All the difference in the world: the simple hard v the complicated easy

With an election in the offing there are even more commentataries on the problems of the NHS than usual.

There are the  party political pieces of course, and with the depressing convergence of political left and right  it is perhaps not surprising that these are now so similar it is hard to tell them apart,

And then there are the logically argued, seductively compelling perspectives of the big three NHS think tanks the KIngs FundThe Health Foundation,  and the Nuffield Trust. Not to mention the widely acclaimed Five Year Forward View

With such intelligent, well informed thinkers earnestly seeking plausible ways forward we might reasonably expect that within these or between them we might find some answers to the problems of the NHS.  But any of us with a sense of history will recognise almost all the solutions presented here. We’ve seen them in different guises and under different titles in myriad reports and strategies over the years. We recognise the same calls for changes in behaviour and culture as before, and note that these have never yet been achieved. We wonder wearily what will be different this time.

This is because, like all their predecessors, these authors all start in the same place, they look at the NHS as an entirety, they see it like this

photo 3


And if we look at the NHS as an entirety we always tend to think in langauge like this





But if, instead, we look



we see things very differently. If we look inside the NHS instead of at it we don’t naturally use that language – unless we are persuaded to by reading these analyses.

Here is what I see when I look inside the NHS.

I see the NHS full of good people (not saints, but people who are competent, rational and well intentioned)  – as well as a few not so good. Good people who cannot be as effective as they wish to be, and who feel part of an organisation that isn’t offering the kind of care they want it to. As a result they feel helpless, or angry, or just plain exhausted as they focus their attention only on the immediate workload in front of them.

So if we start here, we ask ‘how is it that good people can’t be as effective as they want to be?’ – and then we do something about it.

After all, if they were all able to be as effective as they want to be, NHS productivity would increase by percentages that those looking at the NHS as a whole can only dream of.

I suggest there are five reasons and that they can all be tackled simply and cheaply.

Here are my five observations.

One. People cannot engage effectively with the other people who will need to be involved if they are to offer good care. They cannot delegate to, negotiate with, rely on, refer to, supervise, influence, support, challenge, enable, persuade or enthuse the people around them. Nor can they respond in constructive ways to others attempting to do this. (They are particularly bad at dealing with those individuals who have lost all motivation and make life difficult for everyone else).

As health care (at every level) is a collaborative activity these abilities are crucial, even fundamental. But in health care we have great differences in social status between those involved, and when a workforce incliudes some of the highest status professionals in the country then our natural instincts for healthy interaction are inhibited. So unless we take an active interest in how well everyone is able to engage with others we condemn the NHS to being less effective and productive than we need it to be.

Two. They (we) don’t realise how we ourselves are contributing to the problems we experience, because we don’t see the wider picture. We see a narrow picture which allows us to criticise and blame others, and in which we fail to recognise the number of unwarranted assumptions we are making.

In other words, we don’t grasp the complexity of the situation and our own contribution to it. We don’t realise how we ourselves are contributing to the problems described by the people looking at the NHS as an entirety.

Three. We aren’t able to respond constructively ‘in-the-moment’ to the people and situations we face, so we compund problems instead of resolving them. We don’t respond with courage, integrity, concern, discretion and compassion, because we don’t know how to resource ourselves enough emotionally to be able to do so. Instead we so often respond with blame or shame.

Four. We ask ‘what’s the matter with this patient?’ rather than ‘what matters to you?’. We care for people (‘you have condition X for which the evidence based best treatment is Y, and I will fight to ensure you receive Y’) rather than caring about them ( ‘I care about what matters to you and will try to address that, this will often but not always include Y’).  We have a natural ‘provider focus’ which is so pervasive and deep-rooted that we genuinely believe we are doing the best for our patients (since we are dealing with a clinical situation that we understand better than they do) without investigating what kind of help they want from us. And we can be amazed to learn how patients view our contribution. Once learned though this shift of focus allows us much greater satisfaction as well as less squandering of resources.

Five. We have very little sense of personal agency beyond our technical skills and arena. We often choose to try and progress in our careers by furthering those technical skills rather than by expanding our ability to influence events. Crucially we have no sense of the possibility of taking action to achieve what we care about – we have no idea how to devise and enact a personal strategy for achieving this, or even to feel we have a right (and responsbility) to do that. Indeed we rarely articulate to ourselves what it is we do care about.

