Although I don’t always agree with Polly Toynbee, I thought this was an interesting article on the challenges of NHS Financial (and other back of house) management. Worth a quick scan at least:
This is a really interesting paper from Deloitte Australia, about the origins and costs of having too much red tape. Whilst acknowledging that rules are necessary to prevent anarchy, the paper talks about how overlapping rules, multiple conflicting compliance regimes and over caution stifle businesses and cost the Autralian Economy an estimated $249AUS billion a year.
Another interesting finding in the paper was that the private sector is, at least in Australia, no role model for the public sector. The private sector was as likely to be drowning in foolish, contradictory rules as the government. The paper talks about one company that introduced compulsory ergonomic checklist forms for each employee to fill in every time they changed desk or chair, and then imposed universal hot desking, costing 20 minutes per employee every single day. Another company introduced an “approval to seek approval” process with so many hand offs that it took 270 days.
As well as the interesting case studies, the paper produces some steps for reducing rules – 5Cs, in the best tradition of alliterative management techniques. I hope that Deloitte will forgive me quoting verbatim, as their language is a little punchier than I’m used to in policy documents!:
“Cleanse:
Slash the stupidity – ask staff to list thedumbest things they are required to do as a result of the business’s own rules, then stop doing them.
Challenge:
Businesses should stop asking “What could go wrong?” and focus on “What must go right?”, then challenge their rules in that light. What are their rules really trying to achieve, could they be improved and are they cost-effective? If not, there may be more to dump.
Create:
Foster a culture focused on performance rather than compliance, and ensure the organisation’s rule-makers are aligned to its business goals.
Change:
Businesses and others should change the way they set new rules and audit old ones to better link rules with strategy and risk appetite.
Capitalise:
Make the most of these changes to realise the business’s full potential.
I think these are great headlines when reviewing processes. Of course, in the British Public Sector, some of the rules we follow are legislative and we don’t have a choice. But there are many places I’ve worked where internal rules have grown up around the legislation, often intended to be helpful. I worked in one place, some time ago, where three separate teams had to review each job description to ensure consistency, but didn’t know roles in each others’ teams well enough to spot actual errors. There is a lot of potential for improving productivity even in small ways, by taking small delays and irritants out of processes. Worth bearing in mind!
NHS Change Day is, for those of you who aren’t familiar with it, a ground-up change movement that is increasingly spreading beyond the NHS to health and social care as a whole.
It has a very simple idea; members of staff and volunteers are encouraged to make a pledge to make small, simple pledges to make something better in the NHS, and then do it. A large part of its power is that the changes are easily do-able. No one is encouraged to say “single handedly overthrow the unfair levers in the tariff system.” It’s more likely to be “I will remember to introduce myself to my patients, no matter how busy the department is.” And this is why it works. Each of those small changes makes life better for patients, a little at a time, in the ways that matter to them.
So I was sad to read this blog here: http://rolobotrambles.com/2015/03/06/what-i-learnt-this-week-whose-change-is-it-anyway-wiltw/
The blog is by a doctor who was instrumental in setting it up in the first place, talking about the criticism he has faced for doing so. People have said that the changes are too small – that, for example, smiling and introducing yourself are weak changes, that people should be doing anyway, that it’s reactionary, and that it’s just a surface level response to the Francis report based on mollifying the press.
These attitudes are typical of a sort of aggressive helplessness you find all too often in the corners of the Public Sector. Because NHS Change Day won’t cure everything at once, because it won’t tackle underfunding or bring about overnight parity for mental health, it’s dismissed as worthless. And not only do the cynics refuse to join in, which is absolutely fine, they attack those that do as somehow letting the side down. We should all sit around waiting for the revolution.
But small changes do save lives, let alone make things better for patients. Remembering to check something every time will have an impact. And there is a vast literature around the power of public statements. If you say something in front of everyone – your friends, your colleagues, that pain from down the corridor who you just don’t get on with and you would HATE for them to see you fail – you’re just more likely to actually do it, every time.
And the morale effect is huge too. Change Day trended ahead of Jeremy Clarkson on Twitter all day. Thousands of staff were connected, however briefly, with other people who are doing their best, across the country. In a sea of negative coverage, the many, many people who are delivering great care got to highlight it. People were allowed to be proud of the hard job they do.
There’s nothing especially clever or noble about attacking people for doing their best and for trying to improve things. Oh, it all sounds very convincing when you do it. But essentially the cynics are coming up with an intellectual framework for being scared to try, because the risk of failure is too great. Because they can’t fix the big problems, they refuse to start with the small ones.
