The purchaser-provider split hasn’t worked – what could take its place?

Talk for the Islington  U3A on 19th September 2019, under the heading: The NHS is 71 –should it retire?


I was invited to give this talk shortly after I’d heard yet again (and at a U3A event) the phrase ‘creeping privatisation of the NHS’. As always I’d ignored it at the time but I thought I’d take this opportunity to explore that. To suggest that while a stealthily creeping anything would be a worry, privatisation isn’t the main concern. There is a much bigger one, and that’s been as much a feature of Labour as of Tory governments.

I want to look at what has been going on in the NHS and in wider society;  how that’s affected the kind of care that is on offer; contrast that with  the kind of care we want and need; and then look at the options open to us about the shape of our national health system.

I’m approaching this, not from a health policy standpoint, nor that of an historian. My interest for the last 40 years has been in behaviours and dynamics within the NHS, with a particular interest in status differences and how those affect decision making.

I’ll start by looking very briefly at what I see as some seminal moments in the history of the NHS since the 1960s, then at the background forces influencing these, at how where we are today is hugely suboptimal, and at what other ways forward could offer. I’m hoping to interest and energise you, and expecting along the way to irritate you!

Seminal moments in NHS history

The Salmon Report on Nursing   1967

This was the end of the Hattie Jacques stereotype: the matron very much in charge of a ward was replaced by a much clearer nursing career structure with every hospital having a Chief Nursing Officer. This was responding to changing expectations and attitudes of young women.

(In passing, I think its worth remembering that the nursing professions had been profoundly influenced by the first world war and the number of intelligent, educated young women who now had no chance of a family life and for whom nursing was much more than a job and an income. Sometimes I feel our expectations of nurses are still shaped by that very important part of its history and we can be more disappointed than we realistically should be by the nursing care offered to us).

This was a very sensible report, but every change always achieves losses as well as gains and its important to notice both, and here there was some loss of ownership and continuity at ward level.

The Griffiths report   1983

Roy Griffiths (chief executive of Sainsbury’s) proposed replacing the existing Management Teams of Medical Officer, Nursing Officer and Administrator with a single General Manager – because ‘if Florence Nightingale were to walk the corridors of the NHS today with her lamp she would be trying to find the person in charge’. In other words decision making was, he felt, slow and involved too many people. And his changes did indeed make decision making quicker, but with the loss of involvement of key players, so that critical issues were often not considered or understood.

What Griffiths never understood was that the NHS is an example of a ‘disconnected hierarchy’. Unlike Sainsbury’s where people can be told what to do, professional organisations like healthcare rely on professionals with a knowledge base they deploy at their own discretion. This gives them a status that enables them to (to a certain extent) choose whether and how to engage with the management of an organisation. The tripartite team recognised the reality of that, a management hierarchy does not.

The Purchaser- provider split   1991

Ken Clarke in Margaret Thatcher’s government divided NHS organisations into those providing services, and those deciding which services should be provided and by whom.

The gains were that information about health needs (and public health information more generally) played a much greater part in decisions about the range of services offered, BUT it has taken a long long time to develop effective ‘purchaser’ skills (arguably we still haven’t), because buying health services is very different from buying widgets, and it has diverted a lot of resources into the negotiating and contracting process.

This purchaser/provider split has been modified several times since then, most recently and fervently with  the Lansley reforms of 2010. (This also swept away the Strategic Health Authorities that oversaw the wider operation of the NHS, and insisted that all contracts for services should be open to the private sector as well as NHS organisations).

The New GP contract   2008

GPs gave up their 24 hour responsibility for their practice population, and agreed to a public health agenda at every consultation in addition to the patient led one (e.g. Blood Pressure measured at every visit). This has had a positive impact on inequalities while also reducing the personal nature of the relationship.

Over this time period there were also some of what I call, in this age of acronyms,  TMOs (Tragically Missed Opportunities!)

TMO 1: The Resource Management Initiative   1987

With the advent of personal computers this initiative aimed to give clinicians the information they needed and wanted to improve their clinical care. Because this had clinical benefits clinicians ensured excellent quality of the data entered. This would also allow better management of the whole hospital, but clinical care data took priority and management information was extracted from that. This was the EXACT OPPOSITE of the big NHS computer system that was a total failure in the early 2000s.  The RMI was still a small scale experiment when the purchaser-provider split took place and was lost in that process.

TMO2: New Labour’s exciting amazing NHS targets

18 months to 18 weeks, 4 hours max in A and E. ………

The tragedy is that this could have the most exhilarating and worthwhile, life enhancing challenge: developing new and different and better ways of doing things. Instead it was a draconian and terrifying time for people with responsibility for these, ‘if you don’t deliver this target your job is on the line’, leading mostly to duplicating capacity and redefining activities or spaces.

But where are we today?

Sustainability and Transformation Partnerships      2016 – ongoing

STPs are a new kid on the block and have re-introduced a spirit of collaboration in place of competition. Local ‘accountable care systems’ are groupings of hospital, community, primary care and social care services with a single budget.

There are still only a few, and they depend on the goodwill of Boards and managers involved because their legal status is still as independent organisations. And there’s always the danger of things being rushed and muddled. But for the first time in a long time it feels like a sea change.

And a sea change is sorely needed – because what we’ve discovered in the last 30 years (although not everyone has noticed) is that a pretend or quasi market -the purchaser provider split- is not a half way house between a market and a centrally run system, with the benefits of each – but a completely different animal. If you have a pretend market you end up with a pretend everything else (pretend costs, accounting, management, quality, everything).

A key shift in the nature of management across society – and its consequences for health care

But we’ll come back to that, because something else has been going on in society over this same time period and unless we understand that we won’t get a sea change – we’ll get existing behaviours with new names. We need to get that out into the open, give it a name, and make it an explicit part of the decisions that are made.

In fact its got a name: an old name: MacDonaldisation.

This way of thinking is often attributed to Robert McNamara although I personally think it has much more to do with the increasing role and reach of Business Schools: its about the use of data to chart our progress towards a particular goal; about cutting through the noise of a complex and moving situation to work out what’s really going on and how you’re influencing it through your own actions: about identifying the critical interventions and key indicators of performance; finding ways of using sound logic to chart a way forward.

And surely that is what we want…..

Here’s an example: if you ask the CEO of any large charity they will tell you that their donors want to be sure that their money is being used to best effect, so they want to be kept informed about exactly how the money will be spent and what results that will have, how progress will be monitored, what performance indicators they can expect. The Gates Foundation is renowned for exactly this kind of rigour.

But not everyone sees this as a good thing.

John Ralston Saul wrote a book in 1993 called Voltaire’s Bastards: the dictatorship of reason in the West.

This management method, he said, is one ‘example of reason separating itself from, and out-distancing, the other …human characteristics of spirit, appetite, faith, emotion, intuition, will and experience’.

‘Voltaire’s ‘reason’ challenged the arbitrary absolute power of the aristocracy, Now the dictatorship of the absolute monarch has been replaced by that of absolute reason’.

More recently anthropologist Marilyn Strathern phrases it slightly differently: she talks of a culture of audit in which aspects that can be codified are privileged over those that cannot: ‘the vital wisdom drawn upon to inform an act is as important as the act itself but is not and cannot be captured’, so this leads to ‘hyperactivity and discourse being privileged over wisdom and silence’.

As a result, she suggests, professionals feel they are treated as a depersonalized unit of economic resource whose productivity and performance must be constantly measured and enhanced, instead of an autonomous practitioner making a valuable contribution to society through interpretive application of their expertise.

This is MacDonaldisation. At MacDonald’s everything can be measured (the height of the bun, the weight of the burger, temperature of the flame, perhaps even the width of the smiles!) and in situations where we can measure everything then data based logic like this works well.  But, not everything can be measured…..

And here it’s time to look at a distinction made by systems thinkers in the 60s and 70s: a distinction between puzzles, problems and messes. A puzzle, suggested Russell Ackoff, is a situation where there is a right way forward and we can find out what that is; a problem doesn’t have a right way forward but some ways will be better than others and we can consult experts to see what they are. A mess, though, is very different, its a complex system of interacting problems and puzzles, and here we can only here take a step forward, see what happens, and then decide on our next step. This is technically called ‘muddling through’ and, when done well, ‘muddling through elegantly’!. This is what we need professionals for. This is where we need Aristotle’s ‘phronesis’, practical wisdom, knowing how rather than knowing that, having an ability to tolerate the uncertainty of that and to move forward knowing that you’re not sure.

As Strathern notes: Professionals are society’s way of dealing with uncertain situations and we must encourage professionals not to lose their concern for society and its members and become units of production.

If we are not to drive this out, we need to leave space for our professionals, so we ourselves need to stop demanding answers where there aren’t any.

If we insist on knowing ‘which is the best school?’, for  example, we will get a completely meaningless league table – and the attention of school staff diverted from relating with  our children to focusing on data points that affect their position on the table.

As Strathern notes ‘audit sounds neutral but it fundamentally alters the nature of what is being audited’.

We need to accept that sometimes we cannot know, we will have to make a judgment, and put in the work to make that judgment. Of course its our anxiety that fuels this. (We worry our children won’t do as well as they could). But we need to learn to contain that anxiety and not belch it out into the wider system.

So we need to recognise messes when we come across them. And support the people tackling them on our behalf. We need to support them too when things go wrong:

It was human but very dangerous for Ed Balls to dismiss Sharon Shoesmith in the House of Commons when one of her social workers made a decision and Baby P died. That and the associated headlines did great damage to the practice of social work and recruitment to the profession.

That was an example of what systems thinkers call ‘spurious retrospective coherence’: When we look backwards at something that has happened we find a pathway between an action and the event. But when looking forwards before the action there were many many pathways that might ensue and it is impossible to know which will take place. It is important here that people feel able to take a risk.

Public Inquiries of any kind almost inevitably fall prey to this spurious retrospective coherence. Bristol cardiac centre , Francis and Mid Staffs,…. They all too often result in diligent people who have been working hard in difficult circumstances finding themselves pilloried or sacked for doing their best. Tragedies happen, they aren’t always somebody’s fault, and the kind of things we ‘learn’ from these kind of Inquiries (their findings and recommendations) can also make life more difficult for people facing similar situations in the future. We have to treasure professional judgment and not drive it out with an insistence on pure reason.

How is this relevant for how we organise the NHS? There are two important points:

1.Many health needs, people’s lives, complex NHS organisations and all the interactions within and between these – are not puzzles. They are messes.

2. Griffiths and the purchaser/provider split were both examples of MacDonaldisation.

The kind of organisations needed in health care

I believe that it has been MacDonaldisation rather than privatisation that has taken us down the wrong track in the NHS.  MacDonaldisation (and its offshoot the pretend market of the Purchaser/ Provider split) have distorted our healthcare organisations. We need to liberate them, get them back into a real world , and work with clinicians and their disconnected hierarchy not against that.

What would our healthcare organisations look like if we did that? Here are some of the key features.

