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People often ask me (OK, someone once asked me), ‘do you have any examples of clumsy solutions?’ A clumsy solution, as you will recall, is one which engages the active paradigms (egalitarianism, individualism and hierarchism) of cultural theory (as well as being aware of the ubiquity of the fourth paradigm, fatalism). In his book ‘Organising and Disorganising’ Michael Thompson offers the example of the successful relocation of Arsenal football club, involving as it did an alliance of the hierarchical actor (Islington Council), the egalitarian (the local community) and the individualist (the Club itself).

I will offer a much bigger, and more controversial, example: the NHS. Benefiting as it has done from several years of growing revenue and capital budgets the NHS is in pretty good shape. Long waits – for decades the public‘s greatest complaint - have been abolished, outcomes are improving in key treatment areas such as cancer and heart disease, and patient satisfaction levels are at an all time high. Despite the flu, the weather and the norovirus, another winter is passing without the kind of crisis we used to think inevitable. The test will be when the flow of cash starts to slow down next year but there are reasons to believe the NHS has developed broadly the right balance of change levers.

Of course, there is no shortage of hierarchical levers in the form of targets, regulation and expert frameworks. But the individualist devices of competition and patient choice are also embedded with, for example, more and more patients being aware of, and taking up, choice. The possibility of individual budgets for those with long term chronic conditions could bring another individualist driver into the system. And the recent Darzi review, with its recognition of the need for local discretion in developing health strategies and closer local collaboration between the NHS and local authorities, provides an avenue for benign forms of egalitarianism, focussed, in particular, on addressing public health.

More evidence that the balance of drivers may be broadly right can be found in the modest tone of the Conservative critique; a long way this from the hyperbole of Labour 1997 pledge to save the NHS and its subsequent disastrous dismantling of the internal market (only for it to be rebuilt five years later).

In a huge enterprise like the NHS clumsiness is a framework, not a solution. The inevitable dilemmas of the health service – national accountability versus responsiveness, integration versus competition, public health versus the medical model, and (the most difficult of all in years to come) universalism versus patient empowerment, will continue to create challenges for policy makers, managers and clinicians. These dilemmas will never be resolved but if the NHS continues to be a clumsy system they can be the context for, and not a barrier to, further progress for patients.


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