And there is something wonderful about having the energy to say, “I can’t fix everything. But this one thing here, I can fix that. And I am committing to it in public. And you, my colleague, have promised this other thing – and because I know you’ve pledged, I know it bothers you. So I will help you fix that too.”
There’s a huge power in many small steps.
On that note, I am now freelancing. So I have not made a big NHS Day pledge. But I will make a small pledge here, that I will spot things I can do in each job I take on, and use this blog to tell you about them. And you can all hold me to that.
Agree totally – political point scoring isn’t going to feed anyone.
My column in Society Guardian, Monday 8th December 2014.
“Poor people don’t know how to cook”, Baroness Anne Jenkin said at the launch of the Feeding Britain report yesterday, and suddenly it was as though ten months of evidence gathering, and 160 pages of written report, hadn’t happened, cast aside to be summed up in seven words.
Welcome to the new politics, where every character counts, and every statement met with an equal and polarising one. Instead of discussing and debating the 77 recommendations in the report on Monday evening, as a former food bank user who had given oral evidence to the committee myself in July, I found myself on regional and national radio and television, being asked about Baroness Jenkin instead.
And herein one of the big problems with politics today lies: instead of discussing the issues at hand, the baying mobs on all sides are waiting in…
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It’s lovely to see HSJ campaigning for some understanding to be shown towards managers in the NHS, especially an acknowledgment from so many clinical leaders that “NHS managers are as dedicated to the service as any other group of staff”.
Most of the managers I have worked with over the years are, indeed, committed to the NHS. We chose to be here. Many managers believe they could make a lot more money in the private sector and have chosen instead to work somewhere where their actions can make a real, positive difference to other people.
Whether that’s true or not is irrelevant. The fact is that hospitals are multi-million pound organisations, employing incredibly diverse groups of people, under considerable pressure. They cannot be run without managerial talent. As the HSJ comments, some of these people are senior clinicians. Clinical leaders often manage services, set direction and make key decision. It isn’t always easy for them to take time away from their patients, of course, and I don’t know anyone who worked in the old PCTs who wasn’t desperate to include more medical professionals in service design and decision making.
But there are problems with not acknowledging that we’ll always need non-clinical managers. Who goes to medical school intending to be an HR professional, dealing with recruitment for a 3000 strong workforce? How many nurses enter a nursing degree thinking “and when I am a great senior nurse, I’m going to also be the best accountant I can be”? My role has often been to line up great clinical ideas with complex, conflicting policies and finding streams – I am sure many clinicians would be excellent at this, but it is time consuming and clinicians are often just too busy saving lives and healing the sick. I’m sure this is where the average patient expects them to be.
Some hospitals have turnovers that dwarf premier league football clubs. The NHS won’t attract the talent it needs if politicians and the press continue to deride NHS managers as bloated technocrats, sponging off the taxpayer. There are, of course, bad managers. Every profession has people who aren’t as good as they should be. But you can’t motivate a workforce to achieve by constantly telling them, and anyone who might be interested in entering it, that they are a terrible waste of time.
Managers are often in the position of having to implement cuts they’d never have chosen, and political policies that make as little sense to us as they do to clinicians. The vast majority do their best to stand by their patients, and their clinical colleagues, and the NHS. Blaming the management is easy, but it’s rarely helpful.
XKCD – a great webcomic for those who aren’t familiar – on the subject of efficiency in finding solutions to your work problems…
There are many things that are different, working in Uganda, compared with the UK, and one of them is the unreliable electricity in Gulu hospital.
To be without electricity, you do without universal, constantly accessed email, hospital switchboards, smart phones and the cultural acceptance that the right time to reply to an email is, through preference, ten minutes before it was sent. And I am also doing without access to a printer, even when I have power. This has profound effects on communication style and the pace of work, which I am struggling to adjust to in two important ways.
Incidentally, before anyone says “first world problems”, this is as much a problem for the other hospital staff members as it is for me – it’s hard to use the e-procurement system if the computers are down here, just as it would be anywhere else.
I actually have to go and knock on peoples’ doors, and sometimes, I cannot work at all.
I have got very used to lurking behind the comfort of setting up meetings in advance. This is, of course, meant to be good management – you email, you send an agenda, you set goals for the meeting. It’s all very efficient, if occasionally lacking in human warmth. But that only works if there is power to the computers, which there seldom is at the moment. Knocking on office doors, on the other hand, feels uncomfortably demanding. What if people are busy? What if I am interrupting something more important?