  1. Staff of all sorts would be being supported, challenged and enabled to do their best through ongoing conversations with their seniors (or peers for the most senior). In this way they would develop and maintain their ability to work with ‘messes’ as well as ‘puzzles’ and ‘problems’.
  2. The most junior staff (especially, but not only, doctors, nurses and therapists of all kinds) would be being well looked after, as the organisation recognised that these early days will influence their behaviour, confidence and performance over the next 40 years.
  3. Money would be being used wisely through a widespread understanding of costs and cost structures (fixed and variable costs, direct and indirect costs) and how changes in volume of activity, and changes to product mix or skill mix, all affect the ‘bottom line’. Only in this way do people know how to make savings, and how to invest new money wisely. In a pretend market using tariffs instead of real prices and costs this is impossible.
  4. Experienced members of an organisation would be contributing to strategic decisions about it. Clinical leaders, instead of being tasked to ‘win hearts and minds ‘ to a ‘compelling vision’ already developed by external consultants, would help their colleagues understand the complex reality of the challenges facing the organisation so that they can all contribute solutions and understand the reasons for the direction eventually chosen. Yes this is time consuming and expensive but not  as expensive as big change programmes collapsing part way through their implementation.
  5. People in the organisation would be constantly keeping their eyes open for better ways of doing things, taking an interest in how patients experience their service, trying things out, seeing how patients react, offering genuinely different options about how care is delivered.
  6. Organisations would be demonstrating the same ambitions (for achieving optimal health) for all their patients regardless of diagnosis. For example being as ambitious for patients with schizophrenia as for those with cancer; for those with dementia as those with a heart attack or stroke. The NHS prides itself on making care available to all, but it doesn’t have the same ambitions for all. We need to reclaim the purpose of healthcare: it is not only about providing a set of auditable transactions in the form of a predesigned evidence based care pathway. It needs to be wider: my own definition of health care is ‘acts of work and courage in pursuit of flourishing’.
  7. Enough people in the organisation would have an understanding of how work flows through it: some basic knowledge of systems engineering enables people to design queues and waiting lists out of their local system. Calling for more money without that kind of analysis should be unethical.
  8. What it is that patients want and most value would be widely understood. Not through Patient representatives on Boards etc, nor ‘Friends and Family’ tests, nor Pat Sat questionnaires. But by (a) high quality ethnographic research about the kind of relationship people want to have with the NHS. Currently we have no idea- we make assumptions , we simply don’t know. (b) Using Citizens’ Juries for difficult decisions that are essentially political. For example decisions made by NICE are currently based on the seductively simple but philosophically questionable QALY, a Citizens Jury could replace that (as advocated by two Nobel Laureates Amartya Sen and Daniel Kahneman).
  9. And last but not at all least: there would be a range of effective treatments that are good Value For Money for the widest range of ill-health conditions. Currently we have sky high prices for lacklustre, me-too drugs , serving only lucrative diseases (leaving some orphaned and many underserved), and almost no research into non-pharmaceutical avenues of care. We urgently need a change in our method of funding innovation and research.

How to achieve a National Health System with organisations of this sort

So if that is the kind of organisation, the kind of energy and dynamics and behaviours we want in our health system, how can we get that?

Well we’ve given the Purchaser/Provider split a very very good go, and if even one of its designers, economist Alan Maynard, can say that it is ‘neither effective nor cost effective’ then we really must let it go. What can we choose from instead? I suggest that we can choose between an effective centrally run system and a carefully designed market. Let’s look at these.

An effective centrally run system

Let’s imagine a system directly and actively managed from the Department of Health. But perhaps managed isn’t the right word,  because we do not want a return to the system we had before Ken Clarke’s purchaser-provider split. Instead  we need to use something we didn’t have then: a plethora of relevant information from a range of different sources.

The role of the DH would be to gather, hold and provide, rich and relevant information from a wide range of sources to local healthcare organisations.

The information could include, for example, the NHS’s own (rather scattered) data, the rich data held by the tech giants, and that held by drug companies and other suppliers. It would need conversations with Big Tech to encourage them to make available their information about people’s needs and wants (on an aggregate and anonymised basis); also contracts with Big Pharma and other suppliers that ensure all research data is made available as part of their ongoing relationship with the NHS. And all of these would need to be supplemented by high quality research by anthropologists and sociologists and others into how people feel about different kinds of care in varying circumstances.

As well as gathering and providing data and information the DH would ask what uses these were being put to and how services were responding: being developed, altered, monitored, etc. Clinicians are much more likely to be inspired to design new and better services when given good information about what patients want and need than they are by targets set by managers, so we can imagine very different services emerging. In other words, robust varied information would act as the fuel that stops this large centrally held organisation from being a lethargic bureaucracy.

The DH could also encourage the sharing of information between organisations. For example information about costs and cost structures, and how product mix, staff mix, etc varies between services in different organisations and what impact this has on outcomes and satisfaction. Not in a command and control way – but an informative one, expecting and encouraging interest and enthusiasm.

In this process the boundaries between organisations may change as the information flows indicate more exchange of information (and hence activity) between some activities than others. In this way service redesign and hospital reconfigurations would be based, not on politics but on real activities rooted in real patient needs.

Instead of argument and insistence, this would lead to everyone becoming interested in the data and in how to improve services in the light of it. Even the thorny issue of the different status of different diagnoses (cancer v dementia for example) is likely to be addressed as information about the impact on the quality of lives is collected and not only on their length.

There would still be a need for making difficult decisions, for example those currently taken by NICE on the basis of the QALY, and in these areas Citizens Juries could be convened. indeed the DH could usefully develop an expertise in supporting such activities.

So the role of the DH would not be management as we have known it, it would be that of ensuring that information is available and used, that decision making processes involve the voices of people affected by them, and that political decisions are taken in genuinely political ways, remembering that the original Athenian democracy focused on discussion and increasing awareness of an issue and used a vote as only a last resort.  In this way it would ensure that resources are being used wisely and well.

The Sustainable Transformation Partnerships could form part of this and lead into it.

Now lets look at another alternative.

A genuine but regulated market

Before we think any further about this lets remind ourselves that there are lots of different kinds of market and there is no need at all to adopt the kind of market we see in parts of the US system.

Let me tell you a story. About something that has been happening in the Netherlands. 

A few years ago an ex-health finance manager, Jos de Bloc, set up an unusual community nursing team. It had no manager, the nurses themselves (together with their patients) took all the decisions about the best care for those patients, and managed their resources and their case loads themselves. This proved so popular with both patients and nurses that within a few years over 60% of the Netherlands had local teams offering this service, known as the Buurtzorg system.

How had Jos de Blok and his nurses achieved this degree of coverage in such a short time?

To set up a new team he needed to have 20,000 euros available. The team was set up, registered with relevant organisations and started offering its services. Patients liked this service more than others on offer and chose it. By the time his euros were running out money was flowing in from the insurance companies, the service was viable and he could set up another team elsewhere. In other words if the patients chose the service the  system supported their choice

Many people in the UK are very interested in this system, commissioners, managers and nursing organisations are keen for it to be offered. Jos de Blok is keen to offer it here. His UK agents, Public World, are doing sterling work. But to date nothing like 60% coverage has been achieved. Why? Because the decisions are being made by commissioners and managers. Not patients. When patients can choose they make different decisions from managers.

Of course not all services are as easy to choose between as community nursing care but in a system where decisions are not tested with real patients we can never be sure whether we are meeting their needs and preferences.

The Netherlands used to have a system similar to ours but in 2006 it switched to a market system that they designed for themselves reflecting the values they considered the most important. The three they chose were  access to care for all, solidarity through insurance which is compulsory, and high quality services.

It consists of two compulsory basic insurances that between them cover both the care we expect from our NHS and also long term care. These are paid for by a premium, set by the government, paid to a private insurance company. This is accompanied by an income-related payment from employers. People on low incomes can apply for a reduction in the basic premium. The private companies are not allowed to charge anyone a higher premium than agreed with  the government, nor to reject an applicant.

(It is also possible to buy further insurance to cover additional aspects and for this the companies can charge what they like and can reject people they see as a bad risk).

I suggest that this is not hugely different in terms of financial contribution from that of residents in the UK, and that we would not notice a large difference to our personal finances if it were introduced here. And I am not suggesting that we adopt an identical scheme but that it would be possible to design one ourselves. I am merely observing that with their system patients are offered services they want more readily than here.

I believe we could valuably include a move to a market system that we design, again perhaps using Citizens Juries in the design process, in our options for a way forward.

Plus a different system for research and innovation

Neither of these options addresses the need for much more effective innovation resulting in a wide range of effective and reasonably priced health treatments. And that is still very much needed whichever system is chosen. For that we need to make changes to our whole system of research and innovation.

Marianna Mazzucato, Professor of Economics at UCL and head of their Institute of Innovation for Public Purpose,  points out that major advances in technology are rarely made by the private sector. For example all the technology that was used by Bill Gates and Steve Jobs to build the PC and iPhone was developed using government money in the US DARPA programme in the 1960s. In other words the  government declared their research objectives, invited interesting projects to be put forward from the widest range of bodies, selected the most promising and funded them.  In this way technologies make a leap forward in new and surprising ways. There is then a vital role for companies in developing new products based on those technologies, and they should be encouraged to do so and reap the rewards for so doing. However the government should also earn a return on the earlier investments they have made and currently this is not happening.

This is the exact opposite of the story that we are often told: that governments can’t innovate, that governments make bad investments in new technologies (Concorde is usually mentioned), and that only businesses can be creative. However the full data simply negates this view. Sadly the financial rewards have largely gone to the companies that exploited rather than developed these new technologies (who have then even avoided their fair share of taxation on their profits) but that could be changed so that the government secures a fair return on its investment.

This government-led ‘moonshot’ approach is totally different from todays pharmaceutical research which is cautious and  repetitive, and results only in large companies enhancing already large profits without introducing ground breaking new ways forward. So if we are to see this kind of genuinely innovative endeavour we will need the government to take on a much bigger role. This would be even more effective at, say, a European level but it is something that could start with a UK government.

So, as well as a change in the way our NHS is run, a government truly concerned about the health of its citizens would want to tackle this aspect of innovation.

An exciting choice – and the likely reality

The choice

So I suggest we have a choice between a regulated well designed market and an information fuelled centrally directed system but that either of these would benefit from and work well with the kind of ‘moonshot’ approach advocated by Marianna Mazzucato. For such a radical change cross party support would be needed, and maintained through successive parliaments. Thus political parties devising policies will need to think about what package of these will most likely secure cross party support.

My own feeling is that it may be more possible to secure that cross party support for a combination of ‘market and moonshot’, unless it proved possible to convey a vivid enough picture of the way the information driven centrally run system would work. And indeed all three of these systems would need persuasive, eloquent, principled advocates.

Is this likely?

Of course there is only a minuscule chance of this happening. We are much more likely to go on tinkering with the NHS systems in ways that are not understood by the public, and which fail to deliver the care needed.

And that is why it is so important that we all take an active, informed and intelligent interest in what is happening and do not subscribe to sound bites like ‘creeping privatisation’ without fully exploring them and the wider picture.

So do please take a wide and active and informed interest in the NHS – for the benefit of all of us. That will mean listening to a much wider range of voices than healthcare professionals themselves. It means taking an interest in how organisations work, how professionals need both freedom and boundaries, how to approach ‘messes’, and being able to look clearly at the benefits and disbenefits of different kinds of system.

One way of describing this could be a creeping expertise in how a health system ticks – now that would be worthwhile!

A twitter challenge


FullSizeRender[3]To which I, of course,  replied, less testily(!),  that I’d think out my favourite five. But which five?

There are fashions in books, and organisational life has changed since I was at the stage of my career that I imagine is where Adrian Plunkett is now, and the books one learns the most from aren’t always the most elegantly written or enjoyable ………… but these are excuses!

Which do I think most influenced my life?

Here are some candidates:

Leadership is an Art, by Max De Pree

Max De Pree was Chairman and CEO of Hermann Miller Inc., the US furniture manufacturer where Charles and Ray Eames designed their iconic (still highly desirable) furniture. Here he talks of what he learned from the Eames’ (e.g. the importance of working with ‘good goods’) and of his views of leadership:

Leadership: Liberating people to do what is required of them in the most effective and humane way possible. Leaders don’t inflict pain, they bear pain.

Leaders increase the performance of an organisation by developing the maturity of its members.

Maturity includes a sense of self worth, a sense of belonging a sense of expectancy, a sense of responsibility, and a sense of equality.

