We need to talk about Andrew

First there was the complete Zombie/horror genre.  This passed into the auteur stylistic fusion of "Kill Bill", before supporters of the Bill came out with the action/fantasy "Kick Ass".  But as the week has progressed it seems we have moved into psychological thriller territory.  It seems there are some who think "We need to talk about Andrew".

In the same vein as the book of a similar title, the last week has been characterised by Government Ministers (at least those willing to say publicly they support the Bill) trying to justify the Bills behaviour.  The SoS is even writing letters to the (estranged?) trade rag the Health Service Journal.  At least it's happened before the massacre, unlike the retrospective reflections that forms the basis of the book.

There is an old adage - no-one wants to be told they've got ugly kids.  Certainly that was the case shortly after the birth of the White Paper.  Who wouldn't agree with devolving decision making to people who do the work, removing unnecessary bureaucracy and focussing on delivering better outcomes?  Early concerns were dismissed, much in the same way as one dismisses normal children's behaviour.  Nothing to worry about - "just teething" or "got a bit of a cold", or "very tired", or "it'll be alright when we come back from our break..."  But what were seemingly innocuous events at the time have, for many, become a major concern.  So much so that not only are some saying "your kid is ugly", but that it has no redeeming features whatsoever.

Events over the weekend are just another example of how much confusion reigns.  First, ConservativeHome claim that at least 3 Cabinet Ministers want the Bill to be dropped, other political bloggers and commentators queried why Tim Montgomerie could only find 3, the Daily Mail claimed, in a nutshell, that the DoH was being run by McKinsey's with much of government policy written by them and now a report in the Lancet casts doubt on the claims that NHS productivity has fallen over the last 10 years.  On the back of report after report by independent bodies claiming the NHS to be one of the most effective and cost effective healthcare systems in the world, it is no surprise that Coalition MPs seem to have a hard time explaining the purpose of the Bill.  It can't help that Baroness Williams now seems to have added her clout suggesting that Part 3 of the Bill is dropped.  All this culminating in intense pressure on the SoS and questions about how long he will be in the job and a mixed narrative about the changes themselves (as explained by Paul Corrigan here).

And therein lies the rub.  Supporters and detractors of the Bill are now engaged in a rational debate.  But not only is the debate confused because there remains no clear underlying narrative (is it competition, is it collaboration; is it radical, is it evolutionary), it is also the wrong way to solve the problem.  Opinion based argument is no substitute for empirical understanding.  Currently the debate around the Bill can be characterised by  the difference between searching for evidence to justify a position versus searching for evidence to establish a position.


This isn't about the SoS or the Bill, or the Coalition as much as it is about the thinking that goes behind much of the design and management of work.  The Bill itself is even called the Health and Social Care Bill, emphasising an already unnecessary divide.  Lansley has come out fighting, underlining his commitment to choice and competition as the way of driving up standards.  But this is policy based evidence at its finest.  And that's the trouble with evidence.  By the time it reaches Ministers ears it has been transformed into opinion.  That makes it easier to ignore.

Applying the Vanguard Method has taught me the importance of moving from opinion to knowledge through experimentation as the most powerful way to think about the design and management of work.  With that knowledge one can begin to understand that social care provision is commissioning and competition based already - the very system the SoS wants the NHS to move to.  One can also start to understand that it is not providing people with the support to solve their problems that they need because the system views people as commodities, units of activity, transactions and episodes.  And that, empirically, is both more costly and doesn't work.

What we design should be a consequence of knowledge, not an inevitability of policy.  There is a better way.  And our experiments are proving this - listen about it here.  What's missing is method and taking the time to deploy this method to get this knowledge rather than continuing to implement the latest initiative.  If we can change this then maybe the next genre might be the "feel good" movie

Plan B

If I had been David Cameron, the Bill would have stopped after the foreward to "Equity and Excellence: Liberating the NHS" and been followed with: "And this is how we are going to do it..."





Ann Anderson, Deputy Director for Strategic Development, NHS Somerset talks of an experiment to understand what it takes to help people live a good life.  Users love it, staff love it and costs fall dramatically.  No targets, no pathways, no referrals, no moves from one specialist service to another.  No plan.  Just understanding. And a willingness to create solutions based on this.

It is an experiment that shows that understanding people in the context of how they live their lives can halt the flighpath to dependency.  It is an example of genuine leadership using evidence to design the right responses for people.

It works, it's happening now and it shows that there is a better way.  It just means being prepared to change the way you think and go seeing for yourself how current management convention ends up costing us more and gives people a life the system wants not the life they want.

I'm Amy

"Hi, I'm Amy and I used to be a physiotherapist".  It was a sentence that took everyone's breath away.  In 10 words this physiotherapist had set the scene for a story that was forever going to change the way the leaders around the table thought about their system.