I’ve worked out, over the years, that these are post hoc rationalisations for “what if someone is cross with me?” I have to psyche myself up for unbooked phone calls, too. I don’t know where my terror of this Mysterious Cross Person is from. I don’t recall any particular childhood trauma or early career problems that would make this make sense. And very few people who have met me in person would credit these sudden doses of social awkwardness – I’ve been in trouble many times over my life for being overly chatty, too much of a Tigger and too questioning, so I doubt anyone would consider me a candidate for Woman Most Likely to Be Lurking Outside An Office Looking For Excuses Not to Knock. The Mysterious Cross Person is, in fact, almost certainly a nagging conscience looking for failures.
The thing is, actually talking to people works. One of my major concerns about the trend towards home working is that the actual, face to face conversation cuts out the scope for the miss-readings, loss of nuance and just plain forgetting to ask something that goes with electronic conversations. In fact in previous jobs I have nagged my teams to talk to each other face to face more and email less, and I am absolutely fine doing this with people I know. So I guess that in terms of gifts Gulu is giving me, learning to overcome my fear of the Mysterious Cross Person and talk to strangers. Who knows – next stop, networking at conferences!
And I do have plenty of slack time to draft informal agendas and pluck up the courage to knock. I don’t have a printer here, so I am reliant on soft copy – and when the battery goes in my laptop there are only so many jobs I can do on paper when my reference documents are locked in what has suddenly become a very expensive paperweight.
And this enrages the Mysterious Cross Person. I am not Doing All the Things! I am letting people down! My boss will find out and – never mind that when I have power I am still happily writing well into the night – be Terribly Terribly Angry with me!
Given that “I didn’t have any electricity” is a reasonably acceptable excuse for not emailing someone, I don’t think anyone is actually going to be Terribly Angry. Just like I am sure that no reasonable boss would object to me taking proper lunch hours, or especially mind that the only place I can reasonably charge my computer in long power cuts is the local hotel swimming pool and that the price of charging your computer there is swimming for a while. The Mysterious Cross Person thinks I should somehow be typing from the pool.
It’s harder for me to draw a lesson from my inevitable down times than from the need to talk to people in person. After all, I don’t want to lose the Mysterious Cross Person. She goads me on, it’s her credit that I have more qualifications than any one person could reasonably need, that I keep my word even if it means going out in the rain, that I do voluntary work and run 10ks. But I could do with her shutting up from time to time. She absolutely gets the “courage to change what I can” part of the desiderata but stopped listening when the bit about “serenity to accept what I can’t..” came up. There are times you have honestly run out of work arounds, there is no printer, there is no electricity, you do need the internet to check a fact.
At the moment, she and I are compromising on the idea that swimming lengths in the pool is Proper Exercise Likely to Enhance my Future Productivity. I guess I can live with that if she can.
On Saturday, I was invited to attend Gulu University’s graduation ceremony. GU is a reasonably new university, with a lot of students doing development studies, business studies, agriculture and medicine, and about 1,300 students were due to graduate.
Graduation here is a major event. The whole town seems to turn up – not just parents and partners, but a great array of doctors, politicians, officials, small children being brought along for inspiration, and delegations from partner institutions and many of the NGOs in town. I
After some traditional Acholi dancing whilst everyone settled down, there was a formal procession, complete with marching band, of the Chancellor and Faculty in their red gowns. There were government ministers to do speeches – in fact two, because the Deputy Speaker of the Parliament was late so someone else did a speech and then he did one again when he was able to arrive – there was a solid two hours of speeches, in fact, including a speech by Attila Vegh of University Hospital South Manchester, my ultimate boss, about the importance of recognising that the young graduates are already leaders and committing to a continuing educational link.
Uganda is extremely worried about youth unemployment, so many of the speeches included mention that young people need to think about creating jobs, not finding them. It was interesting to hear such a strong message on entrepreneurship – my degree graduations talked a lot about service and future leadership but very little about starting from scratch by yourself. The honorary doctorate award reflected this. Simon Gicharu founded Mount Kenya University, now one of the leading universities in East Africa. It was first an Institute of Technology and has gradually grown to have campuses across not just Kenya, but Rwanda and Somalia. It’s also respected as a good quality university. Starting a private university from scratch is an astonishing achievement – this was the sort of example the Vice Chancellor wanted to hold out to the students.