 When I first read it I started by underlining everything I thought was wonderful or important and soon decided it would be easier to underline the things I didn’t!

 The Fifth Discipline, by Peter Senge

As I was based in a department of Systems Science when i read this I was familiar with many systems concepts but it took the Fifth Discipline for me to fully understand their essential day- to- day practicality and find ways of conveying these simply and persuasively to others. I can’t think of anyone I haven’t recommended this to!

People are almost instantly hooked by ‘does your team have a learning disability?’ (and then find boiling frogs (among other disabilities) all over the place!)

Systems of Survival, by Jane Jacobs

Recommended to me by someone in whom I had the utmost faith, I struggled with this at first, finding the construction (a series of conversations between friends) laboured. But the key message, that there are two distinctly different sets of behaviours with which we can approach our organisational lives, and that they must not be merged, and that we must choose the right one for the right situation, was profoundly important and helpful.

It has become more relevant rather than less as so many more aspects of life have become marketised, and should now be compulsory reading for all clinical leaders as well as politicians and, well everyone!

 Transitions, by William Bridges

Here Bridges distinguishes changes that we make (new job, new partner, new location) from our transition from one set of understandings and sense of self to another. He helps us grapple with the sense of discomfort and uncertainty and not-knowing when we are in the middle of the transition that we had embarked upon as a simple change, and offers support in the manner of a sensitive wise friend.

You may not recognise the wisdom in this until you need it!

 Understanding Variation: the key to managing chaos, by Donald Wheeler

Definitely not a self help book, this is so fundamental to managing any kind of organisation that I’m surprised it isn’t more widely known. Wheeler contrasts the voice of the customer (the specification or requirement) with the voice of the system. ‘The voice of the customer defines what you want, the voice of the system defines what you’ll get’. ‘It is [our] job to work to bring the voice of the process into alignment with the voice of the customer’.

In other words, ten years ago when it came to implementing the 18 week and 4 hour targets, NHS organisations had a choice between focusing on improving their systems and as a result achieving the target, or solely on meeting the target. Sadly, encouraged by bullying at all levels from the very top downwards, almost every organisation chose the latter, in the process wasting the very considerable extra money provided, and leaving the fundamental systems as decrepit as ever.

Wheeler instead shows us how to hear the voice of the system by means of Walter Shewhart’s statistical control charts. Truly every clinical leader needs to understand and really use these.


But this leaves out so many others, for example:

The Unconscious at work by Anton Obholzer

‘Groups that are part of a larger organisation have directly observable structures and functions, and also an unconscious life, comparable to heat described by psychoanalysis in an individual’.

‘Institutions pursue unconscious tasks alongside conscious ones and these affect efficiency and the degree of stress on staff’.

‘Social and psychoanalytic perspectives must be deployed together to achieve real change’

Systems thinking in the public sector, by John Seddon

John Seddon’s self belief can be slightly irritating but he is completely right about the importance of applying systems thinking to public services, and of ascertaining and meeting he needs of the customer – as seen by the customer. This book gives him space to convince us of that.


But then there are so many others. For example there was a brilliant plethora of those on supporting change in organisations, published in the ‘80s and ‘90s which was a period of fantastic flourishing in this kind of literature: still drawing on excellent observational research and not yet trivialized into simplistic buzzwords, charts and tick-boxes.

So at the end of this blog you’ll find my list of those classic texts. I do want to mention though  two of my own books, written especially for clinical leaders:

Really Managing Health Care

This weaves together many themes from these books with practical examples from my own experience and has been popular with clinains and managers alike for 20 years now.

 Why Reforming the NHS Doesn’t Work: the importance of understanding how good people offer good care.

A look at the wider political influences on health care ,  the ways these diminish the quality of care and how we can challenge that influence.

And what about that kindness industry mentioned in the original tweet? ‘be kind: to your self and others’

I think that may be a  busy man’s understandable take on some rich and valuable books, or it may be that Adrian has missed the best of them. So when you are looking for books that support your ability to look after yourself, go for the real experts. I suggest these will include

 Awakening Joy, by James Baraz

A step by step guide that I think can be profoundly helpful

The Compassionate Mind, by Paul Gilbert

Rather more wordy than it needs to be but very strong underlying argument

When things fall apart, by Pema Chodrun

(or almost anything by her). Does what it says on the tin, beautifully.

Loving kindness, by Sharon Salzberg

A practical guide to the Buddhist practice of ‘metta’ that is just wonderful.


Happy reading!!!!!

Do let me know if any of these change yor life!





Classic books I’m very thankful to have read



The Strategy Process: concepts, Context, Cases Henry Mintzberg and James Brian Quinn
Thinking Strategically: the competitive edge in business, politics and everyday life Avinash Dixit and Barry Nalebuff
What is strategy and does it matter? Richard Whittington
Strategy Safari: a guided tour through the wilds of strategic management Henry Mintzberg,
Competing for the future Gary Hamel and C K Prahalad


Systems Thinking, Chaos and Complexity theory


The Fifth Discipline Peter Senge
Systems and Decision Making: a management science approach Hans Daellenbach
Soft Systems Methodology in Action Peter Checkland and Jim Scholes
Chaos James Gleick
Managing Chaos Ralph Stacey
Complexity and Management Ralph Stacey, Douglas Griffin and Patricia Shaw
Systems thinking in the public sector John Seddon
Why most things fail: evolution, extinction and economics Paul Ormerod
Aid on the Edge of Chaos: rethinking international cooperation in a complex world Ben Ramalingam

Biases in decision making

Judgment in managerial decision making Max Bazerman
Human Judgment, the eye of the beholder Donald Laming

 Operations Management and management accounting

Costing: an introduction Colin Drury
Restoring our competitive edge: competing through manufacturing Steven Wheelwright and Robert Hayes
Understanding variation: the key to managing chaos Donald Wheeler
Lean Thinking James Womack and Daniel Jones


Behaviour in organisations and facilitating change


Perspectives on behaviour in organisations Richard Hackman, Edward Lawler and Lyman Porter
Managing People at Work John Hunt
Organisational Learning Chris Argyris and Donald Schon
Overcoming organisational defences: facilitating organisational learning Chris Argyris
Organisational transitions: understanding complex change Richard Beckhard and Reuben Harris
Process consultation 1Process consultation 2 Edgar Schein
TA today: an introduction to transactional analysis Ian Stewart and Vann Joines
Counselling for Toads Robert de Board
The unconscious at work: individual and organisation stress in the human services Anton Obholzer
Talking from 9-5, language, sex and power Deborah Tannen
Strategies for cultural change Paul Bate
Audit Cultures: anthropological studies in accountability, ethics and the academy Ed Marilyn Strathern
Personal and Group Development for Managers Roger Gaunt

Professional dynamics (in health care)

The Reflective Practitioner Donald Schon
Philosophy of Medicine Henrick Wulff, Stig Andur Pedersen, Raben Rosenberg
The profession of medicine Eliot Friedson
Making Sense of illness: the social psychology of heath and disease Alan Radley
The death of humane medicine Petr Skrabnak
Medical power and social knowledge Bryan Turner
High Technology Medicine Bryan Jennett
Liberating medicine David Seedhouse
The foundations for achievement David Seedhouse
Practical medical ethics David Seedhouse, Lisetta Lovett
Disease, Diagnosis and Decisions G Bradley
Complexity and health care Eds Kieran Sweeney, Frances Griffiths
Complexity in primary care Kieran Sweeney
The renewal of generosity: illness, medicine and how to live Arthur Frank
Medical choices, medical chances: how patients, families and physicians can cope with uncertainty Harold Burzstajn
A Flourishing Practice? Peter Toon
Medicine as culture: illness, disease and the body Deborah Lupton
Meetings between experts David Tuckett, Mary Boulton, coral Olson, Anthony Williams
Information and medicine Marsden Blois
Systems of survival: a dialogue on the moral foundations of commerce and politics Jane Jacobs
The definition of quality and approaches to its assessment Avedis Donabedian

Management and Leadership


Tough Minded Management Joe Batten
Leadership is an art Max De Pree
The one minute manager Ken Blanchard
Leadership and the one minute manager Ken Blanchard
The practice of management Peter Drucker
Good to Great Jim Collins
Mintzberg on Management Henry Mintzberg







Some of the more recent life savers

The Compassionate Mind Paul Gilbert
Awakening Joy James Baraz
The courage to be present Karen Kissel Wegela
The wisdom of no escape Pema Chodrun
Start where you are Pema Chodrun
Confessions of a Buddhist atheist Stephen Batchelor
Loving Kindness Sharon Salzberg
Finding meaning in the second half of life(and many others by JH ) James Hollis
The Divided Brain and the Search for Meaning Iain McGilchrist






Whatever the problem, whatever the problem, the answer is ……….


……… never an abstract noun.

It’s not leadership, innovation, reconfiguration, choice, competition, creativity, efficiency, culture (or change of). It’s not transformation, not sustainability, not even communication, effectiveness or evidence.

The answer is always in the verbs. It’s in what real people really do.

Archeologists tell us that our ancestors 2-3000 years ago used far more verbs than nouns. Today we use a far higher ratio of nouns to verbs. Partly that’s natural because we own and use more ‘stuff’ and our world is more complex; but perhaps it is helpful from time to time to remind ourselves of the importance of verbs.

One time when that is especially true is when we are addressing problems and introducing change. Here we often want real people to do things differently.

And if we discipline ourselves to thinking about exactly what it is that we want specific people to do differently, we not only choose different language to describe our change, we see the change itself differently.

So if you are faced with a problem, whether you’re leading a team, department, organisation or partnership, can I encourage you to resist the tempting pull towards those familiar abstract nouns and think clearly instead about what it is you want done differently and by whom?

Unfortunately your in-tray is likely to be full of abstract nouns, and deadlines for delivering them! So below I’ve taken some commonly used NHS abstract nouns and suggested a verb-rich description of what it is you may be aiming for.

See what you think.


 The standard NHS interpretation

Telling. Telling nicely, but still telling. (I notice that lists of management competences in NHS literature now often include both communication and listening skills).

Verb-rich description of who we want to behave how

People talking with, listening to, asking of, discussing with, telling about, enthusing about, encouraging, celebrating with, mourning with, reaching agreement on, giving feedback to, seeking feedback from, offering help, asking for help, applauding, critiquing, ………

One or more of any of these, and because it’s vitally important to be clear which, we could usefully ban the word communication (and be very suspicious of anything coming to us via something called ‘Comms’). Seriously, its worth thinking through exactly what kind of communication it is that will help your change succeed.


Standard NHS interpretation

Bright new ideas about ways of doing things that reduce costs and increase quality reliably and sustainably, immediately. Often involving ‘care closer to home’.

Verb-rich description of who we want to behave how

All of us working in the NHS acting awarely (i.e. consciously aware of what we are doing and how we are feeling); thinking about what we are doing and what we’re achieving, and whether we could be doing it a different way to better effect. Sharing ideas with others and responding generously to the ideas of others (with a healthy helpful skepticism rather than lazy, unhelpful cynicism). Looking for good ideas outside the NHS and adapting them to fit.

Culture – change of

Standard NHS interpretation

The 1/50th of the UK population who work in the NHS behaving differently from the other 49/50s and being unfailingly loving and heroic in a punishing environment.

Verb-rich description of who we want to behave how

Everyone asking themselves ‘is this how I would want to be treated?’, making a note, and raising concerns.

Leaders at all levels (especially clinical leaders) ensuring regular, skillfully facilitated team discussions at which these can be raised.

Supervisors at all levels conducting regular and frequent 1-1s, ditto. Making it normal to seek challenge from juniors, making it okay to challenge up constructively.