For Amy went on to describe an experiment in which she, as part of a team including GPs, Nurses, OT's, Social Workers and care homes, had truly been liberated and transformed lives as a result.  In this experiment, outside of remaining legal, all rules were to be suspended.  No existing criteria or protocols were to be applied.  No permissions to access budgets, no targets, no referrals, no lean tools, no process mapping, no hierarchies - none of the usual paraphernalia of the system to get in the way of making the right decisions for the person.  Instead the team was going to focus on using their skills, building relationships and understanding the person in the context of how they lived their life and pulling the necessary support when it was needed.  What mattered to the person was all that mattered.

Although there were countless examples she chose to speak of one person in particular whose story typified their approach.  He was a young man with a young family whose life was irrevocably changed in an instant as a result of a freak accident that left him tetraplegic.  Amy was helping him around what was going to be his new home, aware that the team was selecting people to be part of an experiment.

She was already concerned when, on arriving at the new home, they were greeted by an elderly woman.  Not a problem in itself, but her patient was in his mid-thirties and this was a home for elders.  The system had decided that this was where he was going to spend the rest of his life.  The look of desperation on his face when the implications of this had sunk in was bad enough, but it was when she couldn't fit his wheelchair through the door to his room that she decided that he was going to be part of their experiment.  She wanted to know if there was more that could be done to give this man the life he wanted rather than the life the system had designed for him.

Through the process of understanding, Amy and the team began to see how the system had medicalised his problems to such a degree that they had completely lost sight of his other, natural needs in living a good life.  Not one functional assessment had considered his desire for a career, or his concerns about money which was creating anxiety which, in the opinion of the psychiatrist, would most likely result in him becoming depressed.  Not one functional assessment had considered his desire to be active.  Not just by being merely moved around but truly active and participating in things that were important to him.  Not one functional assessment had truly understood his desire for family and personal relationships that had gone so disastrously wrong since the accident.

Through understanding him they began to understand themselves and each other and how, important as their skills were, there was more to helping and supporting him than the focus on mechanical, technical or medical issues.

They began to understand what it meant to be in an experiment where none of them had roles.  Not flexibility within their existing roles, but no roles - at least not in the way they had traditionally viewed them.  Instead they brought skills to the team and used them or pulled them in from others dependent on what their patients needed at any particular time.  At first it was confusing.  So used had the team become to writing referrals for one assessment or another it was hard to trust their instincts and just do what was right for someone when they needed it.  So common was the process of seeking permission from managers to spend even the smallest amounts of money that it took time for the team to believe that they could JFDI - just do it.

But as time went on their confidence began to grow - in themselves and in each other.  They began to see just how much their judgement and experience was restricted by a system that required them to fill in forms, seek permissions, justify and attribute their decisions.  They began to see just how self serving the system was, with different rules for accessing different pots of money, all with the intention of controlling expenditure but, in reality making things more costly end-to-end over time.  A pot of "Red" money here, a pot of "Blue" money there - when what they needed was "Purple" money.

It took them some time (and encouragement) to believe that by focussing on creating value for their patients they were not only doing the right thing but it was also cheaper.  And more rewarding - both for the staff and their patients.

For, in this case they were able to provide this young man with a life that would never have been possible under the old system, far more rapidly than would conceivably been the case before.  They didn't wait for protocol to allow them to get him in a specially adapted wheelchair for him to race the physio and OT around a running track.  They didn't wait for approval to provide him with basic amenities, like a cup he could drink out of himself, because of concerns about who would pay for it.  And they didn't wait to see what boundary of the system he had crossed over and watch carer after carer become involved in his care - they just did what was needed to help him.

The outcome?  For the person - hope.  And a belief that there was a better future.  And as a result a young man moved from being a person in despair of what the future held to a person who had something to live for.  No need for medication for his mood.  No need for counselling.  The team was his drug of choice.

For the team - reward and revelation.  Reward from being able to use their skills and directly see the difference their engagement was making.  Revelation from realising just how much the system got in the way of actually creating value for people and giving them a good life.

And for the system, reduced costs as people are taken off the flightpath to dependence, the level of carer input reduced and the number of repeat visits reduced; improved morale of staff and a much better patient experience.

The leaders Amy spoke to were CEOs and Executive Directors of all the main organisations in the local wellbeing economy.  An audience that, before the experiment started, she admitted to feeling somewhat intimidated by.  By the end of the experiment she had so much to say that she felt the leaders needed to hear that nothing was going to get in the way of her telling them what she had learned.

By experimenting with the Vanguard Method she had experienced first hand what it was like to be truly liberated.  She had begun to realise how convention was getting in the way of caring and creating value for people.  She understood that the role of her manager was now to act on the system conditions that got in the way of creating that value, not create more barriers.  And she discovered that the skills she had as a physio were useful but didn't define her and her relationship with patients or other professionals.