I’m not sure how many people could start an international University with a few thousand USD and a dream, and I’m fairly sure I couldn’t do it, but there is a real challenge in Uganda where there simply aren’t enough businesses driving the economy, and the delegates were very keen to get the message out that you can’t wait for the world to come to you. They asked the students, what can you create?
It’s an interesting question for a career public sector employee. What do I create? What can I create?
The graduates were also asked to “die empty” – to live up to their full potential, not to put things off for later, to publish every piece of research and give everything they have inside. There’s another thing to think about. We are used to thinking of emptiness as a negative; to feel empty is to feel hollow, sad, listless. But what use is the last two inches of wine in the bottom of the bottle? Thinking about it, why should I not finish each day empty, having lived with as much energy as I can, having given everything?
With those thoughts in mind, we spent the night at a graduation party dancing with the whole district. In Gulu, elderly ladies in gomesa, the traditional dress, and tiny children take to the dance floor with as much enthusiasm as everyone else, and they were all enthusiastically trying to teach me to shake my bottom in a more convincing manner. The elderly ladies generally still work hard, but they play hard too – there’s no sense here that dancing should be the preserve of the young. They won’t die with dances un-danced.
So, I have mostly been thinking about dying empty, and about what I can create.
Like many hospitals world wide, Gulu Regional Referral Hospital is preparing for viral hemorrhagic fevers (VHFs). It’s freeing up isolation space, auditing its infection control practices, and making sure that there is sufficient personal protective equipment available – at the moment, there is a specific lack of gumboots (wellies). The response is pre-emptive – there have been no cases here – but Gulu remembers its last outbreak all too clearly. The lessons from that are clear – health workers are most at risk, barrier nursing works if you are rigid about it, minor slips kill, and you can reduce the spread.
Despite its image in the West, Ebola patients don’t always present with bleeding, and they don’t die from the visible haemorrhaging. They die of multiple organ failure due to vascular leakage, and dehydration. And they present with fever, vomiting, diarrhoea, and malaise. This means that there is a long and illustrious list of differential diagnoses possible – everything from malaria through to flu, and almost every other tropical illness. By the time the bleeding turns up the patient is massively infectious and very hard to treat. But if you can maintain blood pressure and support the organs, the patients’ chances increase. So early case identification is also essential – nurses and doctors need to be very aware of symptoms. But amongst the other unseen heroes in an outbreak are the lab workers that exclude malaria (you don’t want a patient with malaria dying of it, on an ebola isolation bed) and confirm ebola or one of the other viral hemorrhagic fevers. The first two people confirmed to have died of Marburg fever were European lab workers isolating a monkey virus.
One of the key challenges here is to ensure proper barrier nursing. The story goes that several of the health workers who died in the 2000 outbreak made relatively small slips, rubbing sweat out of their eyes whilst working in gowns and face masks. This is one of the suggestions made for how Matthew Lukwiya contracted Ebola.
Matthew Lukwiya is a hero, as are many of his volunteer staff in the isolation unit he founded. He came back from Kampala when Lacor hospital lost three nursing students to a then unidentified illness, sat up through the night, identified Ebola and got hold of the WHO manual on treating VHF. In the middle of a civil war. By the time WHO had arrived he had a functioning isolation unit set up, with a volunteer staff, and proper barrier nursing despite equipment shortages. The outbreak – one of the first in an urban area – claimed 250 lives and left 500 orphans behind, but it could have been far worse without the staff standing firm, and he was a highly visible figure urging calm. He appealed through the media for the public to trust the medical teams, to report cases and to amend burial practices. Of course, he was already a hero to the public here. When the LRA had tried to abduct nurses from Lacor, he had gone in their place and then made it home safely. A grenade had landed in his house but not exploded, and he had not left, despite having the option to.
Prayers were said at the planning meeting today. First, that Ebola and Marburg pass Gulu by. But if that is not the case, that the plans work. That there are enough gowns, gloves and gumboots. That the people don’t panic and the hospitals stand firm. And it closed with Dr Lukwiya’s words, on realising that he was going to die – “Oh, God, I think I will die in my service. If I die, let me be the last.”
Unfortunately, West Africa now has its own stories like this – its own brave health workers refusing to flee (and this includes essential, unsung workers like the cleaners in the hospital, the people that incinerate the waste, and the lab workers risking needle stick and splash to identify the virus), its own foreign medical relief doctors risking everything to come in. And I am sure that many of the health workers who have died echoed Dr Lukwiya’s prayer.
But Gulu is preparing.
