In the race to the future bet on citizens, not organisations.

There is a deep asymmetry between the demands on the NHS and the demands on patients in all three areas of governance, procurement and regulation.

Governance is hard – but only for the NHS. For citizens it is a doddle. Who cares how I use my Fitbit?

Procurement is a nightmare for the NHS. For citizens it is a consumer experience and a trip to the Apple store.

Regulation is a knotted mass of conflicting accountabilities for the NHS. For citizens it is just part of the terms and conditions and who cares about them?

The NHS is continually constrained by the genuinely hard problems of:

  • Information governance: how to balance the need to share data against justified privacy concerns
  • Procurement: what is the best way to buy health services? For a £120 billion industry that can account for upwards of 30% local economic turnover in deprived communities, this is a non-trivial problem
  • Regulation: health services are subject to multiple conflicting accountabilities (to patient, profession, organisation, quality, financial efficiency, education, research, local community etc.) These accountabilities lead to a knotted mass of conflicting regulatory regimes.

These genuinely hard problems also become the focus of those internally who wish to resist change and those externally who are fighting wider political battles around say privatisation or privacy.

One way of understanding these differences is that NHS systems need to be tightly coupled: people, things and actions all have to be lined up in the right order in an operating theatre if death is to be avoided. By contrast citizen and online patient systems are loosely coupled: no one dies if they don’t join Patients Like Me (or any other online health community). Patients don’t, ultimately, have to take as much responsibility as does the health service.

The net effect of all this is that it creates a huge barrier to anyone wanting to move seamlessly between the world of patients and the world of the NHS. Entrepreneurs complain endlessly at the slow pace of decision making (all those conflicted accountabilities at work), and the ‘last mile’ of connection into NHS IT systems is immensely hard to overcome as all that information governance (rightly) swings into action.

One possible solution to these barriers is to focus on patients rather than the NHS – after all if citizens are investing in IT ten times faster than the NHS and if governance, procurement and regulation are all much easier for patients, then what’s not to like? However there are two related problems with this approach:

  • The NHS is where the money is so online organisations frequently turn to face the money and end up trying to sell stuff to the NHS
  • The NHS is where the patients are: if you really want to change things for lots of patients then you may have to engage with health services.

So anyone in the online health world seeking permanence will tend to be drawn inexorably into the tangled thickets of the NHS, and in this way their attempts to create governance structures will be unwound.

The emerging counter-point to this can be seen in the new digital apps that are emphatically citizen-facing. Whether they can prove themselves beyond the world of fitness and deliver value day in day out to people with long term conditions is a key question for the next few years.

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