"Hi, I'm Amy and I used to be a physiotherapist" she said "and when my presentation is finished you will understand why I am not going back to the old system".

It was breathtaking, it was inspirational and it was truly liberating.

Where are all the learning organisations?

A report in the HSJ today revealed that all but 6 of London's non-FT hospital Trusts will be unviable by 2014 - 15.  £1.1bn of savings need to be found, a third of which are in nursing.  £421m can be made from "optimising skill mix, reducing agency use, increasing share of patient-facing time and aligning staffing levels with clinical need" - although the last one sounds a bit like the first one to me.  The rest is made up of getting to levels of performance of similar benchmarked Trusts.

Whatever the logic behind the analysis and whether you agree with it or not, it begs the question - "how can this be?"  What is happening with our learning and understanding of how the system works that these issues are never resolved.  Or as Ackoff would have said - never dis-solved?

In Peter Senge's bestseller, "The Fifth Discipline" he popularised the idea of a learning organisation.  Fortune magazine went so far as to say that "the most successful corporation of the 1990s will be something called a learning organisation, a consummately adaptive enterprise".

This adaptive learning, or survival learning is important and necessary.  It is probably what NHS organisations across the country are engaged in.  But Senge talked of "generative" learning, learning that enhances our capacity to create not just survive.

All very plausible.  So why is it that some 20 odd years later we are not surrounded by these learning organisations?  How is it that we remain in the repetitive cycle of learning the same stuff about how, in this instance, to run hospitals.  I haven't read the full report but my guess is none of the areas of productivity gain will be new.  It presumably will have all the usual suspects around length of stay, day case rates, new to follow up ratios and the like.

Does this raise a problem for you?  Do you think there is something wrong?  As systems thinkers the answer is clearly yes.  And a clue as to what is wrong is in the review of Senge's book itself by W. E. Deming.  He said:

"Our prevailing system of management has destroyed our people.  People are born with intrinsic motivation, self respect, dignity, curiosity to learn, joy in learning.  The forces of destruction begin with toddlers - a prize for the best Halloween costume, grades in school, gold stars - and on and up through the university.  On the job people, teams and divisions are ranked, reward for the top, punishment for the bottom.  Management by Objectives, quotas, incentive pay, business plans, put together separately, division by division, cause further loss, unknown and unknowable"

It was only after reading Demings review that Senge "slowly started to realise (Deming) had unveiled a deeper layer of connections and a bigger task than I (Senge) had previously understood".  The mistake that organisations typically make is to believe that performance is all about people and their activity.  This is, as Deming pointed out, to focus on the wrong things.

What I see when I study wellbeing systems is that Demings prevailing system of management can be characterised by "command and control" thinking.  What managers in such systems typically do is concern themselves with three things:

• How much work is coming in?
• How many people do I have?
• How long do they take to do things?

In this dominant paradigm managers think of their job as a resource management one so typically do these things to best manage activity:

• standardise work processes
• outsource work to lower cost organisations
• reduce average activity times (e.g. los)
• increase functional specialisation
• use IT to replace, support or control staff

Not unlike what seems to have been done in the NHS London report.  These are all examples of what Argyris and Schon would call "single loop learning".  Learning does happen and improvements are made through doing some things better, but they fail to challenge the underlying beliefs and assumptions behind the problem they are trying to solve.  I don't think that it is, ultimately, an approach that will help wellbeing systems orientate themselves around users and by doing so generate savings that these reports would never dream of being possible.

If we are to do better things we need to understand what the underlying causes of the problems are first before jumping to  the tried and tested techniques from the core paradigm suite of solutions - or double loop learning.

Demings crucial insight was to focus and act on the system.  It is the flow of work through the system that is important rather than measuring and managing work in functional activities.  Having worked in the NHS for nearly 20 years, I couldn't conceive that there was a better way of managing.  And yet, through studying, I have come to learn that the industrialisation of the NHS in particular and public services in general has caused and is causing significant amounts of waste and is itself the key driver for the costs we see in the system and the harm we do to patients.

The biggest lever for change is to understand demand.  And not in the way we typically do it in the NHS, by counting activity, managing volumes.  Understanding demand means understanding  the difference between value demand - what people want - and failure demand - the failure to do something or do something right for people, by going and seeing what we actually do to people.

This is so powerful because once it is done you can design against that true demand and begin to manage value rather than focus on cost.  And it is through this approach that managers can actually act on the system and remove all those conditions that get in the way of perfect.

I know there is much to learn but my experiments are proving that there is a different and better way of looking at how we make public services more efficient.  But first it requires us to change how we think about what good looks like and a recognition that there is no efficiency without effectiveness.