If you are interested, there is a long obituary of Dr Lukwiya in the New York Times – http://www.nytimes.com/2001/02/18/magazine/dr-matthew-s-passion.html
I am being irritated by Facebook. I know this is many people’s default state, and mostly they are annoyed about cats and babies and holiday photos. I like cats and babies and holiday photos. I am being annoyed by one particular meme, the one where the little girl says “why do I have to go to school?” and the mum blathers on about how it’s so that she can be indoctrinated into following the herd, get a job and become a tax slave.
I am PROUD to be an indoctrinated tax slave, if that’s what it is. This sort of blather is only ever posted by people who have benefited from both education and tax based services.
What good is an education? Let’s leave employment out of it, for a minute, and deal with this indoctrination thing. I think for myself. I have got in trouble for it. I have got in trouble for questioning received wisdom in lectures for my MSc. And the reason I have the strength and the intellectual finesse to do this from an evidence base is my teachers. Miss Helling in Shetland noticing I was bright and not just disruptive when I misbehaved aged 5. Mrs Cooper in primary 5, helping me learn to argue nicely. Science teachers teaching me how to spot bias sources. History teachers who gave us newspaper articles, made us pick out evidence from opinion, and made us then draft articles with the opposite point of view on the same evidence. Could I have figured that out on my own? Maybe, but maybe I would just have believed what I was told because without an education, I wouldn’t have known (or been able to read) the counter evidence to anyone’s claim.
And I might not have lived. There’s evidence from the developing world that if a girl can stay in school for five years, her own children are 40% more likely to live.
Not just live well, not just get good jobs – to live past their 5th birthdays at all.
There are many reasons for this, starting with employment options, but this is true even when mothers remain subsistence farmers. A literate mother is more likely to be able to access healthcare, more likely to realise when a child is seriously ill as opposed to poorly, more likely to know about basic nutrition, more able to cope.
Now school isn’t the only option for this, obviously. Many people in the world are home schooled. But for the vast majority of the population, across the world, school is simply the most practical option.
And that’s not to say you can’t attack the ways things are taught, what’s on the curriculum, and in particular the evils of teaching to the test. But you don’t go to school to be brainwashed. You go to learn to live, and to think.
So, tax slavery, then. Oh gosh darn it yes isn’t tax terrible. I’ve got friends who honestly claim not to use tax funded services – they are privately insured and educated and why should they pay for others?
So let’s leave my usual hobbyhorses of schools and hospitals alone and talk about roads. Yes, roads. They’re in a terrible state, aren’t they? Gee, I don’t know why I pay my taxes either.
Except you can travel on British roads reliably pretty quickly – 200 miles tends to take 3.5 or 4 hours, depending on the route. Which means we can move people and goods. Which means we can have an economy. If you eat, if you buy anything, you benefit from tax funded roads. And British people, a few Highlanders aside don’t know a bad road from their left nostril.
Bad roads are murram roads in the rainy season, periodically impassable where a swollen seasonal river has just washed a section away. They’re tarmac roads that were probably perfectly good 20 years ago but were never designed to deal with modern heavy trucks, with axle busting pot holes big enough to swallow landcruisers. They’re the fact it takes about 7 hours to drive the 250 odd km from here to Kampala. They’re the main reason that the supermarket up here has empty shelves, even though there are people like me who can pay inflated prices for their goods.
Again, we can attack how taxes are spent, criticise who is taxed and how much by, and talk about whether the richest or the poorest bear the brunt (it’s probably the poorest, as a percentage of income, incidentally, but that’s a rant for another day). But without taxes, things as basic as food on supermarket shelves can’t happen. Let alone that lifesaving primary education I mentioned before. Let alone healthcare.
So, people posting about sheeple and tax slaves, I am proud to live in a country with a tax base, and proud to pay those taxes. I am very, very proud of my education, but prouder of living in a country where completion of five years of education is universal and where most people finish secondary and almost half tertiary schooling. That doesn’t mean I don’t hate Michael Gove as much as the next bleeding heart liberal, and it doesn’t mean I don’t campaign for improvements in both tax and schooling. But do you really think you’d be better off without tax and education?
Go and live in a state with neither.
[I don’t have enough bandwidth to post photos today, but when I get some better data I will post you a photo of some of the roads round here so you see what I mean – in the meantime, here is a link to a photo in my travel blog showing what happens when a truck falls off the road on the main highway to Kampala – http://www.travbuddy.com/photos/blogs/6516779 ]