Beyond the Backlog

0:03

Hello, I’m James. Hi, I’m Jimmy and welcome to A Job Done Well, the podcast that helps you improve your performance enjoyment at work.

James: 0:15

Good morning. How you doing?

Jimmy: 0:17

I’m doing well, James. How are you?

James: 0:19

Fabulous. Thank you very much. Although the weather is really quite nasty out there this precise moment in time.

Jimmy: 0:24

this is like the ultimate British podcast, isn’t it? So apart from the weather, James, what are we going to talk about

James: 0:31

Well, today we talked last week, I think about the Darzi report, which was this review of the NHS

Jimmy: 0:38

Oh yeah, yeah,

James: 0:39

And then we sat down and we had a look at it and as we read through it, we thought, well, there’s a load of, um, commonalities with things that we’ve seen elsewhere. So we thought we’d have a chat about those commonalities, what we’ve seen and, uh, not that we are in any way, shape or form qualified to sort out the NHS, but sort of things would we do given that piece of information? So. That’s what we’re going to chat about. It will be riveting.

Jimmy: 0:59

Commonalities and learnings

James: 1:02

But anyway, in the interim, what have you been up to?

Jimmy: 1:06

in the interim. I didn’t even think what I was going to say about what I’ve been up to.

James: 1:10

It was the interim bit that confused you, wasn’t it? Hang on, let me say that again. At the weekend, what did you do at the weekend?

Jimmy: 1:17

Well, uh, Forrest lost their unbeaten record, not surprisingly this season.

James: 1:22

on, how long is that unbeaten record? How many games?

Jimmy: 1:25

It was single digit numbers of games, so it wasn’t, unbeaten for very long, but that, that went by the wayside. Hence I’ve not been skipping around full of the joys of spring. How about you, James?

James: 1:36

I was going to go to the Southwell plough competition.

Jimmy: 1:41

that?

James: 1:42

Well, I didn’t go. So the Southwell ploughing competition, if you don’t know, is a very sort of oity toity. It’s all, green wellies and barber jackets, flat caps. The sort of landed gentry of Nottinghamshire were there. But I

Jimmy: 1:53

you had your uniform

James: 1:54

I had, I was all ready to go, but instead I went to the Goose Fair, which is, which is chav tastic. It’s the, I think it’s the second largest, traveling fair in the country. So I went there

Jimmy: 2:04

that’s, that’s a come down for you though, James. You were going to be with the, uh, the country set. And now, you’re, you know, rolling around with, with hot dogs and mushy peas and

James: 2:15

Now, yeah, there’s nothing quite like the smell of diesel and, um, candy floss combined., I took my 16 year old daughter and I thought, well, I need to be the brave father. I need to, take her on the ride, protect her. So we went on the waltzers and, um we both got off. She was saying, again, again, again, and I’m thinking, no bloody chance, I’m gonna vomit.

Jimmy: 2:36

I used to, I used to have a mate who used to, work in the waltzes, a local fun fair near me, and he used to make more off the money down the back of the, seats than he did from his actual wages.

James: 2:48

imagine you could set up a mobile phone shop now with what goes on in those things.

Jimmy: 2:52

That’s true.

James: 2:53

Anyway, moving on, more, prosaic things. The Darzi Report. So, what were your overall impressions when you, read that then?

Jimmy: 3:01

Well, I think it’s probably worth us just giving the listeners who may not have, uh, heard of the Darzi Report a bit of the background. So this was commissioned by the Home Secretary. It’s meant to be a definitive view of the NHS performance and challenges to help the government to create a 10 year plan for turning the NHS around. Now, Lord Darzi is a former health minister under Gordon Brown, and he’s an eminent surgeon who’s worked in the NHS for over 30 years, and he’s been a big advocate of reform and improvement. So definitely more qualified to opine on all this sort of stuff than you or I. Ever would

James: 3:41

Yeah.

Jimmy: 3:42

an overall, he paints a pretty bleak picture. there’s not been much noise about the accuracy of a report, which always means that, it’s going to be pretty, pretty bang on the money. And he focused on the, very much on the state of play, not the solutions.

James: 3:57

So, well, let’s start then with what got us into this mess then. So how did the NHS get into this position?