The NHS London report doesn't seem to be saying anything new in terms of the scale of the financial problems in capital.  Nor does it seem to point to any new ways of working through the problem.  It implies that some hospitals will need to close (something I wrote about here), a conclusion that I would find unsurprising given what I have learnt.  I just hope that any decisions on closures are made by first understanding value from a users perspective and designing against demand, rather than as a result of crunching numbers on a spreadsheet.

The Vanguard Method is a powerful way of leveraging change at a system level and generating benefits to staff and patients alike well beyond what the system is currently capable of conceiving of.  Unless our systems deploy such a methodology we will continue to get stuck in the single loop of trying to solve the same problems that created the mess we are in in the first place and truly learn, as a system, what it is we need to do to solve peoples problems.

The basis of this blog was an article by Prof. John Seddon and Brendan O'Donovan "Why aren't we all working for learning organisations?" in e-Organisations and People; Vol 17, No 2, May 2010

  

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Wellbeing myopia

It's been another harrowing week for the SoS and the tortuous passage of his Health and Social Care Bill.  So badly conceived and executed has it been that, on top of outright opposition by the Royal College of Midwives, the Royal College of Nursing and the British Medical Association, a combination of the Health Service Journal, the British Medical Journal and the Nursing Times has concluded in a joint editorial that even if the Bill does make it onto the statute books it simply paves the way for yet more reform 5 years from now.  It is scarcely believable.  A very helpful blog summarises just how confusing the whole thing is here

The debate, so often polarised with the inevitable consequences this brings, has now deteriorated into personal comment on supporters, detractors and fence sitters alike.  The search for someone to blame has, it seems, started in earnest.

But who is to blame for this unseemly mess?  How can the debate have moved from one of broad consensus at the level of principle in the initial responses to the White Paper to outright opposition by some?  The obvious response by critics is that the Bill does nothing to really deliver on putting those who do the work in charge of the work, fails to reduce bureaucracy and reduce costs and risks widening rather than reducing health inequalities because of the emphasis on competition rather than collaboration.  The blame, therefore, lies squarely with the SoS and the Coalition Government.

This may be true but, in my view, it misses the point.

In reality the answer can be found in the historic lack of leadership by all the main groups involved in providing NHS services and a failure to understand, over time, what "business" the NHS is in and how to think about the design and management of work to solve peoples' problems.  Without this complicity and complacency none of the current Bills plans would be possible.

In his classic 1960 text, Theodore Levitt coined the phrase marketing myopia.  He asked the question "What business are you really in?" and with it claimed that in every case that growth is threatened, slowed or stopped is not because the market is saturated.  It is because there has been a failure in management.

It is, he argues, the failure of those leaders who deal with broad aims and policies to move from being product oriented to customer (his words) oriented that resulted in growth being affected.  He asked the question - would the railroads have stopped growing if executives had realised they were in the transportation business?  Would Hollywood not have been ravaged by TV (at the time) if they had not incorrectly defined their business in relation to their product (movies) rather than what people wanted (entertainment).

The link with the NHS may not be obvious.  After all, it is the containment of growth that leaders would say they are concerned with.  But the principle is the same.  You are not a leader of a Trust, a PCT, a Local Authority, a Union or a Royal College.  You are not a leader of a health system or a social care system.  You are a leader of a wellbeing system.  Your business is wellbeing.  Your purpose; support people lead a good life or die a good death.  And as obvious as that might sound it is the lack of this as a compelling vision for the design and management of work that has enabled the Bill to take it's current shape, even though it does nothing to address this simple fact.

Until now, our leaders have collectively been blind to this, spending too much time defending their own interests or designing systems where goodness happens in spite, not because of, the system.  I do not see wellbeing systems where organisations are seamlessly connected around the needs of the user.  When I study wellbeing systems I see individual organisations struggling to survive in their own right.  And yet the shape of how their users present to them has changed.  We cling to "product" solutions (services) when we need to focus on what users need, or person shaped solutions.  This needs to change.

The joint editorial makes two very salient points:

• what problem is the Bill trying to solve
• by what method will it solve it

The Bill is not clear on either.  My studies tell me that we are trying to solve the problems created by a management paradigm long past its sell by date (Policy Zombie).  Building relationships and developing understanding of people in the context of how they live their life has shown to be a major lever for change.  No plans, no structures, no tools, just understanding.  An acceptance that change is emergent, but so long as the user sets the boundary of the system, it will be change for the better.

As for method - well by really understanding purpose from a users point of view, using measures that relate to the delivery of that purpose and designing from studying and experimenting rather than "planning" or "specifying", leaders will design systems that deliver what people need.  At the same time it will drive out costs by managing value far in excess of anything that could be conceived through conventional thinking.  We call it the Vanguard Method.  Others call it common sense.  Either way the results speak for themselves.