Standard NHS interpretation

The personal qualities manifest when a select few are sprinkled with fairy dust, that enable them to win hearts and minds of the most intelligent and obdurate opponents of their proposals.

Verb-rich description of who we want to behave how

Leaders, managers, clinical seniors at all levels supporting and encouraging people in their team when they are behaving well, challenging them gracefully when they are not, and thus enabling to be the people they aspire to be. In the process encouraging and enabling their teams to collaboratively develop new ways forward.


Standard NHS interpretation

The hugely expensive mechanism by which commissioners succeed in ensuring that the goods and services purchased are cheaper and worse.

Verb-rich description of who we want to behave how

Significant numbers of NHS staff experiencing the energy that drives human beings to see how other people/teams are doing things and to want to do them better. An energy in support of their desire to offer great services to people who need them.

(There are lots of ways of encouraging constructive competition and a market is often the least effective).


Standard NHS interpretation

Expensive mergers of all the hospitals in a given area into one super specialist high status hub, thus increasing costs and financial risk and furthering the careers of ambitious, high status, clinicians and managers.

Verb rich description of who we want to behave how

Local leaders identifying any structural factors that inhibit front line staff from working effectively with colleagues based in different organisations, to offer the multi-faceted care that patients with complex needs require – and then making the smallest number of structural changes that overcome these barriers.


Standard NHS interpretation

The delivery of innovation (qv) often through reconfiguration (qv), often using transactional rather than transformational change methods.

Verb-rich description of who we want to behave how

Everyone visualizing how they could contribute to achieving better outcomes and waste less time (their own and others: time is the largest and most precious resource in the NHS by a huge margin) by changing, together, the systems in which they operate. System leaders reflecting on how (a few) organisational structures and boundaries may need to change.


Standard NHS interpretation

The results of transformation (qv), especially those involving heroic assumptions about the capacity of primary and community care.

Verb rich description of who we want to behave how

hmmmmm, perhaps:

A network of local leaders ensuring care systems are future proof, ensuring that the quality of patient care does not rely on systems and processes that can be changed arbitrarily, but rests in knowledge, behaviours, attitudes and systems that can be moved across organisational boundaries when these, inevitably, shift.

Service leaders being (and being seen to be) so focused on being efficient and effective they can be trusted to increase their productivity wherever possible – and hence exempt from cuts imposed ignorantly from the outside.


Standard NHS interpretation

There are two kinds of choice in standard NHS speak, the meaningless and the terrifying, and neither fits the normal consumer model of choice (although that is the one implicitly assumed). In both of them the clinician is expected to make sure the patient understands the choice, but not to guide them. For example the choice of:

  • two or more alternatives that differ slightly from each other in ways that matter little to those faced with the choice (e.g. MRI scan by x or y provider).
  •  alternative treatments (with accompanying statistics) in a situation where the option chosen may have life changing consequences.

Verb-rich description of who we want to behave how

Clinicians discuss with and offer support to Individuals and families faced with a set of options which will have an impact on their lives and for which the outcomes are to some extent uncertain.


Standard NHS interpretation

 The application of quality improvement methods approved by the QI establishment and their accredited disciples.

Verb-rich description of who we want to behave how

Everyone working in the NHS getting as close as we can to achieving what our patients long for; questioning any shortfall and looking for ways of achieving more next time. Naturally this involves us taking an active interest in what each patient does long for.


Standard NHS interpretation

Cuts: usually cutting the costs of everything except frontline staff budgets, thus requiring frontline staff to take on additional non-clinical roles that reduce the time they have available for clinical contact. But as frontline staff pots have been ‘protected’ this is not a cut -it’s efficiency.

Verb-rich description of who we want to behave how

Everyone making the very best use of their time, where best = meeting the needs of patients/client and/or investing in their ability to do so. NB ‘clients’ may be other teams or departments…


Standard NHS interpretation

Protocols being adhered to.

Verb-rich description of who we want to behave how

Patients and other clients feeling that their needs have been met.


Standard NHS interpretation

The RCT that lies behind the protocol invoked when a particular diagnosis is made.

Verb rich description of who we want to behave how

When making a decision about how to proceed, the people involved seek and consider information about outcomes in other, related situations. This may come from a range of sources and RCTs will be a gold standard in only some cases.


 Standard NHS interpretation

The source of all the problems of the NHS, largely because of wicked, incompetent, unprincipled, untrustworthy politicians.

Verb-rich description of who we want to behave how

There are lots of different kinds of money, let’s look at them in turn:

 NHS budget

Everyone in the UK population contributing to the health of all, through a just and competent tax system. NHS staff honouring this colossal act of collective generosity and wanting to make it have as great an impact as possible (including by taking an ongoing interest in what types of expenditure do have the greatest impact).

 More money

Everyone working in the NHS using their time and other resources thoughtfully and wisely: and after having explored and exhausted all the ways they can meet patients’ needs within resources currently available, making a reasoned case to government.

Government minsters sharing their concern and values, and even if they choose not or cannot always grant the request, acknowledge the impact of the decision and take some responsibility for the consequences.

Both parties choosing to have confidence that the other will behave in this way.

Department budgets

Resources being actively managed by team and department leaders to meet patient and client needs. This requires at least a rudimentary of simple management accounting, sadly a skill rarely developed, encouraged or used at team level)– see page 105 of Chapter 4 of Really Managing Health Care

Organisation budgets

Organisational leaders seeking constantly to meet patient and population needs as effectively as possible, by supporting, challenging and enabling their own staff and leaders of other organisations so that the greatest care is offered by the organisations best placed to do so. The figures in organisational budgets reflect this real activity rather than fictions such as tariffs.

 (Its always worth remembering too that money itself is a fiction


Standard NHS interpretation

 The papers describing and making a spurious but convincing case for reconfiguration (qv).

Verb-rich description of who we want to behave how

Being clear about what it is you want to achieve (what it is you really care about achieving ); how you are going to be able to achieve it in the environment you are in, and how you need to deploy your resources to achieve it.

All strategies should be clear about all three of these aspects (aim, environment, resources). Our tendency is always to focus on resources and pay only lip service to the other two.

 Demagogues and abstract nouns

And while we’re about it, lets remember that demagogues are particularly fond of abusing abstract nouns.


 Standard misuse

A majority vote

Verb- rich description of who we want to behave how

Constituents of a country, locality or organisation, go through a process of discussion, argument, and debate, about an issue; and in the process discover more about that issue and together reach a way forward, sometimes through a system of voting. The greater understanding is of as much -or greater – value as the decision made.


Dictionary definition

Supreme power, authority.

 Standard misuse

We get to do what we want.

Verb-rich description of who we want to behave how

Perhaps: All those nationals of a country who are competent to do so are able to make choices about their lives in such a way that they gain as much of what they want as they can without infringing the ability of others to do the same.

Where these choices require an understanding of specialist areas of knowledge experts in these fields support them in understanding relevant evidence.

People are helped (through education) to see that sovereignty does not always (indeed often) result in having one’s own way


Standard misuse

The only thing that matters for a government

Verb-rich description of who we want to behave how

Every member of society leading a fulfilling life. (It is often instructive to replace the word ‘economy’ with ‘society’ whenever it is used – it highlights situations when the two are at odds).

Making our lives richer

While our world is more complex than that of our ancestors, may I suggest that our experience of it is less direct, less sense based, in some ways less rich? That we spend more time in our heads than directly in the moment – and that perhaps a focus on verbs in place of nouns allows to regain some of that richness of experience.

Oh and that we will implement more successful change programmes too?!


Valerie Iles

October 2016

Reviewing the Rose Review

 I had been secretly hoping the reason for our long wait for the Rose Review was that Lord Rose was insisting on it fitting on the back of an envelope. Once I’d overcome the disappointment of finding 68 pages though, well, I think it’s the most useful review we’ve had for ages.

In his observations Rose is tactful without pussy footing, and friendly while forthright. Indeed most of the observations have a feeling of freshness about them, even as they address issues most of us are familiar with. Why? Because he focuses on the one thing that almost no-one else does. More of that in a minute.

He and I got off on the wrong foot: ‘the Review aims to make people better qualified to manage and lead, p5’. Oh no, I thought, not again. But, reading on, I found myself thinking ‘no, he really gets this. He understands how to manage people and he’s looking afresh at the NHS: friendly but not dewy eyed, thinking clearly but practically. He’s not a Robert Francis. He’s worked with real people managing real change, he’s put things into practice. He’s not McKInsey.’

I liked his expressed surprise: ‘It is striking that the NHS has a central resource for quality but not for people.’p5. His sympathetic concern: ‘The NHS is one of our society’s proudest achievements but the challenges it faces could hardly be more daunting’.p7.

The kinds of people he has worked with are different though, and he doesn’t take enough account of that. This means his definition of leadership needs to be amended (as I’ll show shortly). But his overall emphasis on helping people throughout the organisation to be best they can be is music to my ears. I’ve said this so often and for so long that it feels so familiar and yet it is still almost completely lacking in training programmes, in organisational systems, in NHS culture. Its not that it has been driven out by constant reform –in my experience, except in isolated pockets, it has simply never been there.

So his emphasis on excellent people management may seem overly simple to some, but is actually radical (radical: affecting the fundamental nature of something; far-reaching; thorough).

I enjoyed his use of the term ‘performance management’ – rescuing it from our own debased usage and restoring it to mean the managing of people and how they are performing – and his insistence on having ‘proper time set aside for that’. And as for the thought of ‘a concerted effort to help people give and receive praise, encouragement and advice’ and ‘feedback that is constructive and thought provoking’, well it’s what I’ve spent the last thirty years encouraging.

This fits so well with what I personally believe: that what we need is much more good practical day-to-day management at every level: the everyday conversations that support, challenge and enable people to become the people they want to be. I’ve always called this ‘real management’ and I like Beverley Alimo Metcalfe’s term ‘nearby leadership’. If we had this in place at every level we would find organisations readily leadable, really manageable. If we think top down and focus on finding leaders for organisations before we put in place these day to day practical conversations we fail – we have tried this too often.

And Rose knows this. He seems to feel the need for it in ways that other observers have not. Here he is:

Performance management means thinking about how best to train, equip and assign the right people to the right roles. Done well it improves organisational performance. In the NHS it means something negative, It should mean a communication process that occurs throughout the year between manager and employee to support both the employee’s and the organisation’s objectives: a regular conversation on an individual’s career development.

Here is the Iles version!

The one thing he doesn’t get – or get sufficiently – is that the people he has worked with are different. The dynamics of retail or manufacturing organisation are different. Henry Mintzberg captures this neatly in his distinction between connected and disconnected hierarchies. I use and explain this here.

Doctors hold high social status, they are not sales staff; in the lengthy (important) process of acquiring their professional identity they are given very little insight into the nature of organsiations and how to behave productively within them. In the ignorance that comes of their separation from other students and careers they can make inappropriate judgements about the performance of others, and ascribe ill motives to those who are simply fulfilling a different role.  Crucially, too, they have never been taught the skills to engage in these all-important supportive, challenging, enabling conversations. This is a tragedy-for them, for patients, for taxpayers. And it needs to be remedied.

The usual response is a call for ‘leadership’ and indeed Rose includes that here (to be fair that was his brief!). But what these behaviours mean in practice is that an emphasis on leadership and leaders is not enough: there is a corollary need for followership. Without followers leaders are useless: literally: they have no use.

So any effort on leadership needs to be twinned with persuading and enabling clinicians to respond constructively to challenging circumstances, to take collective responsibility for outcomes, to reflect with others on how to redesign services to make the best use of resources and achieve the best outcomes for patients -instead of self righteously, complacently ignoring the wider picture.

