Whether its Mid Staffordshire hospital or Child P, the only thing that politicians and bureaucrats seem to be able to say is that ‘lessons will be learnt’. The problem is that learning the lessons will involve more of the same policies that drove Mid Staffordshire NHS Foundation Trust to ignore its patients in the first place: More targets to make sure that the latest ‘lessons’ really are being learnt and more pressure to become more commercially successful and market driven. 

Hearing these tired lines being rolled out yet again really is painful. The record is so worn that even the politicians seem to sense that given the complexity of our systems and the fact that 'stuff happens' it will only be a matter of time before they are wearily appearing on the Today programme or Newsnight telling us - again - that lessons will be learnt. Is there an alternative to this. Well, yes, it’s called listening - really listening - to patients, families and staff. Sounds almost as Pollyanna-ish as Alan Johnson doesn't it? So what's changed? After all when did you last hear a patient say ‘please can I fill in another survey?' or 'Can I please come to lots of focus groups?'  

What’s different is the economics of the web: cheap public voice, our increasing ability here at Patient Opinion to identify the 'thoughtfully passionate' people who, with recent experience of a service, really want to help change it, and easy tools that promote collaboration - that’s what has changed. Which doesn’t mean we've all caught up with he possibilities yet, but they sure are more interesting and likely to delivery better care right across the NHS than one more heave at 'learning lessons'.  

What might this mean for the “appalling care” identified by the Healthcare Commission at Mid Staffordshire NHS Foundation Trust? Well, here are recent three stories that we have published about the trust: Last week: Good care: no complaints.  Three weeks ago: Mixed care; worries about cleanliness persist; includes response from the hospital Last month: worries about short staffing persist: But the web offers much more than timely, human stories that get beyond the spin.  Cheap voice means cheap ways to collectivise wisdom. Done thousands of times, day in day, out this, the web gives us the new ways to really listen to patients that we need. Then perhaps we'd see the lessons that patients and front line staff saw years ago at Stafford and they could have enough traction against institutional and government pressures to get something done.  The NHS may not have caught up with the web but the web is certainly catching up with the NHS.  

We've just published a posting from someone who spent a few days on a hospital surgical ward.

It includes the following eye-witness account:

"When this very frail old woman as asked if he could pass the tea to her that he had just poured into a beaker for her, he said, 'Sorry love I am not trained for that', and just left her."

Hard to believe. Could this be the most depressing bit of feedback we've ever had?

One service user describes why she likes Patient Opinion.

It's been my lifelong ambition to get a letter in the Guardian. (I know, I know. But it has.)

And finally, after 35 years of trying, I did get one published, on the first day of 2009, about the plan (announced again yesterday) to allow patients to "rate" their GP practice on the web.

And today I did it again - well, not quite, since it is in Society Guardian, but close. This time, about feedback from users of mental health services.

Oh, one more thing.. er, there was story about Patient Opinion in the Financial Times today too.

Not a bad day.

Sitting on a working party the talk was all of governance, protocols, making sure that ‘the lessons are learned’. Life was proceeding as it has in the NHS for several decades on the general assumption that if control is good, more control is better.

This might be called the One Last Heave model of service improvement: having implemented  the 137 recommendations made by Lord Laming following Victoria Climbie’s death, and being faced by the appalling case of Child P, the system homes in relentlessly on ‘further lessons that must be learnt’, another inquiry, yet more checks and controls. One Last Heave will get us to Nirvana where bad things can’t happen. 

Such is life in an environment where systems are tightly coupled. And sitting there not doing full justice to my working party, I realised that’s been the major characteristic of the last 20 years of my life as a clinician in the NHS. We’ve been busy using the power of newly digitised practice to build ever more tightly coupled systems. More and more is governed, linked, joined up, defined, evidence-based. Variation has been driven out, and following agreed practice is valued over the exercise of judgement and discretion. 

The dream behind building tightly coupled systems is that they will lead to control, equity and cost-effectiveness. Which may be so in the short run but in the longer term tight coupling leads to rigidity, risk aversion and declining innovation. Tightly coupled systems deliver decreasing returns – every additional goal, policy, organisation, partner or issue leads to less return.  There are two reasons for this. Firstly because variation is seen as the enemy: noise, randomness, error and failure are all things to be engineered out where as in fact they are often needed to make the system work. And are an important source of insight and innovation. Second the coordination costs of tightly coupled systems rise non-linearly as the number of things to be coupled increases.  So ‘joined up government’ quickly becomes toxic.   

And now we are faced with an economic situation that gets ever more uncertain. It is unlikely that the ‘one more heave’ philosophy of tightly coupled systems will work in a severe recession. Being risk averse, relying on protocols, KPI’s and micro-management will fail in the newly austere state because such approaches deliberately exclude the variation from which the new solutions will emerge.

The answer to all this? Look for systems that have increasing returns. Google, Wikipedia, e-Bay, the web itself – all deliver increasing returns. The more people use, edit and review Wikipedia the better it becomes. Such systems are almost always loosely coupled. No body is forced to use Google, no one accredits e-Bay buyers, and there was no government roll out plan to teach teenagers to use SMS text messaging. Is it possible to build increasing return systems that help improve health? Don’t know yet, but if it is I know they will look more like the net than NICE, more like Wikipedia than Whitehall.