Editorials

Imagining futures for the NHS

Familiar institutions might be revamped and strong 

The future is unknowable. "Nothing in the world can one imagine beforehand, not the least thing," said Rainer Maria Rilke: "Everything is made up of so many unique particulars that cannot be foreseen." Nobody predicted the explosion of the internet, the faltering of the Far East economies, or the outlawing of the communist party in the former Soviet Union. But many people have predicted the paperless office, the leisure society, and the death of the booknone of which have happened. Yet paradoxically those who look to the future flourish, and the world's biggest and most successful organisations devote resources to imagining futures. The trick is not to predict (although the first box includes some predictions) but rather to gather data on recent trends, talk to lots of smart people to identify drivers of change, and then to relax and imagine scenarios of the future. You then use the scenarios to stretch current thinking and as a "wind tunnel" to test current practices and plans: will they still work in the new world?

The NHS Confederation, Institute of Health Service Management, and International Hospital Federation have been busy imagining future scenarios for the NHS, and the scenarios are due to be acted out at the confederation's conference to celebrate 50 years of the NHS. The team creating the scenarios* identified four drivers of change and imagined two scenarios.

The first driver is the development of new technologies and ever larger amounts of information. Technology has always been a major driver of change, and the NHS's 50th anniversary coincides with perhaps the most rapid stage in the transition from the industrial to the information age. This the biggest shift in the world since the dawn of the industrial age some two centuries ago, and the middle of such transitions is probably the most difficult point from which to foresee the future.

The world might rapidly become very different. Miniaturisation, automation, robotics, mininimally invasive surgery, imaging, telecommunications, and genomics may come together to pull diagnosis and routine operations into more local settings while centralising expertise still further. In such a world district general hospitals may have no role. Patients will have access to the same information as doctors, and patients with chronic or rare diseases will regularly have more information than their doctors. But who, if anybody, will be controlling and validating this information? New media will become steadily more important, but will ownership be concentrated or scattered? The answers to these questions lead to very different futures.

The second driver is new power structures in politics, business, and communities. Largescale, producer led organisations (like the NHS) are giving way to smaller, faster moving organisations led by customer needs. The 24 hour society is arriving fast, and old patterns of class, gender, and race are giving way to new ones. Society is becoming much older. More women are working and steadily occupying more powerful positions. The "feminisation" of the NHS workforce will have implications for both the professions and management. National governments may give way to regional governments, but international groupings may become more important. What happens in the Scottish NHS, for instance, will probably be decided much more in Edinburgh and Brussels than in Londonand the Scottish NHS may become increasingly different from the English NHS.

The growing importance of our relationship to the living environment is the third driver. Population growth is concentrated where resources are most scarce, and increasing migration may be inevitable. Global inequalities are increasing. Fresh water supplies are diminishing. New diseases are appearing and old ones re-emerging. Could the NHS cope with a pandemic? The NHS will have to recognise increasing concerns about sustainability, but the role of science in this future is unclear. Will it be seen as part of the problem or part of the solution?

The fourth driver is social and cultural change: the ties which bind us in families, schools, and the workplace (the backbone of community life) will be replaced with new, possibly more fragile, relationships. The automatic deference shown towards professionals, experts, and parents has gone for ever. Instead, there will be more consumerism and greater diversity and choice. How will intergenerational conflict be resolved? How will doctors respond to patients who are much less deferential?

Using these drivers the team developing the scenarios imagined two futures in which the NHS would exist. Each world is equally desirable or repellent. Onecalled "Find my way"is a world with radically different ways of working and behaving. The other"Trust their guidance"is a world in which familiar organisations are revamped. The second box shows the broad characteristics of these two worlds.

"Find my way" is a world of individuals. People have immediate access to global information. Partnerships and networks spring up in business, politics, and peoples' lives but are short lived. There is great concern about global issues but no sustained, long term campaigns. "Trust their guidance" is a world where people get access to information through trusted sourceslike the NHSand where well regulated institutions provide stability. Individualism is weakened, and national political parties are strong. People feel secure but stunted.

In the "Find my way" world the NHS would have to work with other bodies in shifting partnerships. League tables of NHS performance would be readily available, and poor performers would find it difficult to maintain trust. Health policy would have to consider environmental issues, and decisions which limited future options would have to be avoided. Health resources would not be allocated on the basis of scientific evidence.

In the "Trust their guidance" world the NHS would have to establish itself as a trusted source of information. Many agencies apart from the NHS would pursue the health agenda, and doing something about inequalities would be important. Professionals would be trusted but only in so far as their organisations have clearly understood and effectively policed protocols. Many of the current institutions of the NHS would survive but only if they could adapt and change.

In both scenarios, the team agreed, it will be important for the NHS to secure the trust and collaboration of the communities it serves. It will have to do more than deliver a high quality service: it will have to become embedded in communities that will themselves be changing fast. This is not easyso another 50 years cannot be guaranteed. Indeed, for an institution born in the industrial age to survive in the information age would be a remarkable achievement.