In short we need to develop followers, supporters, and I suggest the skills and attitudes and insights required for followership are almost identical to those of leadership –including one  important component that doesn’t get mentioned enough in the leadership literature: the willingness/preparedness to recognise another’s authority in particular circumstances. But we also need a helpful understanding of what leadership involves.

Rose supports the list of characteristics in the Francis report of 2013 ‘visibility, listening, understanding, cross boundary thinking, challenging, probity, openness and courage’ and especially applauds the ‘ability to create and communicate vision and strategy’.  I dislike this list. First because it lacks any sense of supporting and enabling. Second because ‘creating and communicating vision and strategy’ here carries the sense of broadcasting not listening. I’ll come back to that later.

So lets use a more engaging definition of leadership and then foster these skills in everyone not only a few. On page 22 Rose gives a list of the people who need to be involved in developing innovative care models: ‘porters, receptionists, nurses, consultants, specialists, technicians, therapists, GPs, service commissioners and many others’. He uses the list to make the case for a ‘single vision effectively communicated and understood by all NHS staff’ – I would use it as an illustrative list of those we need to help to become leaders and followers

Indeed if we add talk of following or supporting wherever Rose talks of leading his observations become even stronger and more relevant than they are already.

Try it yourself here:

‘…….a greater focus on the whole NHS workforce and on developing the talents and skills of its future leaders: they need to be better prepared for the daily challenges of leading [and supporting] a Trust, a ward, a clinical or specialist group, or a CCG’.

 ‘A lack of cohesive leadership [and followership] will produce an organisation where relations between staff and patients are merely transaction, doggedly contractual, obsessed with data and lacking in innovation and inspiration’. P47.

 Strong and capable leadership [and followership] is key to doing transformational change.

More support is needed for leaders [and supporters] to develop large-scale change management, strategic and commercial skills, to be able to lead in a networked or group structure. P24.

Don’t these change? Instead of feeling ‘if only’, don’t you feel ‘let’s do it’ ?

And what about this:

Imagine an organisation where everyone understands and values the role of others, however seemingly small; where the main effort is clear; where local variations can apply without bureaucratic censure; where people trust each other and seek to be trusted; where delegation, training and personal and professional growth are seen as aspects of the same thing. This is what an organisation with effective leadership [and followership] look like. It is an organisation equipped both for long term planning and also for the immediate uncertainties and complexities required of any group of people (especially a large one) that seeks to provide the full range of health care to a large and changing population’.

Add ‘and followership’ and it stops being merely inspirational, it becomes aspirational: something we could actually achieve.

Why do we consistently fail to attend to and develop followership skills? As they are so similar to those of leadership and require the same courage and commitment we surely have the expertise to do so – because it requires us to do what we always shy away from – truly engaging with clinicians.

Instead, as Rose notes:

There is no underlying ethos across all disciplines. Not enough management by walking about and listening. The NHS remains stubbornly tribal’.

 The three prominent staff groups …(Nurses, Doctors and General Managers) …often do not understand each other’s priorities. Despite the importance of clinical leadership a gulf remains between clinicians and managers: it can be hard to get clinicians to sit round a table and be accountable for the organisation as a whole. P47.

 Sadly, as Rose’s experience (and that of his co-author Andrew St George) does not include disconnected hierarchies, the recommendations ignore this need for attention to followers and many are therefore irrelevant or unhelpful.

For example when it came to leadership ‘training courses’ and the need to monitor quality, pluralism and innovation (which was music to my ears), this then seemed to translate into perpetuating existing programmes that have ‘status, appeal and impact’. How disappointing.

If this kind of elite programme (where only the ‘best of the best’ are recruited so that they become the leaders of the future) were the answer, the NHS would be in a very different place today –because we have had these for decades. These undoubtedly advance individual careers. What they don’t do is impact constructively on the system. If they were the answer we would have seen the NHS anticipating change, responding to it effectively, harnessing the energy and enthusiasm of its 1.4 million employees, and not having to be dropped kicking and screaming into a world of (always) about 10-15 years ago. In any time period to date the factors that persuaded policy makers to invoke change should have prompted organisational leaders to do so at least 5 years earlier.

What we need instead is ways of finding the leader [ follower/supporter] in everyone, not badging a few. Everyone in or serving the NHS in any kind of day-to-day management role (which includes most professional frontline roles) should have access to excellent practical training in the simple hard behaviours of management.

There is a similar problem with the recommendations on a shared vision. I’m usually allergic to the term ‘vision’. In the Carnell/Nicholson view of the world that always seemed to mean ‘you do what I tell you, to sort out a problem I’ve defined, to reach a future I’ve decided upon’. But Rose seems to be using it differently, something like:  one feeling, one hope, one driving sense of what it is about.

‘An agreed shared vision would give the NHS a united ethos and a consistent approach to getting things done’.

But would it? Could it? What would have to be different for that to happen? Because its been tried before, in the Constitution, in the 6 Cs, and others. This needs to feel real – not hollow. How? I’m not sure. I’d encourage people to talk about what mattered to them – as part of their performance management (supporting, challenging, enabling) conversations. I don’t think a vision is separate from performance management, or something that is attended to first, each is the way in which the other is brought about.

In other words it couldn’t be imposed, it would have to be found – from the frontline, from patients, from people managing and allocating resources: real people receiving and delivering real services. then it could be exciting and energising, and Rose is right to want it.  But by the time this is translated into the report’s recommendations it becomes:

R1. Form a single service-wide communication strategy within the NHS to cascade and broadcast good and sometimes less good news and information as well as best practice to NHS staff, Trusts, and CCGs.

R2. Create a short NHS handbook/passport/map summarizing in short and /or visual form the NHS core values to be published, broadcast and implemented throughout the NHS’.

See what I mean?

However some of the recommendations do reflect the spirit of the earlier observations. My heart sang again at the thought of ‘a concerted effort to help people give and receive praise, encouragement and advice’. And I whole-heartedly support the wish to ‘review, refresh and extend’ the NHS graduate scheme. I chuckled at the need to recommend that managers should be supported as they progress (der…!). And how wonderful if we had ‘a cadre of capable, trained, current managers from all disciplines and with greater cultural diversity to better reflect its staff ‘– though why ‘better’??? Can’t it wholly reflect its staff? At all levels we need people who can see the organisation and its care through the eyes of their front line.

As for training to enable Trust boards to become a cohesive group of leaders, that sounds spot on – as long as it is not about ‘governance’, NHS finance etc. What boards need is an understanding of the behavioural dynamics that frustrate progress, they need to know how to add value, and how to meaningfully lead the organisation by liberating its people and gracefully holding it and them to account.

And a 90 day training cycle to support the brave idea that ‘people must be equipped for the changes the NHS has asked them to make’ seemed an excellent model.

How about the ‘central body coordinating training effort and resources’? If what Rose means is a shared, stretching ambition for management development then making HEE responsible for this seems right to me. All the fact based, clinical content of training programmes has to be brought to life in encounters with patients and colleagues, and I see the simple hard of managing, leading and following as the way in which we behave any plans and ideas into life. So this surely has to be an integral part of all other learning. If all HEE commissioned programmes included this element we could transform patient experience, and tax payer concerns, and help staff of all kinds to flourish.

So we need to be cautious about some of the recommendations but reflect thoughtfully on the observations and reflections.

What would happen if we did that? Suppose we asked people to come up with their own approaches to the perceptive reflections of a man with truly valuable experience? Suppose we asked all sorts of thoughtful observers, people not so immersed in the NHS that they fail to see it clearly, to develop their own approach to Rose’s most important question: How do we help all NHS staff become the best versions of themselves at work?

What would your reponse be?  What would mine?

Well I’d start without a report. I’d start tomorrow (literally – this is August). I’d start with the F1 and F2 doctors starting work in NHS hospitals. I’d make them the top priority for excellent ongoing support and challenge.

I would give them either:

  • brilliantly facilitated action learning/coaching /mentoring sets, or
  • one-to-ones with the people in the organisation who have the best people management skills (not doctors unless they have had excellent training and real aptitude for this),

and ensure they learn how to:

  • make the most of the opportunities that face them
  • work constructively with the people around them
  • help the organisation help them to be as effective as they can be
  • identify legitimate concerns and express them
  • recognise unhelpful behavioural dynamics and influence these,
  • and generally how to behave their ideas, their wishes, into action.

In the same way I’d get them

  • sharing good practice and taking an active and constant interest in where it is to be found
  • thinking from a patient and public point of view, and
  • thinking about how they can use their own expertise to empower others.

In the next few months I’d offer the same to all new nursing staff and AHPs, and perhaps eventually to all new staff. Why new staff? Because these are the leaders and followers of tomorrow, these are the people we currently alienate within their first few months. When we neglect their welfare, ignore their suggestions and concerns, and deny them the constructive feedback to help them to grow, we breed a new generation behaving as frustratedly and unproductively as their forebears.

In this way we could build a demand for good management (performance management in the Rose sense of the term) – with doctors leading the way in insisting on their entitlement to those conversations that support, challenge and enable them to be the best clinicians they can be.

Would this fit on the back of an envelope?

photoI think Mintzberg might approve, I hope Rose would as well.




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!

For every complex problem there is an answer that is clear, simple and wrong

(One of the many wonderful quotes from H L Mencken.    See here for more.)

And nowhere is this more true than in health care, where we have so  many highly intelligent people, caring deeply about the quality of care patients receive, who can find themselves, in  tackling problems, devising  solutions that make things worse rather than better.

How can this happen?

One of the reasons is that we can so easily fail to understand the complexity of the environment we are working in, so we fail to identify the underlying trends that are contributing to the problem, and because we do not see them we fail to notice that our response exacerbates them. In other words we tend to look at a snapshot in time and do not explore the historical trends that not only shape our world, but influence how we think and behave.

The graphic shown below introduces some of these trends and how they interact with each other to produce a ‘swirl of forces’ around us that, if we remain unaware of it, pushes us to behave in ways that exacerbate problems while thinking we are solving them.


Screen Shot 2014-12-05 at 12.02.49

Lets have a look at what trends are represented here.

In each of the four corners there is a different coloured lozenge shape that represents an influence of critical significance.

  • Technological advances over the last 150 years.
  • The marketisation agenda that has swept democracies around he world over the last 40 years.
  • The digital revolution
  • The debt crisis in the West.

In the paler lozenges of the same colour some of the consequences of these influences are given.

In the boxes of different shapes in the middle are some significant results of interactions between these ‘corners’, the colours indicating which corners are involved.

Now just imagine that each of these text boxes is a wind. Something that has an influence on us, that we cannot change but must somehow contend with. These winds swirl around us in unpredictable ways, sometimes counteracting each other, sometimes boosting each other’s strength. Sometimes we will experience them as refreshing, energizing, and helpful, and sometimes we will find them gale-force, hindering our progress as we try and steer a path through them. Occasionally they will knock us off our feet or sweep us up and deposit us somewhere different from where we started.

This is the world we face in health care. All of us: patients, professionals, managers, and policy makers. This is what we are finding so exciting and rewarding, and so difficult and frustrating.

When it is the latter we all too easily blame other people or particular events for our difficulties. But this is not the fault of a particular politician or even political party, nor a difficult manager or consultant. It hasn’t arrived  because of a particular decision, reform, or crisis.

We are all caught up in this swirl. Them, those people whose actions and answers we blame, and us too. Yes all of us. We all experience these winds and as we do so we respond to them.

Very often we respond in ways that are anxious or fearful. After all,  we care about health care and our part in it, so, when we find we cannot offer the kind of service we want to, we are bound to feel anxious. But our anxiety often leads us to take action that exacerbates the problem – energises the swirl, whips up the winds. So, inadvertently, we and our solutions become part of the problem.