Jimmy: 4:03

Well, it’s a bit of a perfect storm. It’s not one thing, it is a load of factors. including, obviously, a massive spike in I can demand with, with COVID, but more generally, people are aging. They’re living longer and we’re living in ill health for longer as well.

James: 4:25

the other thing they didn’t call out but I think is probably an external factor is the dare I say the effect of brexit on staffing because if I understand that that’s had a fairly negative effect

Jimmy: 4:34

so all these external factors create, a absolute mother of all backlogs. And that’s really kept the focus over the last few years on hospital care because they’re needing to deal with a backlog.

James: 4:48

Well, hang on. Let’s play the Politics. It’s not a backlog. It’s definitely a queue, isn’t it?

Jimmy: 4:54

well, that’s what, what was it we were discussing? It was, um, oh, it was a asylum application where they renamed it a queue.

James: 5:02

it was a queue about the size of a small town, wasn’t it? But this is significantly bigger queue,

Jimmy: 5:08

it’s not a small town. It’s more like a medium sized country.

James: 5:12

Currently there are 7. 8 million people waiting for treatment in the NHS, so yeah, that is I think the mother of all backlogs, I’ve never seen one quite that big.

Jimmy: 5:23

Also in response to some of the, the things that have been impacting the health service, they have gone for one of our favorite things, constant reorganization, keep changing the shape of the organization and with a lack of investment in, in both the technology and the infrastructure overall, the productivity has decreased,

James: 5:47

and just to put the cherry on the top because they’ve got bigger queue and less productivity. They’re paying more in compensation

Jimmy: 5:55

A whole host of factors, what we’re going to do is go through those challenges the NHS has been facing and we’re going to talk about where we’ve seen them and experienced them, in other organizations. So likely. You recognize some of those challenges as well.

James: 6:15

And then we’re going to go on and talk about what we would do When we face some of those challenges in the past But you have to wait till next week till that because then there’s quite a lot to get through

Jimmy: 6:25

Yes. And nobody wants to listen to us

James: 6:28

Turning on for two hours first of all then, funding. What’s the story on funding? Because I’ve heard lots of conversations about funding in my career.

Jimmy: 6:36

There is talk about chronic underinvestment in the NHS, but actually in real terms, between 2000 and 2010 spending on the NHS doubled, but then it slowed down. So between 2010 and 2020, it was only just above, inflation. So it’s still significant amounts of investment, but I think the challenge isn’t necessarily the absolute amount. It’s often how it’s invested. There’s lots of talk about spending it wisely. So I think the two factors here are the absolute amount of investment and how it is then spent.

James: 7:14

Some of the numbers. Apparently the number of staff, um, in the NHS has increased by 17 percent post pandemic. and they’ve got 35 percent more nurses working with adults and 75 percent more nurses working with children than in 2009. So that’s a, a fairly substantial investment. But as you say, the question is, is that investment investment in the right place?

Jimmy: 7:39

Because equally, you could look at the number of people working for the NHS in the community, uh, and things like health visitors people working as mental health nurses, those have gone down over the same periods of time. So again, it is the focus on the hospitals and what’s really urgent and needs to be done now, as opposed to investment in, prevention.

James: 8:03

The thing I’ve seen time and time again, is conversations about funding and costs as if it’s the only lever that can be pulled. And I think it’s clear in most organizations, that’s not the case. There’s a whole host of other things we can be doing.

Jimmy: 8:19

Yeah. And it’s getting value for money from the spend that you’ve got.

James: 8:23

So there’s one thing. Second thing, which I think is endemic across a lot of organizations is short term thinking.

Jimmy: 8:29

Rory Stewart and Alistair Campbell did a piece on the, the rest, his politics they were set, they were pointing out labor have got a job on to fix it and it’s a massive job. they’re saying you’d be lucky to fix it in 10, 15 years. That creates a problem because in five years, they will need to be going to the polls again they can’t just think about it in the required 10, 15 year time horizon. They have to think about what are the ways of progressing in the next five years that’s going to get them reelected. And those two things might be the same, but they might not. The election cycle, same as the annual budget cycle that we all experience, drives shorter time thinking than perhaps is ideal.

James: 9:13

The next one that really struck me, is is this whole thing about denial.

