It’s a garden not a factory

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I sometimes think the NHS has thought of itself as a classic manufacturing process, or at least some people have used that model to try and understand and operate it.

Paul O'Neill
Paul O’Neill

Not that they believe we are manufacturing widgets, but their mental model, their paradigm is that of a system with inputs (sick people) and outputs (people who are either much better, more ill  or who sometimes die despite best efforts) and that everything that happens in between is a process. Classically in manufacturing every stage of the process ‘adds value’. Different stages need different skills and ‘things done’ before the item in question passes onto the next stage and so on through the onward journey until it leaves the factory.

The job of the workforce/managers in this is to be as efficient as possible, follow standardised operating procedures where they exist and continually refine and improve the processes and procedures, reducing errors down to the absolute minimum and using ever smarter methods to get the flow just right and keep costs down and quality up. Nothing wrong with that – as far is it goes.

Now, I don’t believe anyone thinks healthcare is that simple, they know we are dealing with people who are complex but I do think we have been guilty at times of transposing that model onto reality and expecting (hoping?) it would work and left feeling dumb-founded when it doesn’t.

What if we held a different paradigm and thought of the NHS more like a garden than a manufacturing process? There is still a huge role/necessity for some landscape design. They should determine the overall shape, look and feel of the place and put the trees, vegetable patch, and flower beds (primary care centres, hospitals and community services) where they will thrive the best and where they are needed most.

Exactly what happens then is a bit out of the control of the designer, and over to the gardeners and the plants and conditions themselves. Some plants will grow as expected, others will grow bigger or look different than we expected – but that’s ok. In some areas of the garden the plants will thrive and self-seed in others growth may be stunted and the plants will need some extra help. The gardener could try a few things to try and make it better. More nutrients to the soil perhaps, prune some neighbouring plants to create more light so that the struggling plants can grow?

Now, before I get carried away with this metaphor what am I really saying? The NHS is complex and varied. The thing that makes it work – or not – is largely down to people who are living, thinking, feeling, ambitious, creative, brilliant, flawed, imperfect and illogical beings. To be the best they can be they need nurturing and nutrition and the conditions they live and work in need to be at least good enough. Sometimes the reason they don’t flourish is because of where they are positioned or the conditions they are trying to live in are just not right.

The landscape designers need a deep understanding of how things grow even if they aren’t doing the day-to-day tending. If the flowers aren’t growing, issuing instructions or shouting at them to grow straighter, taller or with more colour is as futile as it sounds. It doesn’t matter who does the shouting or how loudly, it’s still futile. You need to tend to the conditions (culture and resources) and try a few things that should make it better, accepting that whilst it should work it might not – try something else if it doesn’t.

Finally, take a step back, not everything in the garden is rosy but overall it looks great doesn’t it? Do some weeding by all means but don’t lose sight of how beautiful it is and the wonder of its potential.