There are some who are concerned that the Bill cannot be stopped and marks the end of the NHS as we have come to know it.  I too believe the Bill is the wrong thing wronger.  And yet I remain relentlessly optimistic.  This is a historic opportunity for leaders to emerge from this debate and design a system based on knowledge and drive change from a pathological understanding of what matters to users rather than vested interest, organisational forms or ideological concerns.

The leaders that can overcome the collective myopia about what matters to users and have the building of relationships at the heart of their design are the ones that will truly deliver transformational change rather than the, at best, polishing that has been a characteristic of change until now.

The NHS in England has been, over the years, so concerned with taking care of business that it has forgotten that it is in the business of taking care.  Overcoming this wellbeing myopia will not be easy.  Nor is anyone to "blame".  It is a genuine challenge to see that it is the prevailing management paradigm that is in itself responsible for many of the problems we now seek to solve.  For those that are willing to challenge the very assumptions upon which our current convention of management thinking is based, the rewards will be significant.  If not, we will remain blind to the opportunities that this change in thinking will bring.

A patients story

One person's account of their experience of the NHS

Six months ago I went for a routine blood test. I’d been for one two and a half years earlier but hadn’t bothered with an annual follow up. There were reasons for this. I’d not been to a GP for years until that first blood test. It was only a passing thought that I ought to have a health check having reached my late 50s. My introduction to the practice had been, ‘can you fill this in’. ‘This’ was a questionnaire about my drinking habits. I found it insulting and demeaning. It turned out, of course, to have been a target that the practice needed to comply with and I was the mechanism. What I learned was that that’s all I really was – a mechanism for the practice to meet targets and get money.

My first health check revealed ‘high blood pressure’ I didn’t really have ‘high’ blood pressure but I had crossed a pre set threshold that meant I should be treated. There was some sense in keeping an eye on it and giving me some informed choices to make but at a stroke I had ceased to be a person and become a ‘patient’. And patients mean prizes –to the GP.

What happened was that I lost all perspective and started to worry about being ‘ill’, and even about having my life shortened. It took me a good year to get back to a normal view of myself and the world.

Subsequent visits followed a routine. The nurse or GP is glued to the screen. They don’t know me (and still don’t) so they hunt the screen to find out what they are supposed to know about me. Then they respond to what the screen tells them they are supposed to tell me and then they have to worry about what to fill in (especially if it means money to the practice). And then 7 minutes is up.

So I learn that my purpose is to help the practice keep the system up to date. I suspect this is made to feel worse than it is because you see the nurse more than the GP and they have much less discretion and are more victims of this system. What I felt, though, was that I didn’t really want to keep playing silly games and as long as I wasn’t ill, I’d stay well clear.

It’s now worth saying that on that first blood test my PSA score was 6. The nurse was feeding back the results and so it was red on her screen. She followed the screen’s instructions and told me about it. I said that I thought PSA tests were pretty unreliable unless you had prostate cancer and she said, ‘that’s true’. End of consultation.

The targets create ‘noise’ and it’s a very fine line between what’s done in the interests of the person and what is done to keep the system happy. It’s all too easy for people to get lost in the noise. That’s what happened to me and it’s a common story – things are done for people who don’t need it and the few who have real needs can get lost

Little did I know that I had just made ‘an informed choice’. All decisions, by default, were now down to me, apparently. I still don’t know what happened. I have heard that many practices get a GP to sign off all test results but that doesn’t guarantee due scrutiny.

So I made the wrong decision and I look back and wonder. I nearly didn’t go back for the follow up test – and if I’d been busy I would not have. It was only a lull in work and a ‘I suppose I ought to’ moment that got me back ‘doing my duty to the NHS’. The PSA number was now 10 and the nurse decided that I should see the GP. I saw a locum and she did a rectal and referred me to the consultant at the County hospital. (It’s worth noting that none of the regular GPs will know what’s happened unless I go back to see them. Everyone, including the hospital assumes the GP knows everything but they don’t. It’s in the system but they will not see it unless I go back to them).

The consultant takes a look and says, ‘it’s suspicious – I’ll get you an urgent biopsy’. The fear ratchets up. (The GP had said it felt OK but get it checked anyway.) The consultant clearly thinks it’s nasty.

Urgent means two weeks but still OK.  I get the biopsy and go back for the results a week later. Now, there’s no good way to tell people they’ve got cancer but this conversation was bizarre. He could have said, ‘congratulations – it’s positive’ for all it sounded and he then went on to tell me how much blood I lose in the surgery. He then said there were more tests to do but they couldn’t be done until the wreckage from the biopsy had settled. He behaved as though he had to tell me everything so that he could record the fact that he’d told me.

