From the Oxford Online Dictionary, the definition of efficient is:

efficient

Pronunciation: /ɪˈfɪʃ(ə)nt/

adjective

• 1. (of a system or machine) achieving maximum productivity with minimum wasted effort or expense: more efficient processing of information
  [in combination] preventing the wasteful use of a particular resource: an energy-efficient heating system
• 2. (of a person) working in a well-organized and competent way: an efficient administrator

And the definition of effective:

effective

Pronunciation: /ɪˈfɛktɪv/

adjective

• 1. successful in producing a desired or intended result: effective solutions to environmental problems

Let’s think of jumping in the car to go on a journey. If the car was efficient it would “achieve maximum productivity with minimum of wasted effort or expense”. It would be efficient if it covered the distance with the minimum use of fuel.

The journey would only be effective if it was “successful in producing a desired or intended result”. So if we got lost and ended up somewhere other than our desired destination then the journey is not effective.

Efficiency is a nice to have in comparison with effectiveness. If we get in the car and arrive at our desired destination then it is good if the fuel usage of that journey is efficient. But who, after ending up in the middle of nowhere, completely lost, has ever said to their fellow travellers, “Well at least we didn’t use much petrol to get to … well … wherever we are.”?

So if we are not being effective we should ignore efficiency until we are. Then of course we could turn to efficiency as a possible next focus.

If we are not doing what we are supposed to for the public, we should never try to remove waste.

Effective first, only then efficient.

Best,

Rob

Asked at his conference in Newcastle this month the greatest lesson he had learnt since taking office, he replied ruefully: “I have learnt, and frankly I’ve learnt it the hard way over the last year and a half, you can’t spring on to the public a solution or a policy if you don’t spend a lot of time first explaining what the problem is.

“If we had spent more time explaining that simply having more and more people going to hospital for an increasingly long period of time is just not a sustainable way to run a good healthcare system … Maybe we should have spent time showing people there is a problem, because if you don’t show them there is a problem first, why should people accept that there is a need for a solution?”

Unless there is more to that quote, I am still not sure that anyone has described the problem that the NHS reorganisation is going to solve.

The general lesson for leaders, or for that matter, anyone wanting initiate or sustain change, is that you must

1. Have a genuine problem
2. Demonstrate that it exists
3. Show that it has a sufficiently bad effect to be worth solving
4. Convince people of all of the above
5. Show that the solution will actually address the problem
6. Reassure that the solution is not worse than the problem and that it won’t lead to further problems

Actually, the best way is to involve the people who will make the changes, to have them discover and demonstrate the current problem, then let them design the solution. That way you cut out the difficulty of telling, persuading and demonstrating and you reduce it to guiding and teaching. They convince themselves which is much more effective.

Best,

Rob

Julian O‟Halloran, the File On 4 reporter is talking to Professor Mike Edmonds.

But I have to disagree with his latest column entitled, “Not like buying a cardigan”. In it he argues that difficulty in contacting your GP, bad hospital food, poor attitude of staff and collecting a hospital acquired infection are not quality issues. His point is that all these should be done anyway. Hence the only thing that is a quality issue is if your hip replacement is successful and lasts. To be clear, I don’t think Roy is arguing that the other things are not important, but that they should be gotten right anyway, so the focus of “quality” is on the core purpose provided. From the article,

Having an operation and collecting a hospital acquired infection is not a quality issue. It is entirely avoidable and actual bodily harm. It is an assault. A bed sore is neglect. Are we to say if you manage to escape from hospital without an infection or a bed-sore that is a quality experience? No! There is no virtue in virtue; you are not supposed to be left hanging on the phone, suffer and infection or collect a bedsore. The absence of any of these is not a quality measure. You might just as well argue they were lucky.

