The Maynard Doctrine: Goodbye to Joe Stalin! Hello Toyota and Total Quality Improvement, care of Comrade Darzi

Professor Alan Maynard OBE suggests that Lord Darzi is a well-intentioned Marxist who does not really understand quality

“If a man is not a socialist at 18, he has no heart. If he is a socialist at 30, he has no head.”

This adage from Winston Churchill seems particularly pertinent to the former comrades who now rule us, as they track even further away form their Marxist and Trotskyite origins and become what the Chinese communist dictator Mao Tse-Tung used to describe as “capitalist running dogs”!

The NHS is moving away from the Stalinist production targets beaten into the psyches of managers over the last ten years. These “targets” have now become “standards” - e.g. 18 week waits for elective surgery and 4-hour waits in A&E are now minimum performance norms.

High volumes below tariff
Their use has led to long-awaited recognition in Whitehall Village of significant, unexplained and unacceptable differences in the delivery of care due to variations in clinical practice. Enter stage right Comrade Lord Ara Darzi, an innovative surgeon interested in data and improving the quality of care he delivers to patients.

He originally rose to some fame when his clinical colleagues were proving slow and reluctant to improve their practices to raise productivity and hit the 12-month and then the 6-month targets for waiting for NHS elective care.

Comrade Ara organised out-of-hours sessions and paid the lads below the going rate to increase surgical service volume and reduce waiting times for NHS patients. His surgical comrades liked working for him at rates below those offered by the private sector because he could offer assured and steady volumes of work to stoke their wallets.

The “revisionist capitalist” notion of wallet-tickling to increase activity brought Comrade Ara to the attention of the Great Leader of the era, one Tony Blur. The subsequent Great Leader, Gordon Brown, made him a Lord and a Minister. In this role, he is seeking to translate the NHS from Stalinism to Deming-Toyota “Total Quality Improvement”.

Deming and the perils of piecework
Deming was an American who working in Japan during the post-second world war reconstruction period. He was the architect of processes in Japanese industry which focused on teamwork to ensure the efficient production of high-quality cars. The Japanese bought into the Deming ethic that quality would give them market success worldwide. History tells us that they made a wise choice, and as a result, many an inefficient (and British) producer of cars were driven out of business.

At the time, the British car industry was remunerated on a piece-rate basis i.e. operatives were paid on the basis of how many doors or wing mirrors they screwed onto vehicles. Speed was thus of the essence, just like the Stalinist targets of the NHS. In the British car industry speed meant that quality was poor i.e. doors fell off, wing mirrors dropped away and engines failed.

As a consequence, much of the British car industry was replaced by the likes of Honda and Toyota, who, by applying Deming techniques of team collaboration and pride in their product, produced high-quality cars that people wanted to buy.

Volume over quality

” In healthcare, the focus of management and clinical practice tends to emphasise volumes and activity targets.”

Sadly in most health care systems including our nice old NHS, the notion of total quality improvement (TQI) has been ignored. In healthcare, the focus of management and clinical practice tends to emphasise volumes and activity targets. As a result, politicians and regulators have found that hospitals and doctors have high error rates. Instead of doors falling off in the motor car industry, patients die or suffer increased and avoidable morbidity due poor standard-setting and even poorer policing of practice by professionals.

”The Darzi report is asking the NHS to adopt principles of action implemented in Japanese industry over 50 years ago”

Demming’s concept of total quality improvement (TQM) has now been adopted by Comrade Darzi, but with no apparent acknowledgement of its origins. Although there is little recognition of it in Whitehall village, the Darzi report is asking the NHS to adopt principles of action implemented in Japanese industry over 50 years ago.

Patients should be grateful: better late than never! And the NHS is no worse than any other healthcare system, public and private. All of them inflict avoidable damage on patients which could be reduced by better standards and delivery of care e.g. witness the tardy but welcome pressure to hit improved standards of care for stroke patients.

“Lord Darzi does not understand what quality is”

So we should congratulate Comrade Ara on his missionary zeal in advocating quality. Inevitably, there are problems. Firstly, Lord Darzi does not understand what quality is and as a consequence he needs to be sent to a party correction centre in order to be reformed so as to follow the true path of revolution

Comrade Ara seems to define quality as safety, patient experience and effectiveness. What a silly Billy! NICE has emphasised cost-effectiveness over mere effectiveness for over ten years; but the message still needs to be drummed into some party deviants from the medical faction.

As for safety and patient experience, these concepts are encapsulated in the notion of cost-effectiveness, so why witter on about them separately?

Darzi the (apparent) Marxist
The other weakness in the Darzi conversion is how do we get from here to his nirvana of clinicians being self-motivated and energised to produce long-needed and long-awaited change? Like Marx he seems to believe that once the promised land is defined, folk will flock to it. Marx was wrong, thank goodness!

How is the good Comrade Ara going to motivate the lumpen proletariat of the medical profession to alter their practices to deliver less dangerous and better-quality care to the citizens of the UK?

Pious advocacy and prayer will not get the changes we need. This was recognised by the Victorians, who, in the 1845 Lunacy Act, not only set out how to measure performance to improve quality, they also introduced fines to ensure that comrade workers in medicine were engaged in the pursuit of quality. Come on, lad! Where is the incentive structure to drive the quality changes?

The Comrades in Whitehall Village who have “progressed” from Stalinism to Demming-Toyotaism should recall one of the remarks of Comrade Mao Tse-Tung: “Knowledge is a matter of science, and no dishonesty or deceit whatsoever is permissible. What is required is definitely the reverse: honesty and modesty” (Mao’s Little Red Book, 1966, page 305)

We need to be honest and recognise that Demming-Toyotaism is not new - and that it is difficult to create and sustain. We all want the quality reforms (provided we abandon Comrade Darzi’s deficient definition of quality) to succeed, but more thought is needed about how to lead clinicians along the path of quality-orientated reform. Just believing in their good will is not enough, as we can see from 60 years of failure to address these issues successfully in the NHS and all other healthcare systems.