Every year the NHS enters into long-term relationships that will shape how it operates, what it can afford, and whether its staff have the tools they need.

It calls this procurement.

And procurement, as currently designed, is one of the most sophisticated mechanisms ever built for selecting the wrong partner.

The matrimonial spreadsheet

Imagine applying this to marriage.

You publish a specification. You score the responses. You select the highest scorer. You sign a contract with a break clause.

We all understand instinctively that a life together isn’t a feature set you can audit. It’s a shared intent you have to trust. It requires honesty about limitations, commitment beyond the convenient, and the willingness to stay in the room when reality turns out to be harder than the pitch.

Nobody would select a life partner this way.

And yet this is how we buy the systems our clinicians rely on to keep people alive.

The Darwinian machine

Our CEO said something on stage recently that got a great response from a room full of NHS leaders.

‘NHS procurement is like a Darwinian machine that selects for sociopaths.’

He wasn’t being provocative for its own sake. He was describing an incentive structure.

The process rewards the companies best at performing trustworthiness rather than demonstrating it. It cannot distinguish between a supplier who tells you the truth about their product and one who tells you what you want to hear.

In fact it actively works in the opposite direction.

Honesty about limitations gets marked down. A clean tick in the box gets full marks. The supplier who says “that’s not quite the right question, here’s what you actually need” loses points for not answering the question asked.

We know this because it has happened to us.

Over the years we have lost tenders because we were honest about how our product works and why it works that way. Competitors said what the specification wanted to hear. The procurement process had no way of telling the difference.

It rewarded the performance. It penalised the truth.

If your selection process produces this outcome reliably, you don’t have a procurement process. You have a filter for the suppliers most willing to play the game. And then you give them a long-term contract and call it a partnership.

The same box. The same results.

The NHS knows what it wants in felt terms. Better decisions. More sustainable planning. Systems that actually get used. But translating that into a procurement specification requires turning something complex, evolving and contextual into a fixed list of requirements that can be ticked.

So it puts the unboxable in a box.

And scores against the box as though it means something.

The marketing thinker Rory Sutherland points out that in high stakes decisions we rarely buy the best — we buy the least worst. The familiar name. The established brand. The supplier whose size feels like insurance.

But in the NHS we have managed to break even that logic. We buy the big name for safety and do it with a blindfold on. We don’t ask about financial stability, future intent or whether the business model makes sense at the price being quoted. We ask whether they delivered what their last contract said.

We treat reputation like a tick box rather than a biography. Sometime we ignore it altogether.

And we have been using a version of the same box for twenty years. The problems it was designed to solve are still there. The systems bought to fix them are largely unloved, underused or already replaced. The specifications have been refined, updated, reissued.

The results have been the same.

At some point the question stops being “did we fill in the box correctly” and starts being “why are we still using this box?”

The scalability trophy

For too many suppliers the NHS is not the destination. It is a scalability trophy. The respectable name on the deck that makes the next funding round or the exit conversation go more smoothly.

Standard due diligence asks whether a supplier has delivered a comparable contract in a comparable organisation within the last three years. It does not ask whether a supplier will still exist in three years. Whether they are running at a loss to land-grab market share before a fundraise. Whether the contract you are about to sign is the proof of concept for someone else’s acquisition conversation.

The exiteer culture has normalised this entirely. Build it. Scale it. Sell it. Move on.

From the NHS’s perspective every celebrated exit is a supplier who decided the return on sale was worth more than the problem they claimed to be solving. Who handed your critical systems to an acquirer whose primary interest is return on investment.

By treating every supplier relationship as a transient line item on a rolling contract, the NHS removes the incentive for either side to actually invest. When you tell a partner you are only with them until a better or cheaper option appears at the next break clause, you are telling them not to plant trees they won’t sit under. You are incentivising them to extract maximum margin now because they are effectively on a temporary visa.

The NHS signed a long term contract.

The supplier signed a short term one and didn’t mention it.

Two questions that cut through the theatre

Forget the framework for a moment.

Ask the person sitting across the table: what happens to you personally if this doesn’t work?

Listen for the difference between an answer that is intellectually correct and one that has something underneath it. Someone who has thought about this problem versus someone for whom this problem has a face. A ward they’ve worked on. A family member in the system. A career spent watching the same failure repeat.

The person with something personal at stake cannot perform their way through that answer.

You will know.

Then ask their references one question nobody asks.

Not “did they deliver” or “would you recommend them.” The supplier chose who you’re speaking to. They would not have given you this number otherwise.

Ask instead: tell me about a time when something changed significantly around the contract. When the environment shifted. When the problem turned out to be different to the one you’d specified.

What did they do? Did they pick up the phone or raise a change request?

Then ask the question they’re not expecting.

Can you give me the name of a client they didn’t put on this reference list?

What a real partner looks like

A real partner is not defined by their feature set today.

They are defined by their intent. By whether they are genuinely trying to solve the problem or trying to look like they are. By whether they will still be working on the same problem in five years, more interested in whether it’s solved than in what the solution is worth on the open market.

A real partner tells you when the specification is wrong. When what you asked for is not what you need. Not because they’re being difficult. Because that’s what honesty in a long-term relationship looks like.

A real partner thinks in outcomes not outputs. Not “we delivered the system” but “did it change anything?” Not “we met the contract terms” but “did we solve what we came here to solve?”

A real partner’s business model makes sense at the price they’re charging. They are not running at a loss to acquire you. They are here because the problem is real and the mission is genuine. And they were here before you signed, and they will be here if the contract gets difficult.

These things cannot be scored on a spreadsheet.

But they are more predictive of whether this relationship will still be working in five years than anything in the standard evaluation criteria.

What we keep getting wrong

The NHS doesn’t need better specifications.

It needs a fundamental shift in how it selects. Away from the audition and toward experience, understanding, intent and stability. Away from what a supplier can demonstrate on the day and toward what they have done when nobody was watching and nothing was going to plan.

We need the courage to stop buying features and start buying intent.

Because you cannot build a ten year transformation on a relationship both sides are already planning to leave.

And our staff are the ones left living in the wreckage of the marriages that never intended to last the winter.

Disclaimer: This information is provided for general guidance only. It may not reflect the most up-to-date NHS policies or local Trust practices. Always refer to current NHS guidance and your organisation’s policies for definitive information.