If the National Health Service was used as the model for how to run Marks and Spencer, what would their stores look like today?

[This article is based on one I wrote in 2018 and which was published in the UK’s Health Service Journal (https://www.hsj.co.uk/service-design/what-if-mands-was-run-like-the-nhs/7023058.article). This rewrite has been produced with the help of a professional writer and friend, Sue Williams (https://suewilliams.com.au/).]

It’s an illuminating thought. 

Staff in one shop would never be able to cover a shift in another, as they’d have to wrestle with several disparate computer systems and unfamiliar working practices.

And what would they be selling anyway? They’d all be offering different ranges of goods, and you wouldn’t find that out until you visited the store.

When they had similar goods, it’s unlikely there’d even be agreement on what they are called. What’s called a pie in one store would be called a flan in another, and their contents would differ too.

After 37 years with the NHS, latterly as the head of information and statistics for Northumbria Healthcare, I’ve learned  – from collecting data, producing statistics, studying the organisation of care pathways and how clinical computer systems should be implemented – exactly how the NHS works – and sometimes doesn’t.

It’s often confusing for onlookers, but the M&S analogy can shed much-needed light on the complexity of the structure of the NHS, and the hurdles to integration we face within it. Understanding those is the first step in trying to solve the problems and creating a better health system for both patients and taxpayers.

Many of the issues, as we celebrate the 70th anniversary of the NHS, are a direct result of both local and national histories. At the start of my career in the early 1980s, every health authority had its own logo, and so the variation was explicit.

When Margaret Thatcher introduced the purchaser-provider split in 1991, every purchaser and every provider created their own logo, and so there were hundreds. They reflected the variation in management cultures and computer systems for example.

It wasn’t until 1999 – after the 50^th anniversary – that the now familiar, and much-loved, blue-and-white NHS logo was introduced, in place of the hundreds of different logos.

But while that might have confirmed that the NHS is a national service, the constituent organisations underneath still have their own cultures, care pathways and vastly disparate computer systems. The NHS may be nationally funded; it has still never been fully integrated.

The problems are at both ends too. To go back to running M&S like the NHS, issues would also multiply at the top of the company, with bosses at head office not quite appreciating the extent of the huge variations between stores. They might conclude – quite unfairly – that one store isn’t selling enough flans, as its computer system and processes work differently. Another might look as though they’re not making enough pies for the same reason.

In medical terms, hand surgery in one trust is done by orthopaedic surgeons, but by plastic surgeons in the next. An electronic referral from a GP for a suspected basal cell carcinoma will need to be made to the dermatology department in one trust but to the plastic surgery department in another.

If M&S were publicly funded and supplied goods free to customers as per their needs, it’d be subject to a great deal of public scrutiny. Journalists and politicians would bombard it with requests for data, but it would sometimes be impossible to interpret the results as they’d reflect different interpretations by each store.

And even if outsiders got the wrong end of the stick, the adverse publicity – however misinformed – wouldn’t stop the company being remodelled with new policies in response.

M&S wouldn’t be able to issue store cards, because there’d be no central function to coordinate them. The only solution would be for each store to run its own system. That wouldn’t be seamless either. Customers would have to identify themselves to each cashier and hope that the ‘points’ were allocated to the correct record (and not that of another shopper with the same name).

Front-line staff in big stores (like those in hospitals) could be too tied up collecting statistical data about each customer to properly service the store. Other staff in smaller stores (like GP practices), might be better off, not under so much pressure to supply information to head office.

But conflict would still be felt through every corner of every store with the constant clash between the interests of the patient and the taxpayer.

People who have worked a long time in the NHS implicitly understand the complexity and the reasons for it, but most people outside simply can’t comprehend why it doesn’t work better, and isn’t more joined-up.

Understanding the history and complexity, however, is the first step towards improving the NHS. And, who knows? One day it might function just as smoothly as the stores that survive M&S’s own restructuring.

The views and opinions expressed in this article are personal and are not necessarily those of Northumbria Healthcare NHS FT.