In a way he is right, but he is missing the point that there are levels of quality. Let’s call them core, essential, expected, nice to have and luxury. Think about a trip on an aeroplane:

• Core – get me from A to B
• Essential – the plane must not fall from the sky
• Expected – a seat on the aircraft
• Nice to have – local airport and a free in-flight drink
• Luxury – seats that turn into beds or a gym on board the plane

To generalise:

• Core – The reason I am taking this service or product
• Essential – Safety factors
• Expected – Things you don’t think about when there, but would really annoy you if they are missing and you tell people when they are broken
• Nice to have – Little extras that make you smile
• Luxury – Big extras that make you tell your friends and family about what happened

So let’s classify some of the things Roy mentions:

• Ease of calling the GP – expected – this should be easy, it is annoying when it isn’t
• Hospital food – expected – a reasonable quality is expected; cold, tasteless food is bad; but caviare and champagne is not necessary
• Bed sores and infections – essential – like the plane falling out of the sky we think that everything should be done to prevent these
• A new hip that works and lasts – core – this is why we underwent the procedure in the first place

So Roy is right and wrong. These other factors are important, and some are essential, but only the hip is core.

But the interesting thing is that from the perspective of providing the best care we should be getting all the core, essential and expected things right. We should do it firstly, because it serves the patient best if they have decent food and don’t get infections in hospital. Secondly, the beneficial outcome is that giving good food helps people recover faster, preventing infections means fewer bed days and antibiotics, all of which means we save money. So better care saves money too.

Roy is half-right, we should do these things anyway, but my point is we need to understand where they lie in the above classification and what they consequences are of getting them right and also of getting them wrong.

Best,

Rob

They have a target; they are bound to cheat. That is what people do.

Carol told Polly that,

She was told to cancel operations for anyone who was already waiting over 18 weeks, and instead to fill that theatre time with people closest to breaching the 18-week limit. “I was told to call people who had already gone over the 18 weeks and pretend there was no longer theatre time for their operation, and not give them a new date.”

What amazes me is that people are so ingenious. What could happen if that creativity was turned to improving the system of treating patients? Well you could make a mockery of the 18 week target for a start. And give better care to boot.

Carol also reports that,

The worst was when she was told to call a mother of three young children to offer her a short-notice slot for Christmas Eve, knowing she would refuse and so could be knocked off the list for refusing.

At least Carol had a conscience, since she quit over what they made her do. But the saddest, most frustrating part of the article is this:

She protested first to her line manager, then to the one above and finally to the one above that. “I said I wanted these instructions in writing before I would lie to patients. Of course they said it could never be written down. But the manager in charge of operating theatres said other hospitals were all doing it, so we had to too. There’s no other way to stay within target.”

That final part is worth repeating:

“There’s no other way to stay within target.”

That’s what makes me mad. There is another way (to paraphrase Deming).

All the effort, time and creativity that is going into making phone calls to mothers, lying to patients, fiddling the figures, messing with the types of operations could be going into making things better. That trust, and others around the country would have shorter waiting times and no need of a target if they simply:

1) Did what the patient needed,

2) When they needed it,

3) With no waste, errors or delay

All the monitoring, expediting, lying, cheating and fiddling would melt into the air, and they would have a nice clean, simple system for treating the public that would smash the targets they are currently desperately trying to meet by any means necessary.

Best,

Rob

Putting the politics of the bill aside, what can we learn from its presentation and implementation so far?

Firstly, while there is not much argument that there is a need to change to cope with an every more elderly population, more expensive drugs and treatments and a period of extreme austerity, there seems to be a massive argument about the need for the changes as proposed.

There are lessons that change leaders can learn from all of this:

1) Ensure there is a genuine need for change.

2) Ensure that you explain why the changes proposed will meet the need.

The other interesting factor is how professional medical bodies have turned, albeit very late in the day. It was always sold that Andrew Lansley, the Secretary of State for Health, was very chummy with the medical profession and would have them on side. This seems not to have carried on through the process of getting the bill passed.

3) Support for change needs to be explained to those affected, in ways that they see that there will be benefits to the service.

4) You need to anticipate that there will be some that reject any change and be ready to answer their objections.

Will regard to this “no man’s land” that Slipman spoke of, this is a situation that no one implementing change should ever get themselves into.

5) Only start making changes when sufficient people are in agreement to carry the changes through to completion.

That doesn’t mean you have to have everyone on board, but you do need enough people to be able to get to the end. The government should never have let commissioning boards be set up before the legislation was passed. If the bill is further carved up in either house and passed it will be a hodgepodge of its original form and if it does get dropped or defeated then where does that leave areas that have dissolved their Primary Care Trust (PCT)?

I think that this bill will now have to get passed in some form to prevent utter chaos in the many areas of the country that have partially implemented it already. But the whole situation teaches many lessons for leaders of change in all sectors and of all scales about support, implementation and timing of the changes they are thinking of making in the future.