I’m sure you can see that these are all a cause and effect of each other. So we would need to do something about all of them. And we could. None of this is complicated. None of this requires long training programmes, or degrees in managment. All of it is simple.

Simple to teach and to learn. Simple to describe and to undertand. Yes, hard too, in that  it requires sone courage to put into practice, but we can help with that too. This would require determination rather than lots of money. The complicated easy – all those grandiose strategies – are what cost the money. This requires a generous cast of mind rather than deep pockets, And the more we tried it the more able we would become, and eventually we would find this second nature.

Please, please do not even think about calling these competences. Or of drawing up a competency framework, or of checking to see if they match any currently in existence. These are the antithesis of competences. They are ways of being that rely on (and support) ways of feeling, they are embodied behaviours.

I would go so far as to suggest that the whole concept of competences is causing a lot of our current problems.

How can we meet the challenge so clearly described by those who look at the NHS as a whole: the flat-lining of financial resources meeting increasing demand? Not by expensive strategic reconfigurations that will go the way of all their predecesors in costing huge amounts and delivering only the same behaviours and productivity. No, the only way is to help the 1.4 million people who ARE the NHS to be as effective as they want to be.

When we can all Engage effectively with others, Grasp the complexity of the situation and see how to contribute rather than compound, Respond wholeheartedly and constructively in-the-moment because we feel emotionally ‘full’ instead of empty, Care about what matters to our patients and colleagues, and experience a deep sense of personal Agency (this is what i care about and this is how I’m bringing it about), then we will all flourish and so will the NHS. Properly supported, challenged and enabled, people fly, they come into work wanting to be there and looking for ways of doing things better.

To help me remember these five I regroup the five blue letters into an acronym: GRACE. And i recall a saying I probably misremember from years ago that ‘people don’t do things that are right or wrong, they just act with grace or without it – they are graceful or graceless’.

So perhaps what I am suggesting is that the NHS we need is this one


photo 5

A graceful one.


And what am I going to do about it? Where is my own sense of personal agency? Well, I confess to despairing of most of the leadership programmes currently on offer for the NHS – with their emphasis on competences and on addressing the ‘complicated easy’ solutions of those who look from the outside in at the NHS as a whole.  My own belief and experience is that what makes a difference is helping people  with the simple hard, with these five components (GRACE) of changing the NHS from the inside out. So I am aiming , over the next few months to put my own teaching materials in these areas on this site for people to use freely wherever in the NHS they  are.

And if your sense of agency prompts you to offer to help(!) I woud love to hear from you!

5 thoughts on “All the difference in the world: the simple hard v the complicated easy

  1. Valerie James

    This is a laser sharp analysis and pragmatic response to the perennial issues haunting the NHS. Valerie Iles’ clear thinking and feeling (she does these simultaneously and that is rare) cuts through the crap and shows us that there is hope, and we have what we need if only we can see and feel more clearly. It’s group capabilities, not individual competencies, that makes the difference. I utterly agree with her that senior leaders should not be cardboard cutouts from a flawed set of competencies. The literature is clear: we need diversity for innovation, not robots. We need leaders at all levels of the organisation, and from within our patients/service users, and we should give them the mandate and space to co-create. We need multiple perspectives, local responses and to stay open the patterns across the most complex and largest organisation in the western world – so that we see the big picture at the same time as we see the local versions of it.

  2. Anne-Marie Archard

    I love the simplicity of this approach, and believe that at the London Leadership Academy we use many of the same principles in our approach. Would love to discuss further with you Valerie.

  3. Charlotte Moen

    I think we are ‘singing from the same hymn sheet’. We have developed an ‘inside-out’ approach that challenges our students to explore their leadership paradigm and to consider how their paradigm impacts on their attitude and behaviour. We also explore how mood impacts on attitude and behaviour and students reflect on how they impact on their team, organisation and culture. They do this though the insight gained from various self awareness tools such as EI. We also encourage students to develop their own leadership personal mission statement (links with your personal agency). The focus is on interdependency, appreciative inquiry, developing an open learning culture and collective leadership based on a principle-centred approach. We would love to discuss this further with you Valerie.

  4. Paddy

    Valerie – I pick up on your blog from Roy Lilly’s update earlier this morning and I still haven’t left it! All I can say is how refreshing and thought provoking (in equal measures). I suppose one of the greatest challenges here is developing a collective ‘mindset’ (along these lines) across all of the ‘tribes’ within healthcare. Love this site and I will be a regular visitor.


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