An Apple A Day

Isaac Newton’s afternoon under an apple tree shook many ideas, not least our understanding of inertia which, it turned out, was not what brought everything to a halt, but the magical something that kept things as they were until something else stopped them or sped them along. Eventually, he wrapped it up with the bit about action and equal and opposite reaction.

From my noisier garden near Heathrow, I look up and wonder not at apples falling to earth, but at hundreds of tons of steel, hurled across the sky by hot gasses streaming out behind. Which brings me to my question: What is the opposite of reactive? Is it active, or proactive, or something else? In the STP Delivery Plans, proactive care is usually the opposite of reactive care. The left side of the diagram describes what we have now, against the right side showing what we will create — reactive now, proactive coming soon.

We dislike reaction, being on the back foot, the delay, the frustration. We want to break free of the inertia, to escape the waiting while the system generates lab results or finds a bed or a place in rehabilitation. But what is the opposite of what we have now?

Oddly enough, the planes streaming into Heathrow provide a clue because landing an airliner involves estimating a landing slot well ahead of time. From hundreds of miles away, the UK’s air traffic management agency, NATS, uses small-speed adjustments to schedule each arrival; not waiting and queuing but planning and predicting. This has cut the time that aircraft loop around their holding patterns over London, and the final goal is just-in-time arrivals for everyone (

For queues, then, predictive is the opposite of reactive. Healthcare is horribly complicated, sure, which is why we must work harder rather than give up. It requires a radically new mindset to move from reactive to predictive practice, something so all-embracing that it cannot be broken down into bite-sized leaps of the imagination. It’s a bit like a country deciding to drive on the other side of the road; you can’t move the cars across one day and the trucks and vans the next.

Looking forward it seems impossible. Looking back it is inevitable. After that, it can be broken down into stages — planning for decades in primary care, or signalling ahead in acute services to open up beds or facilitate discharge. Eventually it goes back to Hippocrates and prognosis, but however long it takes us, being predictive, not proactive, is the answer. And it is something we will have to come back to over the next few blogs.