Will the NHS strategic plan benefit patients?

The first principle of the Toyota way, one of the world’s most successful management systems, is to base decisions on a long term philosophy that generates value for the individual, society, and the economy.1 The new strategic plan for the NHS (which, although often called the Darzi report, results from a year long strategic planning exercise involving thousands of NHS staff) is of international importance because it reaffirms the long term philosophy underpinning the original service, to offer comprehensive care free at the point of delivery.2 3 That philosophy provides the most powerful basis for meeting the health needs of a society in a fair and fiscally disciplined way, especially in the face of increased inequality, rising expectations, advances in technology, and an ageing population.4 The NHS puts to shame American access based on insurers’ ability to select out risk. The American non-system of competitive commissioning and corporate provision has maximised prices and inefficiencies. About 35% goes to non-clinical expenses. Copayments, top-up fees, and limits on service cost patients thousands a year if they become seriously ill. My father had a bad fall, and home care is costing him $8400 (£4200; €5300) a month from his savings. Beyond affirming a solid, long term philosophy, however, the final report of the NHS next stage review does not reflect the 14 principles of “the Toyota way” to manage an efficient and successful healthcare system. Three of its principles, for example, involve thoroughly discussing and considering all sides of a change before introducing it. Careful testing and visible measures of performance must be combined with a culture devoted to identifying problems, analysing their causes, and tackling them before proceeding further, not unlike good clinical medicine. Instead, the NHS strategic plan begins with an eight page summary letter from Lord Darzi that proposes 33 changes in three loosely constructed clusters. Additional changes appear in the three core chapters on quality, but none of them to my knowledge has been carefully considered from all angles or thoroughly tested. Each is presented as a good idea that will be implemented, then on to the next good idea. Here I will focus on four thematic issues: the continued and costly pattern of “ redisorganisation” caused by too many changes not well thought out; the contrast between constant politicised change and experienced clinical leadership; four proposals in the quality chapters; and the future of commissioning.