So I’m left for a month to worry and to research. Even if you know what questions to ask, the answers are very perfunctory and you quickly realise that you have to do your own research to stand a chance. It took me two weeks to get over the ‘OMG it’s cancer – how did anyone else ever make it to 60?’

The other tests were a bone scan and MRI. Meanwhile I was allocated a urology nurse whose role was to be a contact and fixer. She was very helpful and, I quickly realise, the picker up of the many pieces that the system left in its wake. My wife and I were so upset and baffled by the surgeon’s apparent ‘empathectomy’ that I asked the nurse if I could see someone else for what I assumed would be a life changing conversation when all the test results were back. She agreed without hesitation and organised it. 

She also let me know that the bone scan had been benign – a couple of small ‘lesions’ that weren’t very suspicious, nor even adjacent (on a rib).

It was also interesting that the surgical option that appeared to be the ‘no brainer’ is the Da Vinci robot. ( When you get behind the hype, it’s not as obvious but it is clearly superior in the hands of a practised surgeon ( i.e one who has used it a lot). My hospital didn’t even mention it and knew little about it despite there being one 20 miles away.

So, there I am, geared up for my session about surgical options and with my new surgeon who has come well recommended by the nurse. He proceeds to carry out an extraordinary demolition job telling me that its’ about as bad as you get, my body is probably riddled with cancer and surgery is not an option so he’ll pass me on to the oncologist. My wife thought he relished his ‘what a clever boy I am telling you how bad a state you’re in’ speech. I just thought he was an arrogant s.o.b. with even less empathy than the first one and went home ready to slit my wrists. I’d wasted a month, physically and emotionally getting used to the idea of surgery and spent yet another two weeks looking at anyone over 60 and wondering once more how they got there.

It did occur to me that the surgeon who first saw me would have known that the MRI was almost certain to be diagnostic in my case and therefore why didn’t they do that first so that the biopsy could have been done immediately afterwards such that there would be no danger of the MRI being affected by the biopsy activity. The answer was cost and scheduling. It is done some times but not if they can help it. (The MRI operator had told me how busy they were – 12 hours a day, 7 days a week. I asked her how many she thought were really necessary and how many were done because ’they could’. She said probably 60 % weren’t really necessary but that was only her opinion, what would she know!)

So I’m now left to reflect and fester for 6 weeks before I see the oncologist.

I was so geared up for the surgery that it took even more time to readjust and get used to it. It all began to seem like a routine: turn up, get kicked in the teeth, fester for a month and then have it all done again. My reflection was that I had to keep reminding myself that PC was the least serious of all and entirely survivable. Whilst honesty is essential why was it that they were so insistent on brutal ‘this is how bad it could be/probably is’ when the disease was so curable? Why couldn’t anyone say, ‘don’t worry, it’s not good but we can get you through this’? Why, when a free person comes with every condition and we know full well that if you treat the person you’re half way there, if not further, were they going out of their way to ignore that logic?

What it was doing to me was to make me doubt the rational knowledge I had that it was indeed survivable. Was this the risk averse NHS?

On the allotted day, I saw the oncologist. I did wonder, if an oncologist is someone who diagnoses and treats cancer, why I was seeing him last and why I had seen a surgeon first.

The commodity I was missing was perspective. I had had great support from lots of people and the PC charity is wonderful but I still had little perspective – or rather I still had to keep convincing my irrational self that this was not life threatening. I asked him what would happen if I did nothing. He replied in a very unconcerned way that after 3 or 4 years it might have spread a bit. He then talked about how easy it was to treat, how easy it was to pick up any eventuality. I told him what I’d been through and he was rather taken aback. He dismissed the conclusions the surgeon had jumped to as improbable and excessive. I asked him why these surgeons (in his own department) would have behaved that way and his response was, ‘all surgeons are like that’.

I still don’t know whether to believe him but I am very angry at having been put through so much unnecessary grief and I’m very angry that family and friends have been put through such unnecessary grief. If I’d had a conversation with that oncologist 4 months earlier….

I think also that the current system has cut the GP out of the flow (and they have been willing partners) that the person who would have been the anchor of perspective was not there and the patient is cast adrift into a system where you are a series of test results being passed from person to person.

This transactional view is driven by the perceived need for the system to be ‘efficient’.  The paradox is that it makes the system inefficient by creating tons of failure. Medicine is about relationships – and the GP is paramount for many experiences. There are cases where a simple transaction is all that takes place but then you need to design against the value.

