Cowper’s Cut – On the NHS reaching Peak David Brent

Well. That was different, to put it mildly.

At a time when chief executives are being forced out of their jobs, we find out that in last Monday’s shenanigans, a regional leader for the NHS Commissioning Board thought it appropriate to lead a group in a roof raising chant of “We can do this! We can do this! We can do this!”

It’s hard to avoid the conclusion that the NHS has reached peak David Brent. 

Leaving aside for a moment the sheer crassness of this behaviour, for the third column in succession we return to H L Mencken’s line from The Divine Afflatus: “explanations exist; they have existed for all time; there is always a well known solution to every human problem - neat, plausible, and wrong”.

 There is a real problem with performance in accident and emergency. It is not a single problem everywhere. It is not a simple problem everywhere, either. One size does not fit all.

In some places, the problems are about simple lack of sufficient staff: A&E consultants, junior doctors and nurses. In others, the physical infrastructure of A&E departments built for x thousand attendees a week struggle given that the demand now presenting is 2x or more.

And of course, there is the issue of being able to safely discharge medically fit frail older people from hospital where no social care packages are available.

History is not destiny

Some provider organisations which had historically been doing badly against the national waiting time targets for A&E have significantly improved and sustained their performance.

Some other provider organisations are still doing badly, having been doing badly for long periods. And some of these latter group of organisations are still failing to exhibit appropriate curiosity about what has worked for their peer organisations, despite repeated encouragement from national bodies. 

In such cases as these latter ones, system leaders and political leaders have good cause to be exasperated. However, what they have signally failed to do is to flag up this issue - of failing to learn or do the obvious (things as basic as regular available beds meetings each day) - effectively across the system.

Management by shouting at people

This communications failure has been compounded by a tendency in parts of system leading organisations towards “management by shouting at people”. Mystifyingly, some people still confuse this with “being effective”.

Sometimes, people do indeed need to hear tough messages about their own or their organisation’s performance: to do this effectively will almost never involve shouting.

There are all sorts of problems with the “management by shouting at people” approach. The first is how silly it makes the person doing the shouting. The second is that if a manager at any level in the system defaults to shouting or barking at people, their audience will quickly take permission not to listen to what is being shouted or barked at them.

Sometimes, people do indeed need to hear tough messages about their own or their organisation’s performance: to do this effectively will almost never involve shouting. System leaders need to pay more attention to their communications style and personal impact. A system running under sustained pressure needs to be run with high levels of emotional intelligence, listening and respect.

The NHS still needs a chief anthropologist much more than it needs any chief inspector.

Postmodernisationism

Equally, the lack of a national non-optional support offer for those struggling with A&E performance is hard to understand. Readers with long memories may recall that the NHS Modernisation Agency used to be quite good at this.

There is a significant variable around workforce and motivation. The impact of Jeremy Hunt’s Pyrrhic victory over the junior doctors continues to reverberate. More than a few clinicians have separately told me that in their view, the main result of the strike was that Mr Hunt  “lost the dressing room”, in the football sense. It’s far from clear that any system leaders have done much to try to get the dressing room back.

The lack of a national non-optional support offer for those struggling with A&E performance is hard to understand

And every good manager knows that you won’t make any change stick if you can’t get the dressing room onside.

Poor communication isn’t the only cause of this set of problems. But it’s a significant contributor across the piece. If there is a desire to see a more “can do” attitude, then system leaders have got to think about their message. Content matters; delivery matters; culture matters. We are not what we say about ourselves (“values driven”, “solutions focused”, “patient centred”): that is just public relations. We are what we do consistently.

And where there is inappropriate behaviour from system leaders, the service needs to show resolve in calling it out and pushing back effectively.

The wrong question and the right question

“We can do this! We can do this! We can do this!” Ahem.

Can we do this? It’s the wrong question.

The right question for provider leaders is “how will we do this?”

The right question for system leaders is “having decommissioned management by shouting, how can we get them to want to do this? And how can we help more effectively?”