NHS reform and relational public servicesLike many people, I was holding my breath again waiting for another report regarding what should happen with the NHS The Darzy report and now the 2025 plans paint a picture of both crisis and solutions. The three key primary strands are:
And we can add to that, multi-disciplinary team in localities, working across the public sector. Here we recognise both short term and long term reform. However, words of warning; The reliance on digital as being the saviour - why have we not learned the less from so many failed attempts at real improvement through digital? But the common patient record is a potential threat to real change, it was tried once and resulted in the largest ever failed cost in the public sector. The problem lies in attempting to tie everything together when they are not designed to do so. When in fact the patient record problems is one far bigger than simply a new implementation. It will also hardwire in centrally designed flows of work that are highly inefficient, thus making change even more difficult. Systems thinking allows us to shift our perspective from the traditional machine based paradigm, to other perspectives where we can see things that we could not see before. Systems thinking uncovers the fact that health is about creating value, and the determinants of health lie outside the medial health system. So rather than cutting costs, we have to highlight the causes of cost. To make this happen, we need to do something that our current health system is very poor at doing; It is still very much the parable of the six wise men and the elephant, each person recognising their part of the whole system and none recognising the elephant. We need to start with the whole elephant.  The mindset for reformDarzy mentioned; ‘A core tenet of industrialisation that transformed our prosperity in the 19th and 20th centuries was increased use of capital relative to labour to drive up productivity. In recent years, it appears that the NHS has been subjected to a kind of capitalism-in- reverse: forced to increase labour relative to capital, rather than the other way round.’ The danger is that our mindset is still lingering in Command & Control - or New Public Management, which is still the predominant paradigm in government. Looking at the concept of the systems thinking, the deepest roots of how an organisation is understood is down to the mindset of those that make the decisions. Traditionally, our organisations work through Taylorism, or as some call it, Command & Control. This is not one thing, but a myriad of beliefs about how organisations work. If we look at the changes Thatcher put in, they were underpinned by one set of principles, which we now call New Public Management, NPM. Everything that has occurred to the NHS since then, has been in line with those principles. Reform needs us to challenge those principles, and offer an alternative. We know this because up until now, we have simply attempted to place new approaches into the current NHS system. So, no matter what improvements are made, the principles will ultimately dictate the fundamental design and behaviour. This analysis is the result of many interventions where alternatives to NPM have occurred, and the results studied.
The next steps for reformThe 'health system' is not in fact one thing, but a collection if many and complex systems. We need to start by recognising that when we put it all together and thought off it as one system, we have already design it in a way that causes it to fail.
These are highly complex and interrelated systems. As with any complex system, and to avoid the mistakes of the past, we need to try things out to discover what works, and what does not work. What we need next is to create new systems with those that work in them, and with patients. For those of us looking with systems thinking lenses, and that have tried out systemic approaches in the NHS, we know what needs to shift for true reform. This type of transformation is exemplified by approaches like Human Learning Systems, and the growing body of thinking and designing called relational public services. . Using these methods we can highlight an example is of a reform that was performed by liberating staff from any of the rules, structures and procedures of the current NHS, and replacing them with relational principles. And this is what they achieved:
Integrated health & social care case study
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