A further thought that has come from this experience: screening is either ‘a good thing’ or ‘highly dangerous’. The latter view comes from the high level of false positives and the invasive and dangerous treatment that can ensue. PC generates huge debate on both sides of the Atlantic because the PSA test is so inaccurate. I think it is the wrong debate. Screening per se is not the problem it is the mindless reaction to positives that is the problem. I suspect the US and UK have the same problem for different reasons. In the US, it seems a lot of surgery and medicine is dome because it can be and as Wennberg highlights, without enough data about life quality. In the UK it happens because the brain has been taken out – triggering a threshold leads to automatic responses. I saw a reaction to this to the point of reluctance to act, which is equally dangerous. I think it would be helpful to stop the screening v. no screening debate and say, screening is just fine but let the GP help people make informed choices with support from specialists based on what they know of the person and the merits of the case. The best action in many cases is just to be watchful.

I now await Radio therapy. As I do so, I come across more and more people who have had treatments other than those offered to me. It creates the sense of just being offered ‘what they do’ and nothing else. If I had not continued to research I would found none of this out. The treatments may well be ‘OK’ but relative to other centres appear to be 10 years out of date.

I used to be very anti private medicine seeing it only as a means to jump a queue and get a bit of pampering. Now, though, with the deterioration in the NHS system it is clearly a means of better diagnosis and a trusting relationship with one practitioner who has time for you and will see you through the process.

I am now convinced that I need a second opinion – watch this space.

Kill Bill Vol III

Its been quite a year since the Bill was first published.  With calls to "kill the bill" it has at times been more like a real life version of a Quentin Tarantino movie.  At first what was general discontent grew into more serious opposition requiring the Government to put their plans on hold while they paused to listen to the concerns in more detail.   Then there was the letter from over 400 public health consultants to the House of Lords that they reject the passage of the Bill (see my blog here).

Commentators from Roy Lilley to the Kings Fund and many more in between have continued to highlight problems with the Bill.  Surveys have shown large numbers within professions are opposed to it.  Marathon debates in the House of Lords led to further amendments followed by actual marathons run by a doctor - he ran 6 in 6 days to highlight concerns about the Bill.  Incredible.  Others have said they simply don't understand it, most notably the Chair of the NHS Commissioning Board, Professor Malcolm Grant.

Yesterday the Royal College of Nursing, The Royal College of Midwives and the British Medical Association declared outright opposition to the Bill.  Lansleys response to the opposition was more "Kick Ass" than "Kill Bill".

But if there is one thing that everyone can agree on it is the lack of understanding and knowledge that exists.  The problem is that this is an accusation that is levelled by supporters and detractors of the Bill at each other.

Watching the debates unfold, in the light of my experiments with wellbeing systems, understanding and knowledge is indeed missing.  But it is an understanding of the system, outside in from a users perspective that is missing as is empirical knowledge about what works, not the nuances of the substance of the Bill.

For me, Lansley is right to make those who do the work responsible for making the work work.  He is right to move away from delivering targets as the de facto purpose of the system.  But I have yet to hear him speak about the purpose of the proposed changes in a way that makes any sense about what we are moving from, what we are moving to and why.  Maybe I am just not clever enough...

What the Vanguard Method does is to put people who do the work in control of the work.  Because they see that the results of their efforts to improve the work are making a profound impact on the experience of the people they care for, morale improves.  Relationships become more productive both within and across teams.  The relationship with managers moves from one of control from a hierarchy to a more collaborative one where the manager acts on the system and removes obstacles that are beyond the immediate control of those doing the work.  They can then carry on creating value for users in the pursuit of perfection.

Costs come down, staff do good work, outcomes improve and patients and their carers love it.  All because the starting point is to understand purpose from a users perspective and people are given a method to get knowledge.  Its that which needs to be done at scale, not more debates about structures and organisational forms.  No targets, no incentives, no "lean" tools, not even a plan.  Imagine that.

The challenge for policy makers is to move from opinion to knowledge based on a profound understanding of what works, gained from experimenting.  What is needed is a pathological focus on purpose from a users perspective, not competition.  What we design should, therefore, be a consequence of knowledge, not an inevitability of policy.  Without a method for putting those closest to the work in control the best we can expect is that leaders pay lip service to the idea whilst concentrating on delivering what the centre wants from them.

In the end I don't understand the purpose of the Bill either.  And even those who know the detail of the Bill would probably struggle with purpose (from a users perspective) I imagine.

If it results in leaders that understand purpose from a users point of view, uses measures that relate to the delivery of that purpose and designs from studying and experimenting rather than "planning" or "specifying" then it has my support.  Because if you do that you will drive out costs by managing value far in excess of anything that could be conceived through conventional thinking.

The problem is that I don't think the Bill helps change thinking in that way at all and so another opportunity to change and do better things will be lost.

