocation problem, from 1976 onwards, condemned medical staff in London to a lifetime of low growth, while in the north there was steady development. Sir Francis Avery Jones CBE, physician and gasteroenterologist (1910 – 1998), said that inequality is the price of progress.

The timeline shows the repeated attempts by government to solve the wicked problems of the NHS by ever changing management doctrines. Hierarchy, consensus management, general management, the market place, collaboration, competition and patient choice – is government part of the problem or part of the solution?

Financial crisis has continually dogged the service since its earliest days, when the Guillebaud report showed that the escalation of costs that seemed to threaten the service was not all that great and the service provided good value.

Sixty years later, the Massachusetts health insurance scheme introduced by Mitt Romney is leading to increased costs, but ones that seem affordable.

Solving the Nicholson challenge is a wicked problem and most ’solutions’ have been tried in the last 40 years. Few trusts can see how they can save four per cent a year but it could certainly be done as long as we accept that you can have two, but it is near impossible to have three of the triad of volume, cost and quality.

Research and operational studies show that mergers have only a limited part to play in solving our wicked problems.

The King’s Fund, a hundred years ago, achieved much with its Amalgamation Committee, and I am proud of my involvement in some London mergers that created organisations of international standing. I do not know if they saved money but I doubt it.

Recent mergers blithely assume that combining several weak and bankrupt organisations will create financially sound and clinically effective entities, and they seem over optimistic. As our American cousins say, three turkeys do not make a hawk.

However, who would want to work in a service where all the problems were tame, able to be defined and capable of rational solution? H L Mencken of the Baltimore Sun said that for every complex problem there is an answer that is clear, simple, and wrong.

The intellectual stimulus of facing daily and yearly the need to manage and improve a service teeming with problems many of which have not yet fully emerged, with technologies and drugs that have not yet been developed, and for people some of whom have yet been born, keeps us on our toes.

Geoffrey Rivett is a contemporary health historian and author of the website: www.nhshistory.net. Please note that the views expressed in guest blogs on the Nuffield Trust website are the authors' own.

This article also appears on The Guardian Healthcare Network website.