DEMOS

I thought last night's programme was fascinating. Gerry wandered the corridors of Rotherham hospital, met with consultants, nurses, anaesthetists (whom everyone disliked) questioning everyone’s habits, traditions and work.

Some of the problems highlighted by Gerry were: 

• Problems in working relationships between different professional groups
• Tensions between clinical and management lines of authority
• Underutilisation of operating theatres
• Poor coordination between different areas of the hospital leading to delays in patients getting to theatre
• Lack of an integrative management structure to actively manage performance

Gerry identified the operating theatres (the engines of the hospital) as one area ripe for change and waiting lists. Simple ideas that could make a positive difference were continually bogged down in committees, with different groups jealously guarding their own turf and working habits. By the end of the programme he had dramatically reduced the waiting times for children (by supporting a manager’s idea of consultants taking on one or two more cases per day) and making more use of the empty theatres.

One bit of the programme that did strike a chord was the work of a consultant who was breaking rules left, right and centre. Instead of the traditional shift patterns and working to a set list, he had organised his team differently, with traditional working practices struck off. The difference was palpable – he was able to see more patients, work more efficiently, and was able to use his and his team’s time more effectively. It was a shame, therefore, we learnt at the end of the programme he was planning on leaving….  

I didn’t see the first episode last night but reading Gerry Robinson’s interview in The Telegraph raised some interesting points.

Suggestions about red-tape and politicisation are real ‘no-brainers’;

There is no organisation that doesn’t want less bureaucracy – the problem for the NHS is that in an organisation so large and complex simplifying processes and systems is a truly titanic task. The real question is how? Maybe the NHS needs dedicated ‘systems analyst’ departments (in the wider, not IT sense).

De-politicising the NHS is what its staff have been asking for, for years. The NHS was created and came to maturity as a result of the post-war consensus, and has arguably suffered since this was dismantled by the Thatcher government. The problem with a de-politicised NHS is where do you then relocate democratic accountability? Also an ‘independent’ governing body may not be willing to make difficult and radical strategic decisions in the same way as a government with a strong mandate for change. Perhaps Cameron’s halfway house may be a model worth exploring.

Gerry Robinson’s focus on waiting times is also questionable. More important is the quality of treatment; it may be better to wait a few weeks to receive high quality care than receive average care immediately.

Robinson also states that the NHS should listen to its staff, yet in his example of not using operating theatres on Fridays, he makes no comment about how he would satisfactorily resolve the clinical concerns underlying this behaviour. This, I feel, is at the heart of the problem for the NHS. Clinical staff give little thought to the financial implications of their behaviours whilst managers may strive for ‘efficiency’ at the cost of clinical considerations.

No real thought has been given to an operating methodology that can unite both clinical and financial concerns, and I think part of the problem has been the hiving off of clinical and managerial duties into different roles, and subsequent tussles for power. A better alternative is to actually give consultants responsibility for their budgets and train medical students in business and management practice. This may lead to more accountable and efficient behaviours and a management culture more sensitive to the relationship between clinical and financial imperatives.

Finally is the suggestion that what the NHS needs is a superhero Chief Exec. Whilst I do not doubt that a strong and talented leader is required, the idea that they can turn round the NHS under the sheer force of their talent is ridiculous (see Henry Mintzburg’s thought on this). In terms of numbers, the NHS may be the third largest organisation in the world (after the Chinese Army and the Indian State Railway), but it is far and away the most complex organisational entity that has ever existed. It is in an entirely different quantum to any business model (a quick look at the world's biggest companies shows that none of these are service organisations, and none dealing with anything as complicated as human lives). To think that a Chief Exec may walk away humming to themselves that they’ve sorted the NHS is laughable, and is indicative of the mythological status of private sector competence. Of course the NHS can learn from business practice (such as this example of the implementation of lean management techniques), but I think ultimately the NHS will have to be rescued with its own unique solutions.

This programme was excellent and I hope the series continues at this standard. I was struck by a nurse’s description of a staff ‘communication’ meeting; the senior consultants were all seated safely at the back row, in front of them were the more junior consultant and so on down to the nurses… who were ‘squeezed out to the ides’.

It was that kind of reality that led me to resign from a Scottish Health Council. These Councils were meant to give voice to NHS patient and service users issues. In my experience they were the equivalent to ‘peeing against the wind’ in the face of the contending and conflicting medical and union interests.

I also found sympathy with Gerry’s complaint that ‘no-one actually seemed to manage anything’. Again in my experience ojn the Health Council it seemed to me that as soon as you stepped out the medical disciplines there was a real dearth of competence – I mean this as a corporate competence, because there were many capable generalist managers in the service but they were constantly struggling against the vested interests; principally unions and, above all, the mighty consultants.

Speaking of consultants and vested interests; my one significant disagreement with Gerry was his ‘sack the consultants’ (I take it he meant outside consultants i.e. management consultants). This is a tired old cliché. My counter is always to ask what is to be done with those senior decision-makers in a public service who actually go on in unaccountable ways, hiring consultants on an over-costly basis and on bad briefs and then impose the consultants on an at-best reluctant and bemused staff. None of that has anything to do with the much-aligned consultants, but everything to do with the permanent decision-makers who will long outlast the stay of the consultants.