One final thought.  Wikipedia has this to say about Kill Bill:

"A. O. Scott of The New York Times said Tarantino's previous films Pulp Fiction and Jackie Brown were "an exploration of plausible characters and authentic emotions". He wrote of Kill Bill Volume 1, "Now, it seems, his interests have swung in the opposite direction, and he has immersed himself, his characters and his audience in a highly artificial world, a looking-glass universe that reflects nothing beyond his own cinematic obsessions." Scott (also commented on) "the hurtling incoherence of the story" "


I wondered if there were any parallels with what is currently happening

Whats the point of leadership training?

Shortly before he died, Taiichi Ohno, the man credited with the creation of the Toyota Production System was asked, "what are you working on?"  His reply was "cutting the time between receipt of order and getting the money".  This shows a clarity of purpose that, at least according to research by Hay Group consultants, current top leaders in  the NHS struggle to emulate.

According to Hay Group, three quarters of the most senior NHS managers are "not creating strong work climates", reports the HSJ.  The 900 participants in the NHS Top Leaders programme, the report says, are "high on over-confidence" and suffer from "an absence of attention to detail".  It goes on to say that they are "not necessarily understanding their own limitations" and do not tend to listen to others.

Perhaps most revealing was that one of the biggest gaps in an analysis of strengths and weaknesses is the extent to which current leaders create a climate that provides colleagues with "clarity".  It also suggests that senior leaders are equally unclear about their own work.  Quite the opposite of Ohno.

One of the lines of argument put forward for these gaps is because the NHS recruits leaders who need everything spelt out and were modelling their behaviours on Sir David Nicholson's centralist style.

In other words, despite the £2.7m investment and all the presentations (never a good way to learn), time spent learning how to ride a unicycle, finding out whether you are red, blue, green or yellow or ESTJ, or listening to someone play the saxophone with "GRAZIA", there remains a tension between espoused theory and practice.  It's a bit of a worry.

The leadership courses talk about the need to listen and engage, create and deliver the vision, coach and support individuals and teams but the day-to-day life of those attending is more often than not one which requires them to have delivered a specific, centrally mandated target.  The compelling cases for change become "we have been told we have got to do this".  The sense of urgency behind change comes because "they have told us we have to do it now".  The classroom teachings become quickly forgotten.

One can typify the leadership style this produces as one of:

Command - we (the leaders) know what is the right thing to do, people are doing it wrong, they need to do what is commanded to get it right

Control - we (the leaders) need to justify and attribute reasons for performance so create KPIs, performance dashboards, guidelines and protocols to adhere to

Coerce - we (the leaders) would be leading high performing organisations if only we could get the workers to do what we know is right so lets have a system of rewards and penalties, incentives and appraisals

A better way to develop leaders

The kind of thinking described above might lead one to conclude that developing leaders is a straightforward matter of teaching people material in a classroom.  But leadership happens when people study the work, lead learning through this study and lead action on the system based on this learning.

In other words the best way to learn is by doing.

For systems thinkers, learning by doing is the only way managers can unlearn and find out for themselves that their current beliefs about the design and management of work are flawed.  It is the only way to avoid managers hearing things that they think they understand, only to rationalise it from the perspective of the status quo.  It is the only way to avoid an emotional response to the counterintuitive truths that are revealed when leaders get understanding and knowledge themselves direct from seeing how the work works.

It is the only way to systemically and systematically develop the leadership qualities our organisations need and deserve:

Clarity - unequivocal about purpose and relentless in understanding all that gets in the way of clarity of purpose

Capability - lead action on creating the capability to deliver purpose, creating value for patients from a users perspective

Capacity - invest time or money where it is necessary to create clarity and capability

What is the point of leadership training?

If your leadership training is classroom based and does not help you to understand your system outside in from a users perspective then there is little point in it.  At best you will end up with polished leaders, but polishing is not transformation.

Transformation happens if your leadership training helps to create clarity, capability and capacity by getting people to understand what they do and why they do it through getting knowledge about how the work works.  For managers to directly see for themselves how the design and management of work gets in the way of sorting peoples' problems out.

So if you want to know if your leadership training is giving you what you want to transform your system apply the following tests which John Seddon taught me:

• Will it lead to the creation of an organisation where people who do the work control and improve the work?  In other words, will it move people from saying words like "empowerment" to actually giving up their current conception of management?
• Will it prepare you to change your own role to one of acting on the system.  A role where you understand what gets in the way of perfect from a users point of view and you remove those obstacles?

• Will it leave you prepared to do these things when those above you might not understand or condone it?  Will you be better able to resist managing with the measures or targets centrally stipulated?

• Will it leave you able to be the carrier of this new knowledge and the changes that it brings to those who may not want to hear it or understand it

The Hay Group research indicates that there is more to do to support the 900 leaders develop.  The question is, will the leadership training as currently designed, help?  Unless it is helping people understand and get knowledge about how the system gets in the way of helping people and helps them to take action to resolve that then the answer is likely to be "no".