NHSE took the blue pill

In the movie The Matrix, where people live in a fake virtual world, Morpheus offers Neo a choice. He says, “You take the blue pill... the story ends, you wake up in your bed and believe whatever you want to believe.” But taking the red pill means you wake up in the horrifying real world and have to face the consequences.

As far as I can tell NHSE took the blue pill.

They seem committed to ignoring the horrible real world of NHS problems and, as a result, seem incapable of fixing the problems.

For example, look at the draft plan for emergency care.

NHSE’s leaked draft plan demonstrates only one thing: they don’t understand how to fix emergency care. They are still stuck in the Matrix.

There are not enough anglo saxon profanities that can express how much contempt I have for their draft plan.

According to the HSJ it proposed the following actions:

1. Improving vaccination rates and targeted preventative winter virus care.

2. Reducing 111 calls put through to 999 or directed to ED

3. Improve Hear & Treat, See & Treat, and Reduce Avoidable Conveyances

4. Reducing ambulance handover delays

5. Rapid triage at the front door to navigate patients quickly to the right care and avoid admission wherever possible

6. Getting into a hospital bed more quickly for those who need one

7. Improving access to specialist out-of-hospital provision

8. Shorter Length of Stay

9. Reduce discharge delays

10. Standardising and scaling the six core components of neighbourhood health

This is pure blue-pill thinking.

It is so wrong on so many levels that I cannot hurl enough abuse at it.

To see why, let’s start with two things necessary for good, effective strategies. A good diagnosis of the biggest cause of the problem (you can only do this if you take the red pill). And a strong focus on the actions that will tackle that problem. I’ve pointed this out a lot. Nobody in NHSE, it seems, is listening.

The symptom of the problem is that far too many patients are waiting for excessively long times to get through A&E departments. There were 1.7m waits longer than 12hr last year when there should have been fewer than 0.8m waits longer than 4hr in major A&Es. It isn’t even clear that the NHSE leadership know that the problem is in major A&Es (if this speech by Steve Powis, the Medical Director, is any guide–for critical analysis of what he said see this Bluesky thread).

Worse, the leadership have fought against any admission of the most important consequences of those long waits, a large number of excess deaths (the EMJ analysis of this was published in 2022 but the leadership denied the credibility of the results; the ONS update of that analysis published last week suggests the problem is much worse but the presentation of their results omitted relevant data as if to avoid easy comparison with the EMJ estimates). NHSE overdosed on blue pills here.

It isn’t as if the dominant cause of long waits and poor A&E performance has not been analyzed before. The team that originally delivered 98% of waits in under 4hr in the early 2000s said the primary problem was flow through beds. When the post-Lansley performance declined rapidly, several thorough analyses said exactly the same thing in 2015 (eg this). As part of the new strategy for fixing emergency care in January 2023 NHSE repeated these analyses and reached the same result. The primary cause is poor flow through beds. Attendance is irrelevant. (it might be worth noting that NHSE had to be strongarmed into doing or publishing that analysis by No. 10. It wasn’t just that they didn’t volunteer to do a root cause analysis before trying to develop a solution, they resisted doing the analysis. They wanted more blue pills.)

So, in principle, NHSE know these two truths about the causes of the problem:

• Attendance doesn’t matter and isn’t the cause

• The problem is flow through beds

These are the biggies. Some debate often claims other factors are issues, like staffing. But we have analysis of most of them and they are not big contributors to the problem (staffing levels, like attendance, have no relationship to performance across a very wide range of different staffing levels in different departments.)

So how do the 10 points in the draft plan stack up against those two, critical, facts? At least for those who didn’t take too many blue pills.

Five of the points are about reducing attendance. Some are perfectly reasonable actions that would achieve good things (who wants lower vaccination rates?). None are remotely relevant to the problem of improving A&E. None would contribute a female gnat’s testicles of better performance in A&E.

The other points might superficially look like they are dealing with the problem: Reduce ambulance handover delays; speed triage; lower LOS; speed admission to beds; reduce discharge delays. But all are either restatements of the problem or demands for improvements in the metrics that measure the problem. None are actions that might tackle the problem.

Apparently the strategy is to ignore the problem. And that is the entire strategy. The blue pills have done their work.

Fuck me this is bad.

Even if the draft is merely an outline and there is some document with scores of pages of concrete ideas behind each bullet point, this is a truly bad place to start. And the track record of those longer “strategy” documents does not suggest that longer is better. 

Here are the first steps I would take to generate improvement. Take the entire team responsible for writing or commissioning this draft and let them take blue pills so they can drink fake wine in a fake restaurant serving excellent perfectly cooked steaks. Maybe they can write off the cost of the fake reality as part of the ambitious plan to do more AI.

And find another team willing to take the red pills and solve the actual problems that continue to exist in the real world.