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

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