Jimmy: 9:17

I’ve got to go for the denial is not a river in Egypt.

James: 9:20

It’s all done. Very good.

Jimmy: 9:23

I thought you’d appreciate that is a law of a style joke.

James: 9:26

Good, um, bit of eye rolling going on with that one. Historically there has been this political willingness, um, to look good at all costs.

Jimmy: 9:34

Yes.

James: 9:35

And really interesting. Lord Darzi has come out and he has said, you know, to make no mistakes, the NHS is broken, but the media backlash, Oh, you can’t say it’s broken. It means people lose confidence in it. And I think that’s just absolutely missing the point. Cause if you don’t say it’s broken, you can’t fix it.

Jimmy: 9:52

and even, in Lord Darzi’s report, he had hundreds of things that were, he was pointing out were wrong. But even he felt the need to say that, the vital signs are really good. And reading between the lines that he was talking about is that there is some great clinical talent in the NHS and huge amounts of passion pretending there’s not something wrong, which we see in a lot of organizations, a lot of organizations want to tell you that there’s nothing wrong here

James: 10:25

rosy.

Jimmy: 10:26

performing well, and people make, make their living out of spinning stories. And I’m sure, all our listeners will have examples in their career where someone has tried to convince them that something’s much better than it actually is.

James: 10:40

And it’s that whole thing about Alcoholics Anonymous. They won’t let you join their program unless you admit you’re an alcoholic. So unless you admit you’ve got a problem, you can’t

Jimmy: 10:48

You can’t solve it.

James: 10:49

Yeah. And in Lord Darzi’s defense, that is something that he has, um, drawn out. So I think that’s a good thing. Now the next one is our, you know, favorite topic, lack of clear purpose.

Jimmy: 11:02

Absolutely.

James: 11:04

I did have a look on the internet to find out what the, um, what the purpose of the NHS was. I came up with Two answers, which is maybe missing the point a wee bit. one was from NHS England, which is we aim to improve health and care outcomes, improve people’s experience of health and care services and reduce pressure on frontline services. And I got another one from government. uk, which, um, the NHS is there to improve our health and wellbeing supporting us to keep mentally and physically well, to get better when we are ill. And when we cannot fully recover to stay as well as we can to the end of our lives. And it goes on a little bit, but you get the general gist of it.

Jimmy: 11:46

But I think there’s, there’s a couple of points there. One, one is there, they’re not that short, clearly, but also we would all say something similar, but we wouldn’t say the same thing. And I think that’s one of the issues is. They’re actually being really clear on what the purpose is of the NHS and then making sure that runs through every part of the organization from decision making to the service they provide to the patient’s understanding of what they’re there to do, everything. It is the ultimate purpose driven organization in

James: 12:24

absolutely. Yeah. Yeah. But then there’s that whole thing. Uh, posse would have you had posse wit? I can’t remember when I came up with this, but POSIWID stands for the purpose of a system is what it does. So you can claim that your system is there to do whatever the hell you like, but actually if you stand back and look at it, what does it do? And you’d have to say the purpose of the NHS currently is to create queues and spend money and hide things. So actually there is something, there’s a piece of work that needs to be done there, just being really clear and explicit on purpose, next one that we saw then, something that comes out loud and clear and is alive and kicking in, British industry is silo thinking and optimizing little bits but sub optimizing the whole.

Jimmy: 13:03

definitely. And you see this all the time in organizations, but in the NHS, one of the examples that is talked about is community support versus, A& E versus, ambulances and that whole end to end process is, full of, breaks and delays. there’s some work done to analyze the impact of that. What they found is that if you went into A& E in 2009, you’d have just under 40 people ahead of you in the queue. If you go in now, you’ll have over a hundred people. So the delays that are manifesting itself from not looking at end to end in that process, the delays are killing an additional 14, 000 people every year.

James: 13:52

Yeah, and then,

Jimmy: 13:53

a horrific stat

James: 13:55

The whole thing. It just is case study in Optimizing bits and not looking at the whole Yeah. novel to the NHS. I don’t think far from it It’s the whole sort of dividing conquer management attitude.

