Joe’s View: NHS Alphabet

On his recent trip to the small Greek island of Nisyros, Professor Joe McDonald ponders on the three kings of NHS IT and whether NHSX will be able to bring them all together.

The harbour at Nisyros is only just deep enough for us to moor the yacht so we park up nervously in front of the handful of patriotically blue and white tavernas , watched expertly by retired walnut-faced fishermen on the benches that front the tiny harbour.

Nisyros is a three hour sail with a strong, hot  southerly blowing from the Greek island of Kos, where Hippocrates founded modern medicine. Local legend has it that he opened a health spa here on Nisyros using the natural hot springs that flow into the sea (in places the sea is a hot bath) because of the still active volcano that caused the island to come into being. The island is roughly circular with the steaming sulphurous volcano at its heart, its slopes spectacularly terraced with ancient olive groves and just seven kilometres in diameter.

There isn’t an awful lot to do on Nisyros and the internet suggests three things that can be done in a day trip by rented motor scooter, firstly a visit to the  crater which is fascinating and free if you get there before 10 am, the attendant who manned the ticket office didn’t arrive until after we’d fully explored the site. You need better shoes than we had, the puddles are of sulphuric acid.

Secondly, the nudist beach at Pachia Ammos was reached via a very narrow ledge with a steep drop on one side to the turquoise water and jagged rocks a hundred feet below. I was relieved not to meet more experienced nudists coming the other way. There were no passing places.

The man behind museum 

Once fully clothed we got back on the Vespa to visit the third big attraction on Nisyros the ancient fortifications above the island’s capital, Mandraki (population 682). I was gobsmacked by their scale and the amazing quality of the stonework and the fact I’d never heard of them.

You couldn’t fit a coin between the stones which were still standing two millenia after they were placed here in the days of Hippocrates by King Mausolos of Caria. Mausolos was responsible for another spectacular building project, one of the famed seven ancient wonders of the world, the Mausoleum at Helicarnassus. Yes, he gave us the word mausoleum. He also gave us the spectacular rock tombs at Dalyan in Turkey. So he created three of the world’s most technically advanced engineering projects of their time of which two are still intact 2500 years on.

Pre-internet world

Drinking a pre-dinner G&T back on the yacht and I’m thinking “how did one person run the three biggest projects in the known world across a significant geography without even a postal service, never mind the internet or telephony?”.

The internet has little to tell us about Mausolos because the technology of the written word with which Hippocrates would transform medicine was just coming into being. A few inscriptions tell us he married his sister and butchered those who were disloyal and ruled between 377 and 353 BC.

We also know that Caria was part of the original Lycian federation where the first seeds of democracy were planted and upon which the founding fathers of the USA based their constitution. The Federation (think NHS) was a combination of city states like Caria (think regional health authority) who each sent three representatives to the central meeting point where policy decisions were made and budgets allocated.

Those representatives were then given clear instructions to take back to their kingdoms and a budget to deliver, say a fort on an island like Nisyros. So what’s the secret? How did Mausolos deliver?

I would suggest he had:

1. Absolute authority to set the overall objectives
2. Total control over the budget
3. Faith in his small number of trusted regional lieutenants
4. 23 years in power
5. The willingness to delegate.

I’m pretty sure if Mausolos ever clapped eyes on his fort at Nisyros, and it isn’t recorded if he did, he would have been impressed even if it didn’t look like he’d imagined it back in Carian HQ at Heilcarnassus. He didn’t have the means to micro-manage the project to death from a distance or he was a genius at delegation. He delegated to the regions and his trusted lieutenants. They delivered solutions which stood the test of time.

The three kings of the NHS

So in NHS IT nationally we have had three kings in recent years, NHS England, NHS Digital and NHS Improvement and regionally we have been delivered a revolving shambles of governance by the Lansley reforms in which the many weary lieutenants of the various kings have attempted to deliver an incoherent vision with incoherent funding while micromanaged by a governance systems which places no faith in local NHS IT staff to deliver.

My friend Thomas Webb an independent consultant who has worked on The Great North Care Record recently recorded a video in which he describes the public service “governance cage” in which many of us are forced to live. A cage which Mausolos either understood or did not have the means to apply. Watch the pain he is feeling here.

Now I know some of you are saying that NHSX is “just another letter of NHS IT’s siloed governance alphabet” but given the state of play he took on, Matt Hancock was absolutely right to establish NHSX.

We need NHSX to take Thomas Webb’s pain away, to identify trusted regions and trusted lieutenants to deliver on clear but not micromanaged objectives. We need NHSX to have authority over objectives, standards and budget and especially to govern E, I and D. Too many kings.

The eternal balance between central control and delegation is as old as history but just occasionally someone gets it right. Mausolos? Matthew Gould? Maybe but only if he gets:

1. Absolute authority to set the overall objectives
2. Total control over the budget
3. Faith in a small number of trusted regional lieutenants
4. 23 years in power
5. The willingness to delegate.

Was it Churchill who said “Those who fail to learn from history are doomed to repeat it”?