A letter to the next secretary of state for healthBMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h2296 (Published 29 April 2015) Cite this as: BMJ 2015;350:h2296
All rapid responses
We read with interest the recent Editorial  and recall G K Chesterton’s observation that, ‘The Reformer is always right about what is wrong. He is generally wrong about what is right’.  So we endorse the diagnosis – lucid and persuasive – while questioning the prescription. We can understand the call for more money, less interference and, given recent history, a preference against top down restructuring and competition.
Our question is, will this be enough or is the challenge even bigger than we imagine? We know we cannot blow away bad weather simply by running our wind farms in reverse, but we seem to believe that more money with less central interference can provide sufficient motive force to overcome:
• our inability to manage demand
• our failure to develop systems that align payment to the outcomes we require
• the continued waiting and waste in too high a proportion of pathways
• the lack of effective prognostication on where most patients or services will be in a month, six months or a year – even winter continues to come as a surprise.
John Wanamaker, the 19th Century merchant, noted that half his advertising budget was wasted but that he did not know which half.  We face a similar challenge in health, aware of systemic and ubiquitous waste that all too often occurs in the very same locations as acute shortages of time and resource. How are we to channel savings made from eliminating the one problem into solutions to the other? Until we can answer this question we have no real idea what ‘proper funding’ looks like, and our only option is, like Wanamaker, to pay over the odds.
Surely this is a challenge for the whole nation, with all its resources. It cannot be solved by a single company, a single university or a single Trust, however large they become. The reason that it cannot be solved by any single organisation, is that finding a solution and its adoption at scale are indistinguishable problems. It is likely to demand research that connects deeply detailed analysis with very high-level systems thinking. It is likely to need unprecedented connections between operations and policy. It is likely to require the broadest disciplinary approach imaginable and to occupy the brightest thinkers of our era. As the Cold War and the Space Race galvanised and focused our technical thinking, and inadvertently created whole new sectors for the economy, we have to find a way of restructuring health at scale – without a destructive interlude – and reap an economic reward in the process.
We are a nation that has overcome enormous social and engineering challenges for hundreds of years and we have traditionally punched well above our weight as inventors, innovators and reformers. So what is to stop us now? That depends on how big we think the problem is. We can rise to the challenge if we think it is almost impossible. But if we think it can be solved with a little more money and being left alone, we will be writing to the next Secretary of State for Health, and the one after that, and…
 G Iacobucci, R Coombes and F Godlee (2015) A letter to the next secretary of state for health, BMJ 2015 350:h2296 doi: 10.1136/bmj.h2296
 Chesterton G K. Our Notebook. Illustrated London News. Saturday October 28 1922: 660.
 The exact attribution is contested. A quotation appears in the Oxford Dictionary of American Quotations (2nd ed) and is also attributed to Lord Leverhulme in the Oxford Book of Quotations (8th ed).
Steve Allder, Consultant Neurologist, Plymouth Hospitals NHS Trust
Sally Brailsford, Professor of Management Science, University of Southampton
Rob Berry, Head of Innovation, KSSAHSN
Harald Braun, Operations Director, i5 Health
Claire Cordeaux, Executive Director, Health & Social Care, Simul8 Corporation
Thierry Chaussalet, Professor, University of Westminster
Keith Davies, Managing Director i5 Health
Laurent Debenedetti, CEO, Gordian Laser Ltd
Mike Farrar, Independent Consultant
Paul Harper, Professor of Operational Research, Cardiff University
John King, Founder, ETHOS Partnership
Peter Lacey, Founding Partner, Whole Systems Partnership
Loy Lobo, Founder, Wegyanik Ltd
Justin Lyon, CEO, Simudyne Ltd
Adele Marshall, Professor of Statistics, Queen’s University, Belfast
Sally McClean, Professor of Mathematics, University of Ulster
Douglas McKelvie, Partner, The Symmetric Partnership LLP
David Paynton, GP, Southampton.
Adam Pollard, Research Director, Pollard Systems Ltd
Paul Schmidt, Consultant in Acute Medicine, Portsmouth Hospitals NHS Trust
Sada Soorapanth, Associate Professor, San Francisco State University
Terry Young, Professor of Healthcare Systems, Brunel University London
Competing interests: All the authors are connected with the Cumberland Initiative, a community of clinicians and clinical managers, companies and universities, with the twin aims of: • transforming the quality and cost of NHS care delivery through systems thinking, • securing significant economic stimulus through new products, systems and services. SA, DP and PS are medical doctors working in the NHS. They declare no conflicts of interest. RB is a general manager working in an AHSN supporting knowledge exchange across and within sectors (NHS, industry and academia). He declares no conflicts of interest. SB, TC, PH, AM, SMcC, SS and TY are academics whose research is primarily into healthcare technology, systems and services. As such, they apply for grants in this field, publish in this field, sometimes offer training in this field and occasionally undertake consultancy in this field. SB and TC are also associated with a company that provides software and/or consultancy or training services for healthcare customers. Apart from this, they all declare no conflict of interest. HB, CC, KD, LD, JK, PL, LL, JL, DMcK and AP run or work in companies that provide software and/or consultancy or training services for healthcare customers. Apart from this, they declare no conflict of interest. MF is a consultant to companies and agencies in the health sector. Apart from that, he declares no conflict of interest.
Re: A letter to the next secretary of state for health: the future of the NHS, the internal market and the role of CCGs
It is disappointing that the dual messages, "end the internal market" and "remove artificial boundaries between primary and secondary care" are not coming through stronger, either from politicians or health care leaders. They are there in Simon Stevens’ "Forward View" and it would be good if this well thought-through document was built on to present a clear direction of travel towards a workable solution for our future NHS.
Of course, we must achieve integration of social and health in community services for the frail elderly - as we have already managed for mental health services. We need also to provide a reasonable environment in which general practitioners can work and resolve the tensions between continuity and access, build physical activity and health improvement into our communities, and install patient-led management into our approach to long term health conditions.
The major drain on current NHS resources is the administrative and information overhead of the internal market. Small commissioning groups write detailed specifications and try to find mechanisms to review hospital returns and meaningful ways to monitor other providers. Hospitals ask staff to complete data on the wards in duplicate and triplicate, while still, in many places, struggling to install and make available the patient system.
The perverse incentives of profit-making GP groups offering specialist services while not reducing the burden of hospital referrals, and profit-orientated hospitals providing discharge teams to keep wards full all year round is the rot in our current configuration.
Where does this leave CCGs? Many are too small, have (in general) few seasoned and senior managers, and significant costs (in terms of administrative and resource requirements) fall on hard pressed GP practices. CCGs are beset by too many decision makers, spending expensive time kicking policy between committees, with few available to write detailed tenders or develop models for delivering change.
CCGs need to be bigger and properly resourced with full time and experienced non-clinical managers at all levels. They could then be well placed to oversee the morph of commissioners, public health, hospitals, GP surgeries, mental health teams, integrated community teams and primary care specialist services into one population-focused organisation responsible for integrated community, primary and secondary health services and health improvement.
Competing interests: No competing interests