Jimmy: 14:09

And, and, and everyone thinks in their own little silos of who they’re working for and what team they’re in. And very rarely thinks upstream and downstream about the impacts of what they’re doing and how they’re behaving and what it will cause somewhere else in the organization, so long as they are doing their bit. That’s how people are often driven by targets and by leadership to optimize.

James: 14:35

That moves on to the next thing Which is that you just miss the wider opportunity. And this comes out loud and clear in the Darzi report. I think the stat was there are 2. 8 million people who are economically inactive due to being sick. Now, all those people could be in the workforce and they could be increasing the nation’s productivity and more to the point they could be paying taxes and, and, and.

Jimmy: 14:59

And that is the missing opportunity because you’re focusing back on the backlog and the cost. having a healthy, fit, population does help the overall nation’s economy and, and productivity.

James: 15:16

And again, it’s not just the NHS here. it’s rather mundane one. I’ve seen this in a call center where they miss cross sales activity because they weren’t processing applications quickly enough. It’s exactly the same thing. It’s about standing back and looking at the whole thing Okay, man, another thing here. We keep going So the other thing that, he’s also played out in this report is this whole thing about managing demand and not trying to mitigate it.

Jimmy: 15:40

an example since COVID immunization is down 25%. so well done the conspiracy theorists there. And also there’s been cuts in the grants for public health spending since 2015.

James: 15:54

but then you get to a point whereby you’re investing in nurses Rather than investing in the things which would stop the work coming in in the first place. And it’s not like the NHS hasn’t, or public health England doesn’t have good track record of this. I mean, if you look at smoking rates, they’ve dropped massively over the past, what, 40 years. So you can actually do a huge amount to prevent people coming into the hospitals.

Jimmy: 16:18

The population aging and us living longer and in ill health, that’s not a new concept. That’s been going on for a while and to not invest in figuring out how you deal with that and how you mitigate some of the demand it’s back to that focus thing. Let’s focus on managing the issue when it hits us. And that’s what organizations often do. they love a bit of crisis planning as opposed to, capacity planning and thinking about predicting the future, uh, resourcing and contingency planning, you take completely different action if you knit things in a bud, in the bud early opposed to let them become a big problem. when the NHS focuses on reducing demand, a la smoking, it can do an amazing job. Another good example was the diabetes prevention program. They did reduce type 2 diabetes by 40%. So when they do it, amazing.

James: 17:15

Yeah, absolutely fantastic. of course these things all link together and I’ve seen this again, but you then end up with some sort of knee jerk capacity investment. So things have gone absolutely dreadfully wrong. because they’ve gone dreadfully wrong, it’s in the papers, because it’s in the papers, people need to do something. So we’ll invest heavily in whatever the hell it might be, nurses, ambulance drivers, whatever it is that the public are up in or around, which then of course links back to the whole thing about short term thinking.

Jimmy: 17:41

historically we’ve always, always heard what our overhead NHS managers are. But actually leadership in these situations is so important, but the leadership is described in the Darzi report. It says it’s institutionally inadequate in the way that it, Leadership and management is trained, developed and valued. So funny enough, if you don’t value people, you don’t train and develop them. you end up with poor leaders and managers and, they can’t, they can’t find their way out of these situations. again, another example of a lack of investment in capability. And when we talk about capability, as we’ve touched on before, we’re We mean both system capability. technology facilities, that’s been lack of capital investment in that. They reckon there’s 36 billion needs to be invested in that and people capability. So both of those haven’t been invested in the right way by the NHS.

James: 18:36

And then when they have invested in it, things don’t work too well. not that this is a problem unique to the NHS, in terms of digitization. Well, digitization may certainly help. I mean, it’s worked marvels for the banks. But I think there are two things. First of all, it needs to be designed well. And my personal experience with the NHS apps is it’s not great. But then the second thing is you really need to design for your customers. Yeah. And you’ve got a huge number of elderly people who maybe don’t have phones or don’t have access to the internets. And then the things just don’t work for them.