We all need to move away from autopilot responses in which our clever brains will swiftly steer us away from anxiety (often before we have even noticed it)  by devising for us answers that are clear, simple and wrong.

What do I mean? Here is an example.

Many service providers are fearful that their service will be overwhelmed by demand. That isn’t a surprising fear – we are constantly being told about ‘flatlining’ NHS budgets and steadily increasing demand. As a result many triage systems are put in place. The aim of these systems is seen by the providers as reserving the service for those who really need it. So they are not there to assist the patient trying to access the service but to enable the service to decide whether that patient is worthy of the service.  John Seddon and others have demonstrated over and over again how triage of this kind increases demand, not marginally but dramatically, as patients have to persist in seeking care for the needs that have not been met. This additional demand even has a name: failure demand.

I can attest to this personally: recently my daughter had extreme toothache. I’ve never had toothache myself so I can’t empathise fully, but the only other time I’ve seen her this upset was when she had appendicitis. On both occasions her symptoms only became severe enough to warrant attention out of hours.   The care we needed for what turned out to be an abscess in a root canal was one 10 minute appointment  from a dentist and, 24 hours later when she was bringing up all the contents of her stomach (including the pain killers and antibiotics), a consultation with a GP.

The service given was seven sets of triage (some by 111, some by different out of hours dental and GP services), various appointments around north london,  and a 111 decision that she needed an ambulance to take her to A & E, where  (no, we went under our own steam) we waited  surrounded by posters asking us whether we really needed to be there. NO we didn’t.  More than anything we needed a conversation with a person capable of using their professional discretion, rather than an algorithm.

In anxiously trying to protect the time of our most expensive and expert resources we design systems that waste more than they save, costing more for a lesser quality service.

But the pressure on resources is real – we do need to act to ensure they are used wisely and well. But not in ways that make the situation worse. We need to think more widely and care-fully than our automatic (anxious) response of pulling up the drawbridge.

If we can see the underlying trends and their impact we can devise approaches that do not originate in anxiety and blame. Then we design very different solutions.

For example: we stop seeing people seeking care as the enemy, and stop trying to divide them into deserving and undeserving. We stop seeing politicians as conniving and self serving and see them as caught as helplessly as we are. And, when we see that everyone in this swirl is afflicted with the same feelings of anxiety and helplessness that we are experiencing, we can look for ways of working constructively with them.

Instead of seeking people we can blame  we instead identify the things that are important to us and to them, the aspects of care  we so dearly want to protect or improve. Then we can look for potential allies in our struggle to do so. Very often the people we see as a problem will turn out to be a resource.

This isn’t magic,  that swirl of forces is still there, there are still very real dangers that things we value will be lost and we will still have to fight to keep or develop those aspects of care we know are important. But, if we recognise this, the energy we call upon will be very different. We will still be working as hard but our  enjoyment of the situation will be greater. Our effectiveness too.

So we need to move away from autopilot where our clever brains will devise those answers that are clear, simple and wrong, and towards as sympathetic and wide ranging an understanding of our context as we can.

You can follow up more info on the swirl and on one particular aspect of care it is in danger of driving out here:  What is happening to leadership in health care

Or in more detail here:  Why Reforming the NHS Doesn’t Work



Abstract nouns are seductive but dangerous

Nouns and verbs

Innovation      Leadership    Competition     Efficiency    Choice    Resources    Strategy     Quality

Scholars tell us that 3000 years ago our vocabulary included far more verbs than nouns – we talked in much more fluid ways than we do now of processes, behaviours and actions. Now we refer to what we see around us in terms that are more static and rigid – as nouns. What does this difference reflect? And is it helpful to review our own use of language?

I think it may be crucial.

Something seems to happen when we describe activities as nouns instead of verbs, the energy levels change for a start, but thre’s more than that – see for yourself whether that’s what you find.

Think, for example, of ‘leadership’ and then about ‘leading’.

Typically, I find people’s lists look like this:


  •   relating and connecting
  •   talking and listening
  •   supporting and challenging
  •   caring


  •   creating a compelling vision
  •   developing and delivering a successful strategy
  •   managing performance
  •   effective communication strategies

Leading feels active and fleetfooted, leadership somehow feels heavy and more pedestrian. And this seems to happen whatever example you choose – its quite fun to try it with any verb and its associated noun.   Nouns seem to beget nouns, and verbs more verbs. Nouns give us more things to think about, more nouns – like vision, strategy, and performance – and indeed they can keep our brains happily occupied for hours. Verbs give us a sense of action and energy, of fluidity, contingency, flexibility, of possibility. Verbs keep us interacting with others, having to draw on our courage, judgement, integrity and discretion as we do so. Nouns rely on brainpower alone.

The simple hard and the complicated easy

Years ago I came across the distinction between what its author (an ex US Marine) described as the simple tough and the complex easy. Translating them into a UK usage and reserving the term ‘complex’ for the more specific meaning it has within complexity theory, I’ve called them the complicated easy (activities which use lots of  brain power but little else – doing an analysis for example)  and the simple hard (simple to describe, hard to implement because they require all the rest of you, your courage, judgement, integrity …..  For example having a constructive conversation with someone about something they won’t want to hear).

For a long time I said that both were needed, but increasingly, as the complicated easy steadily drives out the simple hard in all our large bureaucracies, I wonder whether it is needed at all, whether the simple hard is enough. And over the years I’ve come to see, too, that thinking in verbs is one way of helping us stick to the simple hard and not be seduced ( as we so easily are) into the complicated easy.

Do all nouns fall into the complicated easy class? No, I think concrete nouns (like ‘leader’) while not as active as ‘lead’ and ‘leading’, convey a sense of sold reality  in a way that ‘leadership’ doesn’t. So while its helpful to rethink our phrases to include as many verbs as we can, a few concrete nouns won’t mislead us. It’s the abstract nouns that do  – so it’s here that danger lies.

I suggest abstract nouns always tend to lead us towards the complicated easy: away from real personal engagement and towards logical arguments. More than this, I suggest that they fuel our fears, and that because we become more fearful when we think in those terms. we all too often devise strategies that turn those fears into self fulfilling prophecies.

Lets look at an example

If we think of the NHS in terms of abstract nouns like money (one of the most powerful abstract nouns we have), and structure, we can quickly convince ourselves that we don’t have enough of the former and that we must therefore reconfigure the latter, and we begin to talk of rationing. (And interestingly we use rationing here as a noun rather than a verb.)

If, instead, we focus on what it is that money buys, we talk of people: people doing things, people caring for and about other people. And instead of structures we see connections between people, the conversations that support and challenge people, that give them freedom within boundaries, that hold them gently and firmly to account.

Then we begin to see possibilities as welll as worries, and we behave differently. We aren’t cavalier about connections and conversations in the way we are with structures. We don’t leap immediately to rationing, we are thoughtful instead about how we and others can use our time and talents wisely and with care, and we find all sorts of other ways of meeting the needs we know are there and care about meeting.

So abstract nouns are dangerous

Think of innovation, competition, efficiency, choice, strategy. All nouns that economists and Business Schools have loved to formalise for us, think about logically, and develop new theory about.
(Right now, as I write this, the NHS is strongly influenced by the work of two Harvard professors, Clay Christensen’s thinking on innovation, and Michael Porter’s on competition and strategy.)

Typically management consultancies then sell us implementation programmes based around the ideas – all very logical, very appealing to brains – less so to our emotions. They will also help Inspection Regimes devise monitoring tools, to see how well management teams are implementing  the concept.

As an historical example, think of World Class Commissioning – a McKinsey product. Think of all those descriptions, all those competences, all those lists, all those kinds of evidence…
Compare that with the early days of Primary Care Groups when commissioning was new and still a verb, when there was real energy on the ground.

‘But, but, but …’ you are expostulating, ‘commissioning is so much more advanced now, we’re so much further forward, and we’re well on the way to being able to really change things ……, we just need more ………’.
But that is always the cry of the advocates of complicated easy programmes: it is always ‘going ‘ to work, with a little more …. something…….

If you think about your history in the NHS, I think you may find you have come across that? And not just the NHS, think how austerity programmes were/are going to resolve the problems of Greece, Portugal and so on – tomorrow, always tomorrow, (this has been described as the standard  ‘sado-monetarism! of the neoliberals!

Theories not facts

We must remember that these theories based on academic thinking about abstract nouns are just that: theories, ideas. And we should hold them lightly, test them our, always keep them under review. After all, we are not in  territory here where evidence is abundant or helpful.

No? You think there is evidence that will  help? Time for another distinction.

Puzzles, problems and messes

In the 1970s, systems theorist Russell Ackoff defined a puzzle as a situation or conundrum in which there is a right and a wrong answer. He saw a problem as a situation in which there is no right or wrong, just better or worse ways of proceeding. And a mess is when you have a complex system of interacting and interdependent problems.

For a puzzle we can establish clear cause and effect links straightforwardly and  use RCTs to help us choose between diffferent ways of resoloving our dilemma. A problem is not quite so straightforward but there will be experts who have formed judgements about better and worse ways forward and we can consult them. But in a mess the system is so complex with so many different puzzles and problems interacting with each other that the situation will be different every time, and the best we can do is ‘muddle through elegantly’.  And most of the time we are operating in a mess!

(Dave Snowdon of Cognitive Edge is very helpful on the different kinds of evidence and leadership that is needed in these different situations.)

Let me say that again:  in a mess we can be actively misled by the kind of evidence that can be established and used in a puzzle, and by the professional expertise that can help guide us through a problem. Here we are in the territory where ‘muddling through elegantly’ is the only way.

Of course this will be anathema to those who see the world only as a series of puzzles and problems. David Nicholson, for example, always decried ‘muddling through’ as a solution to the future of the NHS, preferring instead to treat this as a puzzle.

The importance of remembering that theories are not facts

So let me say it again: in complex systems (messes) theories/ideas can only be that – they aren’t facts, there is no proven link between cause and effect. And it might be worth remembering some of the ideas we’ve acted upon as though they were facts:

  • the calorie theory of obesity (now under challenge)
  • the cholesterol/saturated fat theory of cardio vascular disease ( now ditto)
  • that merging back office functions saves money  (almost always followed 6-7 years later by the fact that disentangling shared services is much more cost effective)
  • increasing efficiency reduces costs (it doesn’t, some defined parts of the system are done quicker or cheaper but inevitably cause higher costs overall)
  • the wholesale introduction in many businesses of Business Process Re-engineering (now widely seen as a total and hugely expensive failure)
  • the Washington Consensus as the means of preparing  developing countries for globalisation (widely castigated)
  • choice and competition lead to increased quality and affordability ……

If we look at these initiatives  we can notice that we often measure their success by looking at a proxy outcome rather than the one we care about. For example we don’t measure the reduction in cardiovascular incidents but cholesterol levels. We don’t look at whether public services are increasing in quality and affordability but whether we have introduced choice and competition.

If we treated them as theories instead of as facts we would behave differently wouldn’t we? We would proceed with care, we’d measure the outcomes we truly cared about, we’d assume that in different circumstances things may be different and adjust an implementation accordingly. We might stop top down change and allow local teams to make decisions based on an understanding of the theory and of their local setting.

The future is as messy and complex as the present

A large part of the problem is that reality, the complex world around us of which we are a part, is so vastly, mind-bogglingly complex we cannot grasp it logically, cannot describe it, cannot fully understand it. We can usually sense more than we can describe, but muddling through is all we can do, that is after all what living is all about.

We can build islands of puzzles in this swamp of mess, and for each island we can establish evidence of some cause and effect relationship. But then are tempted to string these isolated islands together into a logical argument that we find very appealing – perhaps because it renders that complex mystifying reality tame and amenable.
Pursuing the logical ideas developed in Business Schools is attractive because it avoid us having to understand the mess around us and allows us to focus instead on a simple, logically described, imaginary future. When we get there of course it is not like that at all, it is just as much a mess as the present.

