Reform and the Darzy health report

NHS reform and the Darzy health report

Like many people, I was holding my breath again waiting for another report of the ills of the NHS, but with the experience of being let down each time.
The Darzy report does not hide from uncovering the issues Darzy believes the NHS faces. The report has gone into depths that have previously been hidden, and that is welcome. It is scathing, and reflects what many of those in the NHS have been saying for a long time.
However, the report does suffer from a flaw and that is that the review has been conducted from the perspective of the NHS, retaining the current principles that its design rests on. Those principles are the mechanistic paradigm of a central health organisation that processes people through it. Health is far more than this. Having said that, the report does identify some of its underlying principles,  but it could and should go further:

• the problems of quasi-markets and privatisation, highlighting the fragmentation due to commissioning.
• It does talk about it being about people working together, but it fails to mention the causes of why they are not working together.
• It does mention some of the issues when it suffered another blow with the Health and Social Care Act 2012.
• It does mention leadership but in the context of capability and skills, not the real issue of the leadership style that is caused by the current system paradigm.
• It does mention the terrible state of working in the NHS, but it does not recognise the piece-meal task based roles that de-humanise the work.
• It mentioned accountability, but fails to highlight how the current system has drained ownership.
• It does not recognise that one major reason that demand is increasing is because much of that demand is failure demand - created by the way the NHS is designed.
• And lastly, it does not mention how the focus of managers and leaders is on cost and measures, rather than recognising value and the causes of cost.

There is little in the report that would address these.
In the end it gives some good behaviours that would provide a better NHS. But it does not recognise the reasons why they are not there today. The barriers to good working that are in place today need to be highlighted and banished. And it is the remedy that we always miss the point.
Ultimately, where is Darzy pointing towards. Him primary tenants of change are technical and improvements to the current way of working. This is not wrong when we are facing a crisis, we need rapid improvement. However, we also need real reform. And real reform can only occur when we can understand the whole of health and the NHS as a system. Wes Streeting, the Health Secretary does highlight three shifts that are needed:

• from hospital to community care
• from analogue to digital
• from treating sickness to preventing it

He recognises short term and long term reform. 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 highlights the causes of cost, rather than simply focusing on cost, so where are these causes recognised? There is only partial understanding, and little knowledge of how the whole works together to create a dysfunctional system. 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.

The mindset for reform

Darzy's traditional paradigm is clear from the report, and also some of the wording that highlights that paradigm:
‘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.’
His mindset is still lingering in Command & Control - or New Public Management, which was still the predominant paradigm when he was in government.
Looking at the concept of the systems thinking iceberg, 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. The Darzy report begins to reject some of those principles, but it offers no alternative. Infact it potentiality retains some of those principles. 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.

• Standardised work flows
• People treated as fixed roles in a standard system
• Managers know best, and they use dashboards of measures to evaluate performance
• The end to end flow of work is functionalised into specialisms
• The focus is on outputs, with actions to improve based on fixing problems
• Competition drives good behaviour
• Improvement is via functional cost reduction

The next steps for reform

The '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. And much of what we know is not in the report.
​This example is of a reform prototype that was performed by avoiding any of the rules, structures and procedures of the current NHS. And this is what they achieved: 

• The number of assessments, down 64%
• No of people involved end to end, down 32%
• No of referrals, down 41%
• Total number of hours spent on the cases, down 14%
• Face to face time as a percentage of total time, from 46% to 60%
• Estimate of that demand returning into the system, from 71% to 0%

​Integrated health & social care case study