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The Theory of Constraints…
… no, not manacles and ropes…
… developed by Dr Eliyahu M Goldratt in his 1984 book; The Goal.
A management philosophy focused on identifying and managing the single, limiting factor or bottleneck…
… preventing a system from achieving its goal. It’s logical, common-sense and in English;
Overall performance is best achieved by maximising the efficiency of a constraint rather than optimising every other part of the system individually... fix the bottleneck first.
Simples… and why we can’t fix a lot of the productivity problems in the NHS… because no one wants to fix the constraint of social care.
It's a theory that's designed to fix existing problems... not expected to avoid new problems that an organisation busily creats for itself.
Our wanna-be-leader is determined to run the NHS from his desk in Whitehall.
NHSE disappears. Meanwhile, ICBs are reducing running costs by around 50%. Half the staff will go, in a cobbled together voluntary redundancy scheme, designed to…
… get people to leave and avoid the palaver and risk, of challenge to a proper redundancy programme based on workforce-planning and system design.
Fewer ICBs, slimmer overheads, stronger regions, tighter ministerial grip, but…
… there’s a practical flaw in the sequencing.
ICBs are already shedding staff and the VR schemes typically come with the trap of re-employment restrictions and clawback provisions.
Take yer VR payout, and yer locked out of NHS, regional or some government roles for six months. Twelve for the top brass… or you repay it.
The irony?
Regions, meant to be the backbone of the new system, wont be able recruit the very people they might need, because...
... by the time the Regions are in hiring-mode...
... ICBs will have just finished firing-mode...
Building the new model without first putting regions in place is a classic cart-before-the-horse. Designing-in a constraint we know we should avoid.
Regions are supposed to manage, support, and oversee ICBs, yet they're nowhere near fully-staffed, or ready.
Meanwhile, ICBs are being asked to shrink, cut costs, and lose experienced staff in a future system, they have no idea the shape of.
Regions need people who understand;
- commissioning,
- system finance,
- contracting,
- primary care,
- continuing healthcare,
- safeguarding and the
- mechanics of population health management... all the skills of ...
... senior, time-served people who are mostly leaving ICBs.
Hollow out ICBs without regional involvement, strikes me as creating a constraint, not avoiding it.
It is destabilising.
The logical reform should be 5 steps:
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Design the regional model in detail.
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Identify the skills and roles that need to transfer.
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Ring-fence critical expertise.
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Staff the regions…
… then, number 5, reshape and reduce ICBs.
Instead, the financial imperative appears to be running ahead of organisation-design.
Cut first. Build later.
The NHS is not a start-up that can pause operations while it restructures, because;
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Waiting lists still need managing.
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Urgent and emergency care pressures remain.
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Primary care access is politically sensitive.
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Financial balance is fragile everywhere...
... if ICB capability is thinned before regional capability is mature, a constraint in the form of a vacuum opens up, and...
... vacuums don’t remain empty. They fill, with interims, consultancy, risk aversion and delay. The centre gets dragged into operational firefighting.
Centralisation emerges by default, rather than design.
This is not an argument against reform. The current architecture is complex. Boundaries sometimes blurred. Clarifying accountability and reducing duplication are legitimate objectives, but…
… reform without choreography is not reform. It's moshing.
We’re missing a transparent transition plan. Without even draft legislation showing where statutory functions will sit, workforce planning is impossible. There is no clear protection for critical system roles.
We need a timetable that prioritises regional capability before local hollowing-out.
Without that, the risk is; creating a temporary but very real governance gap (a constraint) at the very moment performance pressures remain acute.
If regions are to be the spine of the new system, they must be built first. Not assembled from whatever’s left in the debris, after the cuts.
This is not strategic reorganisation.
It is disassembly in the hope that a new structure will somehow reassemble itself.
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