What do I mean? let’s look at an example, let’s think of the current ‘solution’ to the financial problems of the NHS: closure of local hospitals in favour of increasing care closer to home and the development of much larger specialist centres.

It’s an idea. Based on just the kind of ‘islands’ of evidence I’ve just described. There is a logic to it, and if the only things driving the behaviour of this massively complex system (relations between the NHS and the UK public) were logical choices within a few carefully described situations then this might work. But reality is SO much more complex than that, behaviours aren’t logical, situations are never as straightforward as they seem in prospect,  and there is simply no chance at all that what happens in practice will look anything at all like the picture described by the planners.

So what can we do instead?

Suppose that instead of using logic to try to  build a nice (logical) attractive but unattainable future we attended to understanding and responding to the present? Suppose we used a simple hard approach rather than a complicated easy one? Suppose we used verbs instead of abstract nouns?

For example: instead of lots of theoretical thinking about ‘innovation’ (abstract noun) we might talk of real people wanting to offer the greatest help to their patients and constantly looking for better ways of doing so (lots of verbs and concrete nouns here).

Then instead of setting up Institutes and developing Diffusion Strategies and Programmes to address the ‘Gap’ between research findings and uptake (all of which are not only complicated easy but hugely expensive), we would talk with people, make sure everyone had regular ongoing conversations with people more experienced than they, about how they are doing, about new ideas, about what is valuable about existing practices as well as what can be done better and differently. This is simple and hard, and it can happen alongside other activities so it doesn’t cost money, what it needs willingness, courage, interest, and judgement.

If we really attended to the present, we would look (really look) at what stopped people being more proactive, and we would find all sorts of things. We would realise that one of the biggest barriers is the status differences between different professions, and the fear of speaking out that this engenders. When we understood that we could teach people how to use their status wisely and well, and not unwittingly abuse it, and we could help people know how to recognise the difference when they see it in others, and give them permission and support to challenge if they choose. You see? paying attention to the proesent takes us in different directions from thinking about the future.

These sound like semantic differnces but if we change our language, we stay with the simple hard, and if we stick ot the simple hard we attend to the present rather than the future, and   we change what we see as important,

Try it for yourself
Think of something you know needs improving. Take a piece of paper and write the heading ‘innovations to improve X’. Make your list.

Now put that on one side and think about what it is you really care about here. Picture it in as much detail as you can. Why X needs to be better. What good kinds of better might look like. How much you want it to be different, what is getting in the way of it being different, and what you value about the way it is at the moment. Try and use verbs to describe things.
And then see what happens. See if often over the next few hours and days you come across all sorts of ideas, snippets of ideas, thoughts, ways forward, in all sorts of unexpected places. See if these build into something very different from the list of innovations you made. Often when we clearly understand the problem and care about it being resolved we become a sort of fertile ground and we find and grow all sorts of seeds!

Is that what you find???

Valerie Iles

1 September 2014

A different kind of conference

mainview_halfscreenI love the Think About Health conferences.
In a world where the prevailing discourse is dominated by management- speak and heartless  variants on outdated economic theories,  I see them as jewels: rare and valuable.

If I could go to only one conference a year it would be this one -there are so few places where it is possible to explore issues in depth and breadth, to come across thoughts and ideas that can change the way you look at the world, and allow you to re-engage with outside world, reminded of what it is important to fight for.  It’s also always in the delightful setting of the ex Cadbury family home at Woodbroke in Birmingham.

Does this sound refreshing? If so what are you doing on 19th and 20th June? If you are interested in discussions that are both thoughtful and practical, and on issues of profound significance to health care, do think of coming along.

This year I am one of the organisers and the theme is Flourishing, and more particularly Flourishing in Difficult Times. Our thesis is that while flourishing sounds like a luxury, a ‘nice-to-have’ that cannot be afforded in times of austerity, it is in hard times that it becomes of critical importance. After all, when money is short it is especially important not to make wrong choices about how to spend it, and our suggestion is that, if we focus on anything other than flourishing, that is just what we will do. Moving on from that we will explore practical ways in which this might be done.

Because contributors are encouraged to contribute ideas they themselves are exploring, these conferences allow fresh new thinking to meet reflective discussion. For that reason they can be difficult to promote – the contributors haven’t finalised their offering into a neat publicity- friendly title until too late to include on promotional material – so it can be a bit of a leap of faith to book!

Key speakers this year include the following (and remember that the description of their subject so underplays the richness with which it will be explored!):
Iona Heath – Immediate past president of the RCGP and inspiring, thoughtful contributor to the BMJ over many years. Iona will consider the role of kindness in flourishing.
Hugh Middelton – drawing on his wide ranging interests as consultant psychiatrist and sociologist Hugh will look at whether our modern conceptions of adversity prevent us from using it as an important stimulus to realising our potential.
And me, Valerie Iles. I am looking at the importance of acknowledging and anticipating death in our ability to flourish, and at dying  as a setting in which we could flourish.

All of us will look at the practicalities of building our thinking  into day- to- day service in the NHS, at simple ways in which flourishing could become core to the service.

But the heavy lifting of the thinking is done in small groups, reflecting together on the issues raised.  So in the course of two days there will be a chance to think (both practically and philosophically) about:

What do we know about flourishing? How does a focus on flourishing lead us to making different choices from a focus on other things? How can we bring that insight into our everyday roles?  

What does it mean for health care users to flourish? How would a focus on this be different to that of current health care? What would have to be different and how can we bring that about?

How can health professionals contribute to the flourishing of others and at the same time to their own? Are there simple, practical changes we could make that allow HCPs to flourish?

How can we support and encourage flourishing amidst ongoing and severe material health care inequalities?

How can we help people to  flourish in the context of disease, diminishment, and death?

How can communities flourish and achieve their health and other potentials?

This year too we are ‘twinning’ with the Human Values for Health Forum  conference on the same theme. This is held three weeks earlier on 2nd June, and  Paquita de Zulueta has lined up a wonderfully star studded set of speakers: Mark Vernon, Oliver James, Edward Skidelsky, Hazel Stutely, and Anya de longh.


Each speaker will leave the audience with a question, a thought, or a challenge, for further discussion. Some of that discussion will take place on that day, but there will be further opportunities to explore these ‘gauntlets’ (thrown down for us to pick up) in our two days at Woodbroke.

If, like me, you value the combination of novel, quality thinking with practical implications, do come and join us on at least one of these two conferences. I think you will come away refreshed and re-energised. They are amazingly reasonably priced (all three days for less than a typical day at the Kings Fund),  and just so different from what you will find elsewhere.

Book here for the two day Think About Health conference Flourishing in Difficult Times on June 19th and 20th

Book here for the HVHF conference Flourishing in Adversity on June 2nd.






Is Change Day the way to foster a spirit of innovation across the NHS?

4 March 2014

You know that feeling when you come across an idea so interesting you feel you may never again see the world in the same light? That’s how I felt when one of the delightful Think About Health  conferences introduced me to the phrase ‘the metaphysics of language’ – the notion that we shape the world by the way we talk of it.

Here’s an example: we say ‘I’ve had an idea’, or ‘it was his idea’, or even ‘she was given the Nobel prize for her ideas about…’ but how do we know it was that way round? Suppose it was the idea that ‘had ‘ us? That would feel the same wouldn’t  it? One moment the idea wasn’t there, and the next it was? This is almost the territory of memes and ‘the selfish meme’, in which we and our behaviours are vehicles for the survival of the fittest idea (that is not the fittest for us, but the one that has a survival advantage among ideas!).

Alternatively we could describe an idea as an emergent property of a complex system, the idea as a result of the interaction between you and your environment. Can we really then say it was your idea, that ‘you had it’?

Both of these are more accurately described in the phrase ‘it came to me that….’  which, oddly,  we don’t seem to use so much nowadays. Why is that I wonder? Is it because intellectual property rights now form part of WTO trade agreements? Because it’s in the interests of large Corporates to have us believe that ideas belong to the person or company that ‘had’ them?

It was American sociologist Robert Merton who coined the terms ‘heroic inventor’ and  multiple discovery(that the same idea is often developed by different people quite independently of each other at about the same time), coming down solidly in favour of the latter.

Merton was a prodigiously interesting man who conceived so many valuable terms it’s difficult to imagine a working day without quoting him. ‘Role model’ for example; ‘self fulfilling prophecy’; ‘law of unintended consequences’. He was working mid 20th century, when sociology and other humanities were valued by decision makers and seen as attractive careers. Sadly they were elbowed out in the neoliberal take-over of intellectual discourse from the ‘80s onwards, and became either enslaved to the corporate world or seen as irrelevant and dismissable.

Is it any wonder that having narrowed so substantially the range of subjects studied we now have to make calls for increasing innovation? Once it could emerge spontaneously from a melting pot made up of minds approaching  a problem from a multiplicity of standpoints, now there is a dull uniformity of view. How would health care organisations look different, I wonder, if they were managed by sociologists, anthropologists, historians, geographers, theologians, graduates with English literature and fine arts degrees and others, instead of only economists and MBAs?

No, creativity and innovation need diversity in which to thrive. They also need permission. To be creative we need to feel able to make a difference. We need to feel our ideas can translate into action that will be welcomed. Although there are many benefits to protocols and guidelines the way these are implemented can lead to the opposite – a feeling that suggestions aren’t allowed, that  the protocol is fixed and unchangeable, or that new ideas must get caught up in governance procedures. . Clearly the use of evidence is vital but surely we can find ways of using it that feel empowering rather than restrictive.

Now it takes NHS Change Day  to give people the permission and motivation to make changes they could make any or every other day. The enthusiasm with which staff have embraced it indicates just how much creative energy is going untapped, and It’s terrific (and significant) that it was devised by three front line clinicians. Perhaps I am being unduly cautious  but personally I’m a little concerned that it’s been seized upon and centralised and turned into a multimillion pound splurge by NHS IQ. I’m sure it has gained in publicity and scale, but wonder whether it has it lost heart? Whether it will lose its guiding enthusiasm. If it becomes part of the centralised machinery instead of being an outsider can it enable genuinely new thinking? Isn’t creativity rather like these wild mustangs?  I wonder whether when corralled it  loses its essence, it becomes tame, it becomes something else?

So if that energy for change is there, just waiting for the permission and motivation of Change Day, how could we offer those on a more consistent basis?  Imagine that every member of staff was part of an ongoing conversation with someone more experienced than themselves about how they were doing, about their ambitions, enthusiasms and concerns, and about the performance and potential of the service. Imagine that in the course of this conversation they were supported and endorsed for things they were doing well, challenged, gently but effectively about aspects they could valuably improve upon, and generally enabled to be the best they could be. That is called management. Actually it’s what I call really managing, and I don’t see anyone doing this.

This is so vital a part of organisational life that without it we have had a vacuum, a vacuum that has inevitably filled with vastly more expensive and disempowering activities such as ‘leadership’ and ‘governance’. It’s my belief that giving senior clinicians the skills to support, challenge and enable their juniors in this way would save the NHS billions even as it improved outcomes and care experience. And that this would be a far more effective way of encouraging innovation and creativity than trying to ‘incentivise’ them, to command them, to control them, to measure the return on our investment, to set them targets, to insist on tests of ‘scaleability’.  

So I suggest that one very good use of Change Day would be to prompt us to rethink how we support front line staff – so that Change Day becomes Change Year, year in and year out.