Jimmy: 19:10

like you say, knee jerk jumping into the solution is, is technology, but not thinking through how it solves the problems you’re facing today. the answer often is technology and human solutions integrated rather than it’s all about the technology. I’ve, uh, got a friend who’s in his eighties and he can’t use any technology whatsoever. But he’s regularly ill. So funny enough, he needs their service, but you can’t access it without huge amounts of stress and frustration, but that’s okay. Somebody’s probably ticked a box somewhere saying, yeah, we’ve automated this

James: 19:48

another thing, which is only called out in the Darzi report, um, tangentially, it’s the use of targets. his point was, well, You get into a downward spiral because what happens is you put performance standards on hospitals so everybody gets excited about the hospitals. The hospitals don’t hit the performance standards so then what you do is you reinvest, so you invest in the hospitals at the expense of somewhere else which then reinforces this silo thinking which then means, of course, that productivity goes down because you haven’t mitigated the demand. Which then means you don’t hit your performance standards. And so the whole thing has a systematic effect, um, of, forcing investment into the wrong place.

Jimmy: 20:27

And I think that the ultimately the issues that you then create with, setting targets, missing targets, downward spirals, lack of investment in capability, is a problem. It’s just really dispiriting for the people working in this system to know that no matter how hard they work, the overall is unlikely to improve you as an individual can’t reduce the 7. 8 million backlogs that you’ve got in the NHS, so it’s just, as they touched on, it’s dispiriting.

James: 21:03

carrying on, a catalog of things not to do. the other thing that comes out loud and clear is multiple restructures.

Jimmy: 21:11

God. Yeah. And, and we, we complain about restructures and the impact they have and the distraction they have. The NHS takes restructuring to absolutely the

James: 21:22

well, and it’s almost as if it’s one of the few levers that the politicians can pull. So they pull it like crazy every couple of years.

Jimmy: 21:29

Yeah. But not only do they pull it like crazy, the, the Darzi report talks about the, the social, the health and social care act of 2012 was a calamity without international precedent. It proved disastrous.

James: 21:44

Yeah,

Jimmy: 21:45

that’s how he describes it.

James: 21:46

and I looked at it, and since 2002, there have been changes to the numbers of primary care trusts, there have been strategic health authorities, community services have been added to and then split away from primary care trusts, then they all became clinical commissioning groups. Then they had, um, accountable care organizations. Then they had 44 STPs. I’m not entirely sure what STP stands for, but it just goes on and on and on and on. And of course, nobody knows which way’s up. And because nobody knows which way’s up, nobody can get a damn thing done.

Jimmy: 22:20

Well, each time you create these new organizations, you’ve got to embrace their new responsibilities, ways of working. And that takes a while. Before you’ve actually done that, before you’ve got used to it you’re starting again.

James: 22:36

Yeah. it really is classic moving the deck chairs. Right. Nearly at the end of our list of, woes.

Jimmy: 22:43

Before we go back, before we go off, you know, we’ve got to talk about our favorite, restructure story, haven’t we? the three envelopes

22:52

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James: 23:24

So the three envelopes, tell me the story.

Jimmy: 23:27

So a guy takes, guy starts a new, new job and the, the previous incumbent says to him, look. I’ve got these three envelopes for you. When the pressure’s on, you know, open the first envelope. If the pressure continues to be on, open the second envelope. If there’s pressure still on, open the third envelope. So anyhow, it cracks on after a couple of months, the pressure’s on. So he opens the first envelope. It says. Blame everything on the previous leadership. Happy days. We’ve all been there and seen there and done that. But that does, that doesn’t solve anything that creates that keeps the heat away for a little while. And then a couple of months later, still feeling the pressure. She opens a second envelope. The second envelope says, Do a restructure. that always looks like, it looks like you’re doing

James: 24:15

Yeah. Progress.

Jimmy: 24:16

you’re changing stuff. So he does a restructure course that doesn’t improve anything. So he thinks, right. I’ll open the third envelope.

James: 24:24

And so what does the third envelope say?

Jimmy: 24:26

The third envelope says buy three envelopes.

James: 24:29

you go. But it’s not three envelopes in the NH s is it? It’s 333 envelopes by the look of it.

Jimmy: 24:34

It could be, it could well be. Anyhow, what else we got

James: 24:37

Well, we’re nearly at the end of Our list of issues, but, employee engagement, um, seems to be somewhat poor.

Jimmy: 24:45

doing your work in these circumstances where the overall system you are working in is so set up to cause these issues. It’s, it’s hard. It’s, it’s almost impossible. They did some focus groups as part of this to see how people describe their experience. The top three words that people use were challenging, tiring, and frustrating.