Best,

Rob

The article nicely poses the question of cost cutting versus the unintended effects of those cuts. Councillor Jane Potter is quoted as saying, “I welcome the fact we are planning to spend our limited resources more effectively by focusing on services for young people rather than buildings to achieve better outcomes.”

But Charlotte Toomer, chair of Redditch Student Council, said the decision was wrong and would force young people with nowhere else to go out onto the streets.
“We haven’t been listened to. They are forever moaning about young people on the streets but by doing this the situation is going to get worse. Taking the youth house away will lead to more kids on the streets and more crime,” she said.

The question is whether the young people will in fact use the other facilities and so see no loss of service or whether as Toomer says, things will get worse.

My guess is that cuts that are driven by balance sheets will, in the end lead to more costs in the long run. I don’t know if anyone stopped to ask the users of the centre themselves what they wanted or needed to improve the service. I’d bet they would have some pretty good ideas of how to improve the service and cut costs as a consequence.

If only users of a service got listened to.

Best,

Rob

The Hospital Guide shows that patients are less likely to get treated promptly and more likely to die if they are admitted to hospital at the weekend. The chances of survival are better in hospitals that have more senior doctors on site. But some hospitals with A&E departments have few senior doctors in hospital at weekends or overnight. The guide identifies trusts with low levels of staffing and high mortality.

The reality is that the public don’t live their lives Monday to Friday. That means that we may very well need care on the weekends. If hospitals are not staffing their A&E departments and wards to match the needs of patients then they need to change how they organise themselves.

It is not a complicated exercise to track admissions and care patterns to see when staff are required.

If an organisation is not matching resource to need it will be performing below optimal levels which in the case of the NHS can mean an increase in mortality and longer times to access care. This is something that is operationally simple to change and however culturally difficult, needs to be done for the good of patients.

Best,

Rob

The reason that I highlight this situation is because the cruelty comes along with stupidity.

In the article, Ros Altmann, director general of the over-50s group Saga, is quoted as saying,

Cuts like this are incredibly short-sighted, because the less that is spent on someone with moderate needs now means more will have to be spent when their needs become substantial.

Focusing on cost cutting means costs go up in the long run.

Not complicated.

And the most annoying thing is that you could reduce costs and at the same time provide better care which keeps people in their own home for longer. Which is what everybody wants.

Best,

Rob

However in reading an article on the BBC website: NHS: Crackdown on ‘hidden waiting’ ordered by ministers there was one paragraph that seemed to stand out from the crowd. The text was this:

Ministers believe there is not enough incentive for these patients to be treated, meaning some are left “languishing” unnecessarily.

Let’s let that sit there and percolate a little while we stand back and recall what the NHS is for.

The NHS was set up as a form of national health insurance. Collectively we pay tax and national insurance and if ever we need health care in our lives in the UK it was to be delivered free at the point of charge. The NHS was designed to give the public peace of mind that even if they fell on hard times that in regards to their health they would always have access to care.

So the reason for the existence of the NHS is to provide health care to the British public.

In my book, “Beat the Cuts – How to Improve Public Services and Easily Cut Costs” I argue that the real motivation to do good work comes from within. This motivation stems from wanting to do something meaningful, wanting to work as a team, wanting to take pride in your own work and wanting to do something for others. The last of those is particularly prevalent in the public sector. That list contrasts with extrinsic motivators such as money, prestige, power and praise.

When ministers are quoted as saying that there “is not enough incentive” I think they must be thinking of the list of extrinsic drivers. My experience in all parts of the public sector is that its staff really do want to serve and provide for the public. This is very strongly true in the NHS.

So I don’t believe that there is not enough incentive. There is. The problem is that too many people only think of motivation from outside and forget the internal motivations. The consequence of that serious oversight is that they further pile on the extrinsic motivations which actually sap the internal drivers. In addition they forget to foster intrinsic motivation in the systems of management that are set up. The irony is that their statement eventually will become true. The extrinsic motivators will cease to be effective and their over application will have crushed any intrinsic motivation so there really will be not enough incentive to care for patients.

However, I am confident that we are not there yet. But we need to be careful not to ignore pride in work or the need to help others any more.

Best,

Rob