But we also need to think wider than the NHS, after all, NHS staff form 1 in 50 of our national population, so whatever is happening in society in general will be shaping the NHS.  So we need to take an interest in the  intellectual diversity of our wider society – currently (I suggest) diminishing even faster than biodiversity. Just look at how our mainstream media have succumbed to a monochrome world in which the news conforms to stereotypical stories of goodies versus baddies that add little to our ability to understand complex arguments relevant to the world we live in.

Even the BBC (whose website, with its fantastic array of the most wonderful programme podcasts, shows us just what fantastic value this much maligned institution is, and just how much treasure can be made for such a paltry licence fee) has reduced the Today programme to a set of ridiculous jousts between opposing views on topics that require much more nuanced consideration. Question Time panelists are limited to identikit politicians (mis)quoting dead economists, and the occasional approval- seeking satirist. Imagine instead a panel of politically thoughtful  physicist, historian, social geographer and ethicist one week, followed by sociologist, biologist, political philosopher and psychologist the next. Wouldn’t those be thought-provoking discussions worth listening to?

No wonder that many of us are choosing to follow fascinating leads on Twitter instead. And that we still seek considered, well made arguments in books . (Although personally I find I have to choose between one and the other, with lengthy periods devoted to one but not both). Indeed we seem to be dividing into parallel streams of awareness: those addicted to news on demand, and those who tune in once a day (to find out whether we’ve declared war) and otherwise apply their intelligence and attention to things of importance.

As part of our wider interest we must not allow ourselves to believe that innovation is more readily fostered in the private sector, there is growing evidence  that the intellectual contribution and risk taking of the public sector dwarfs that of the private.

So, if we truly care for creativity and innovation we must challenge a lot of current assumptions. We must stop assuming the private sector is better at it, stop thinking that it has to be ‘incentivised’ and financially rewarded, and instead put in place the conditions that allow it to emerge.

We could re-widen the range of subjects supported within universities,  re-introduce apprenticeships so that more of our young people can learn-by-doing, in a supportive environment, and innovate that way too. We could reconsider university tuition fees and encourage in students a sense of commitment to society, and a desire to make a contribution.

We could call for changes in the World Trade Organisation rules on Intellectual Property Rights and re-find an ability to enjoy being part of an idea as it emerges without either slapping in a claim of ownership, or whisking it away to be up-scaled and centralised.

We could recruit people, to positions right across our organisations and our governments (from seniors  to newcomers),  who have an interesting intellectual hinterland.  

And we ourselves could start right now by picking up a book instead of a newspaper!

Idealistic? Impossible? Perhaps. But no less so than vainly hoping for fruitful valuable, health and planet saving innovations from an increasingly arid managerialist landscape. And we can each play a part in bringing it into being……


Very interesting. I have often wondered if we had social scientists for example, maybe undertaking ethnographic approaches to public inquiries, what would the recommendations look like? How much might they differ from a barrister’s view, or a politician’s? Thorough though the Francis and other public Inquiries have been, some of the recommendations might be difficult to implement, and some of the findings might have been enriched if different perspectives were at work. I certainly think a skilful qualitative researcher could have helped me discover and share some insights from my experience of working in the system responsible for the poor care provided in some wards in Mid Staffs , whereas a pugilistic inquisition, in a public gallery, rendered me incapable of coherent thought let alone speech…      Yvonne Sawbridge, Senior Fellow, Health Services Management Centre, University of Birmingham

If culture eats strategy for breakfast what does a strategy to change culture look like?

5 November 2013

 I wonder if there is a term for an allergy to certain phrases? My metaphorical histamine levels are being triggered at the moment by two: delivering ‘at pace’ (which seems to have replaced the equally irritating ‘quick wins’ in meaning (well you know what it means) lots of frenetic activity and little real impact, and ‘culture eats strategy for breakfast’ .

Originally coined by Peter Drucker, the latter is of course true – we’ve watched culture defeat strategy time and again; and a healthy culture supports good day-to-day decision-making in a way that the most brilliant strategy simply cannot.

 No, it’s where it takes us that is the problem. What do the people telling us this want us to do next? Surely they can’t want us to introduce a strategy to change the culture?!  (One that will be eaten by that culture?). My fear is that they do.

 But if some of us see that for the conundrum that it is,  what is our solution?  I suggest we will only find one if we try to understand both culture and strategy much better, and  before we rush into implementing (at pace!) a raft of well-intentioned but misguided attempts at change – that will at best irritate and at worst alienate.

 So what do we know about culture?

 We know that culture strongly influences (even determines) many of the default decisions we all make everyday, the ones beneath our awareness, the ones we make on autopilot.  Another (related) suggestion is that culture is those default decisions that members of a group share. In other words, default decisions are both effect and cause of a group’s culture. Personally I find that one of the most useful ways of seeing culture, but we need to explore it further before we can think about how any of us can influence it.

 If we do so, if we think about those decisions we make on autopilot,  we realise that they form the  overwhelming majority of decisions we make every day. Buddhists and neuroscientists tell us that we make these based on instantaneous judgments equally underneath our radar in which we  rate everything we are exposed to as something we like,  don’t like, or something  we can ignore. It is these instinctive reactions that lead to actual thoughts, and these thoughts prompt others and others, in a rapid sequence. We know too that these sequences have a familiar pattern, a pattern of thinking and reacting that is distinctive to ourselves. And that we only become aware of these patterns when we pay explicit attention to the behaviours our mind (without asking our permission!) engages in.

 If we are going to change a culture we need to change some of these patterns, but how? Well we know how to do that on an individual basis, and perhaps there are lessons there for influencing the culture that (as we have seen is both a cause and effect of these.

 This observing of our patterns of thinking is one of the fundamental roles of meditation. Or rather, this is the role of one of the three fundamental forms of meditation, the three being:

1.       ‘losing our minds and coming to our senses’: by focusing on the moment by moment experiences within our body as we breathe, stilling our mind’s propensity to jump from thought to thought like a monkey jumping from branch to branch, without our intention, permission or awareness, developing our ability to stay in the here and now.

2.   ‘showing up for what comes up’: simply noticing, without trying to change them, the thoughts and feelings that arise, noticing patterns, sometimes labelling some of these thoughts, but always allowing them to come, accepting them,  and letting them go wherever they do without any interference, simply staying aware of them. We can describe this as developing the observing self

3. fostering healthier patterns of reaction (including compassion) by practising them.

 All three can be helpful in considering how to influence culture but it is developing that ability to go into the ‘observing self’, whether on the meditation cushion or in the middle of the hurlyburly of everyday life, that allows us to come to recognise some thought patterns as old friends, see how unhelpful they are, and in that recognition give ourselves choices.

 ‘Oh this is me judging and blaming again, how else could I react to this?’. ‘Oh yes, I’m taking this personally again, is that really reasonable?’. ‘I want to be right again, I’m arguing to prove I’m right, is that the most important thing here?’.

 Over time the observing self becomes more able, more skilled at interrupting some of these unhelpful patterns. But our ability to move into it is of course influenced, and often  opposed, by the culture we are working or living in.

 In  a world in which our media headlines delight in labelling this person or that group as blameworthy (as wicked, or stupid, or both), it is more difficult for us to resist that temptation ourselves and instead of seeking the underlying causes of an action, or being prepared to accept that sometimes things that are bad or sad just do happen, we angrily and self righteously join in the calls for retribution.

 Brene Brown’s research shows clearly the impact of this fear and blame and subsequent shame, on our enjoyment of our lives, and it is this that so often drives the culture on wards and in departments or surgeries, the culture that we want to change. So we do need to find ways of  doing so, but in ways that do not themselves induce fear, blame or shame. it would be tragic if in our quest for a healthier culture we instead increase those levels, and I can’t  help wondering whether a duty of candour will do just that.

 So what can we do? Let’s think again about strategy

 It helps to remember that there is more than one way of developing and implementing strategy.

 If we look across the strategy literature (the very plentiful strategy literature!) we find at root three distinctly different strategic approaches. There is a planned approach, in which an (often quantitative) analysis is followed by a plan, implemented by project management methods and evaluated accordingly. This is what that most people mean when they talk of strategy, but it is not the only way.

 There is an emergent approach, first described in that language by Henry Mintzberg,  in which the strategists (often insiders with an in-depth understanding of the organisation that is as intuitive as it is analytical) observe the day-to-day decisions that are being made and reflect back to the organisation the pattern that these form (the ‘strategy in action’ that is being followed), and gently but purposefully foster some behaviours and decisions and discourage others.

 And there is a more spontaneous ‘in the moment’ approach, advocated by complexity theorists, who set a strategic  intention and then focus on the quality of the interactions between the elements  of their complex system – and in health care these components are mostly people. So the attention here is on understanding others, empathising with them and their concerns, supporting them when they are behaving in ways that support the intention, and challenging them (gracefully, firmly, effectively) when they are not. This could be summarised as ‘intention, kindness, going towards the difficult’, a phrase that which mindfulness practitioners will recognise.  

 (To read more about these three approaches to strategy click here.)

 It is the first of these (the planned strategy) that is so often eaten for breakfast by culture. The other two are still open to us, indeed in many ways they are the organisational equivalent of mindful meditation. So, how might we use them to  move forward?

 We could certainly encourage personal practices of mindfulness, not by prescription but by example, but we could also examine our routine organisational processes. We could see whether they are encouraging a confident and  energetic ambition to empathise with others and seek to meet their needs or instead promoting fear, blame and shame.  

 Ward handovers for example: do they focus simply on risks to beware of  in the upcoming shift? Or do they:

  • reflect on what to celebrate from the shift just ending?
  • voice some realistic positive ambitions for patients in the one just starting (of which avoiding risks will be a part but only a part)?
  • and take a moment to feel part of a wider team, across different shifts, all under pressure but all caring about the same sort of things.

 I think we all know the answer, and people protest that to do anything different would take too much time. But I’m not convinced that what I’m suggesting would need to take longer than the existing arrangements but even if it did , the extra few minutes would so positively affect the culture on the ward throughout that shift, and over time, on a more permanent basis, that it would be a hugely worthwhile investment. (Part of our current culture is that  we see time as a cost and not as an investment).

 What about other routine processes – at all levels? Performance management processes. Board meetings. Let’s think about the kind of conversations between GP receptionists and patients perhaps,  and the kind of conversations between GPs and receptionists that shape those? Do they concentrate on pressures, on tactics to contain demand, increasing the feelings of helpless embattlement felt by both receptionists and patients? Or do they refer to the ambitions of the practice to support patients and community and meet needs as well and creatively as possible? What kind of conversations between GPs and  those commissioning and contracting them are most likely to encourage the latter rather than replicate the former?

 If we recognise that looking at our routine organisational processes in this way is an organisational form of mindfulness, we will also look for common patterns in those routines, patterns based on fear, blame and shame, and start to challenge these wherever we see them, becoming gradually more skilful in our ability  to do so .

 SO   if culture eats strategy for breakfast, how do we craft a strategy to change culture ?

 Well we start by rejecting the idea of a strategic plan (because that will be well and truly eaten) and we opt for a more emergent approach that recognises complexity, and that recognises deep-seated fears and anxieties. We acknowledge that culture is something each and every one of us contributes to, and we think about  how we ourselves are contributing to a culture of which we do not want to be a part.

 We see all of our interactions with others as a chance to embody a different culture and encourage them to do the same. We look at the organisational processes and systems that we participate in and consider whether they focus on fear, blame and shame or on celebration, positive caring ambitions, and a sense of connection with others.

 Gandhi may not have actually used the words ‘be the change you want to see in the world’ (apparently this is a ‘bumper sticker’ version of a much longer discussion) but that is the spirit we need.

And one implication of that, of course, is that we should actively ignore anyone calling for a change in culture, or insisting on particular ways of changing our culture, who fails to actively demonstrate in their own actions the culture that we want to see.

 We must each start where we are, gently but purposefully,  with ourselves.