James: 25:09

And when

Jimmy: 25:10

And that’s, and that’s how you feel. We’ve all felt like that in situations where, you just can’t, can’t feel that you’re ever going to be successful.

James: 25:17

well, the stat that got me was the absence levels. So they said that there was, um, areas where people were. Taking one month off every year with sickness, that’s one in 12 or an 8 percent absence level. I have worked in collections call centres where people, their job is to outbound call people and chase them for money. it’s a really hard job and absence levels weren’t that high there. So it just gives you a sense of how poor the motivation must be.

Jimmy: 25:44

And the other thing that Lord Darzi talks about in his report that impacts the staff is the expectations that were put on the NHS staff during COVID were absolutely impossible. The things that they were expected to do the rules, the exposure they had, it was just unreal. And the fact that that hasn’t been, fully worked through, dealt with, appreciated, it’s still an open sore for many people So what they’ve seen is a lot of the discretionary effort. that people put in, an example would be the amount of hours people are, are willing to do above their contracted hours. Funnily enough, they’re not, So all of this situation has meant that, the morale is really, in, in places is very low,

James: 26:36

that brings us on to, the last points, which comes out loud and clear, which is poor patient satisfaction.

Jimmy: 26:46

the lowest satisfaction from patients with the NHS ever, are they really listening and understanding patients needs

James: 26:54

but once again, this is far from a problem just limited to the NHS, I think.

Jimmy: 26:59

the, Darzi report, he does talk about a recent report from the all party parliamentary group on birth trauma, and it says, this really highlights the important ways in which women’s voices have not been heard. So when they delving into. patients issues, they can see that the systemically, patients voices are not heard in the way the system is being designed. you rightly say, though, James, you know, this is not unique to the know, most places we’ve, we’ve worked, they’ll be ignoring what their customers are saying.

James: 27:31

but this has a material effect, my second daughter was an IVF child. And she was also, when nine months later when it came round to it, she was running a bit late. She, obviously was nice and cosy where she was. She didn’t want to come out. And so there was a lot of, um, debate about whether or not they should induce the birth. I can’t remember. I think it’s after, you know, nine months and two weeks, they want to induce the birth so that the baby doesn’t get too big. But I got into this stupid conversation about, uh, when the date of inception was inception was given, um, my wife’s, uh, cycle. And we knew exactly when the date of inception was because it was an IVF baby. But, um, things like that where people don’t listen to their patients or don’t listen to their customers can really have an effect on outcomes.

Jimmy: 28:16

everyone has got stories about the NHS. And almost always the stories that you would have the process or the guidelines or the system while causing a an issue or constraint or whatever that stops you from getting the treatment you need. Whereas all the positive stories I think is because somebody’s looked after you.

James: 28:39

Yes.

Jimmy: 28:40

it’s always the people that are the positive story, and it’s always the systems and the process that are the

James: 28:45

Doing a great job despite the system, but again that’s not, yeah, not unique. there’s a whole catalogue of issues there. But what’s really interesting is it’s just not unique to the NHS in any way, shape or form.

Jimmy: 28:58

Well, I completely agree, James. I think when you look through the report, everything in there, you just sort of think. Yeah, I, I, I rec,

James: 29:08

Yeah, I’ve seen that.

Jimmy: 29:09

Oh yeah, I’ve done that or all that happened to me once because the danger is because the NHS is so large and has so many issues, you kind of get into the view a little bit like we did when we, um, looked at the post office and the post office scandal, or it couldn’t happen here, could it? Well, actually, maybe not in the size and scale because your organization, your team, isn’t the size and scale of the NHS, but certainly some of the things that we’ve seen certainly could happen.

James: 29:37

Um, I suppose the question then becomes, all right, then so smart ass, what would you do about it?

Jimmy: 29:42

as you rightly say, what would you do

James: 29:44

Well, and I think the answer to that is tune in next week. I haven’t got time for that now. All

Jimmy: 29:49

Absolutely. Look forward to discussing that with you next week,

James: 29:53

Well, put the world to rights. Speak to you later. Cheers now.

Jimmy: 29:55

Thanks everyone. Cheers.