I am not sure I agree with your second point Faizal that simplifying processes and systems is a titanic task – it may be across the NHS and it is certainly true to say that cutting through the bureaucracy is going to be difficult but I thought it was interesting to watch how relatively simple Gerry Robinson made the processes of change to be (not all in the editing I hope). He identified the priorities, worked with the relevant people and persisted until change happened, and most importantly he let people feel they were in charge of changing the system and supported them where necessary.

I think you will also find that suggesting a super chief executive was more a refection of Gerry’s personality than a realistic alternative to the current situation!

Surely Edward there are good and legitimate reasons for getting rid of some management consultants at the same time as questioning the work of senior members of staff who employ them?  

Charlie, yes your right that there must be good reasons for getting rid of some management consultants. This must be a logical inference from my assertion of a lack competence and due diligence in appointing them in the first place.

My main point was that the cry of ‘sack the consultants!’ is an easy and populist cliché that serves to distract from other, more pertinent matters.

Incidentally, most consultants would rather be employed on good, tight, value-for-money briefs that enable them to deliver a higher quality outcome. That, of course, enables them to better develop more skills to resell on other contracts and add a lot more to their reputation than they ever would under an over-paid but poor outcome and litigious contract). In the consultancy business, the term the ‘intelligent client’ refers to this scenario.

My twopenny’s worth:

 

Firstly, if it’s impossible to disagree with a sentence i don’t think it means anything. ‘Cut red tape’, for example. What’s the alternative position to that? ‘Increase red tape’? Every opposition in history has said it’s going to do this – what matters is how.

 

Second, some of the other suggestions seem to make sense...on paper...in general terms...but who is the advice for? Policians? Or managers of hospitals?

 

The government already focusses on waiting times, for example. And a good number of people think that this simply produces unintended consequences (people being left off waiting lists altogether, for example) which actually damage overall performance. Would the same be true of the operating theatre suggestion? Who knows. But that’s the point.

 

I vote for Faizal’a systems point. At the moment the whole system seems far too centralised – junior doctors told where they can work and where they can’t (yet we still have surpluses/shortages in successive years); hospitals told how many people should be on waiting lists at any one time; managers told what the turn-around time should be for  illness (a) or operation (b).

 

I imagine saving the NHS means considerably different things in diffierent areas + different hospitals, so why blanket instructions (as opposed to blanket entitlements for patients) are likely to fix it i’m not sure. Robinson may have some ideas to turn round a hospital, but is it the right prescription (get it?) for the NHS?

 

Oh yeah, and what about the Wanless report...

So what did people think to the final episode in the series?

I felt Gerry had come away from the battlefield of bureaucracy a victor. He had lowered waiting lists, empowered frontline staff at Rotherham Hospital to realise their ideas, and imbued the Chief Executive with a sense of confidence. He had slowly begun to transform the hosptial's culture. And then he went to the Department of Health and it all began to fall apart. While Pat Hewitt argued that the department had given all their money to the frontline Gerry kept wincing and rubbing his face – his trademark ‘isn’t this all so frustrating act’. Irritatingly the system won (or was this a cunning ruse by the Open University for a dramatic sequel?) If only Gerry could become a Lord….

Flippancy aside it was disheartening to see his conquests slowly disappear under the red tape of central government (sorry Duncan). What I think the series proved was that leadership, empowerment, a culture of trial and error, openness and sharing ideas at the frontline/shop floor brings results. Which is why we should look again at Jake Chapman’s system failure.

Disappointing the techie problems here much delayed my posting but here goes anyway.

The significant lessons were about leaders giving leadership and winning legitimacy, about shop-floor empowerment and all round teamwork and the politicisation of any targets externally imposed.

The construction industry may have lessons to offer the NHS and other ‘unfit for purpose’ organisations (nudge, wink). The larger-scale construction industry has gone through its Egan Report ‘Rethinking Construction’ and implementation of Total Quality Management systems such as the Europe-wide ISO 9000. Above all, these systems aim at achieving benefits through continuous organisational learning and continuous improvement of all-round team performance.

Two critical aspects to this are, firstly that the continuous learning celebrates what works best and ensures that unintended consequences are either countered – or capitalised upon. Second, is the all-round team empowerment and responsibility; no more senior consultants skulking in the back row and withholding their consents.

I have seen this EGAN/TQM approach working in very graphic terms at the end of a construction contract when the project team peer-group scores are collated on every participant – it’s quite a sight to behold when the lowly clerk of works’s peer group score the developer’s site agents are integrated into the overall performance score for the agent. The scorings are criteria-based and not ‘popularity’ scores. I understand that this forms part of the reference that the next client can ask to see. Some of those senior consultants might find that all a bit of a culture change… nurses scoring the consultant’s performance in contributing to team achievement, whatever next?

I was left by the end of all this with a feeling of whenever I saw Gerry walking down a corridor saying something like ‘I think we are making/have made real progress on this’, I would cover my eyes and know that somehow he was just in for another kicking. I really thought that Patricia Hewitt’s ‘performance’ was so typical of a certain type of Minister– an unblinking and unlearning ‘but we have it all right and we have a justification to anything you raise’

All-in-all an excellent series and we could do with more (but please of course, not on my work, or in the sector I work in).