News and Comment from Roy Lilley

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Amazon can...

There's the right way, the wrong way and the NHS-way.

The NHS almost never do things the right way.  Employee relations, patient safety, workforce planning, finance, regulation, interoperability.  The list is endless.  

But, to be fair, it never does things totally the wrong way.  

It tries but gets bogged down in bureaucracy, silly politics, thoughtlessness, money and the legacy of the past.  It's made huge strides in A&E development and where outcomes are good, they are very good... but they are inconsistent.

The NHS has its own way of doing things.  It is a closed system, slow to learn from mistakes and reluctant to look outside its own carpark. 

We are about to embark on another 'NHS-way', nonsense. This time; the NHS-way of buying... supplies and stuff.  Dull but essential.  Tedious but terribly important.  

I once chaired the National Standing Committee on Supplies and Purchasing.  It was a mess then, and I'm proud to say... it's called something else, but it's still a mess!

It's not right and it's not wrong... it's just an NHS-way... mess!

Buy bog rolls as cheap as you can.  Say a hundred quid.  Have them delivered to the vast cathedral that is the Normanton Warehouse, where the big bulk is broken down and put on smaller lorries and delivered to hosptials and locations up and down England... all of that adds an 'on-cost'.  What is it?  Dunno... 

Make a guess at 5%, some say 11%.  Whatever it is, the bog-rolls end up costing your hospital £105, or even £111.

The next day the bog-roll manufacturer rings up the hospital and says I'll deliver your bog rolls for £104... you say 'done'... and we all have been.

It's the story of the bog-roll that defeats centralised purchasing.  Is there anything the NHS buys and delivers that you can't find cheaper on the internet or high street?

This is what will defeat Lord Carter's byzantine efforts.

Now we learn from the HSJ, more than half a billion pounds will be withheld from NHS providers, during the next two financial years, to pay for a new central procurement service.  

Top-sliced for a service they may not want to use and may not be any good, any cheaper, any faster... like we have nothing else to spend our money on.

The right way, the wrong way and the NHS-way.

There is a problem.  A structural problem.  I know we all perceive the NHS as a huge organisation... and it is.  But, it's not big enough.

The NHS Supply Chain tells us;

'We currently manage more than four million orders per year from over 120,000 order points at 10,000 different locations. We are able to consolidate orders from over 600 suppliers, removing the need for multiple deliveries each day...'

When the world was a smaller place and the telephone on your desk was your only access to it... when the Ford Capri was a car to die for, Xerox was making a fortune and we waited a week for Kodak to send our holiday pictures back... these numbers would have been impressive.  Today, I'm not so sure.

Four million orders from 120k order points is 33 each... less than one a week.

We also learn;

'...so far we have reduced our catalogue from 600,000 product lines to 315,000... to help NHS organisations purchase products more efficiently.'

Actually what they are saying is; to save money we've reduced choice.

Reduce choice... you turn your back on innovations, savings and who knows... safety.

In today's world the NHS is not big enough, to buy enough, to distribute enough, to save enough, to reduce the margins enough... without taking the money out of hospital's budgets, up-front... to subsidise it.  

It's an outrage.

The right way to buy what we need is on a global scale.  Procurement is an international business.  We must think about the value of currencies and its impact on budgets.  We must be open to innovation choice and the next thing.  Order-n-get, from the get-go.

We can't do this but... Amazon can.

Have a good weekend.

That's the point...

Edward Snowden and Julian Assange are not at the top of everyone's Christmas card list but you cannot deny they changed the course of history.

The Greeks and the Romans started it; strategic leaks of important documents to leverage causes. 

In 63BC, Cicero had become convinced that someone was plotting a coup, but was unable to prove it. One morning, outside his door, he found a collection of letters, outlining details of the plot.  The first leak?

Journalistic careers have been built on leaks and although the likes of the BBC and others are very sniffy about leaks... they love them really!  

Leaks can turn the world upside down.  Remember the MPs expenses row... started with a leak.  Leaks invariably come from people deep in organisations, designed to provide embarrassment for the visible ones at the top.

So it is, Captain Mainwaring at NHS Providers, with his BBC trained press officer, is huffing and puffing, telling us the leak of his letter, outlining their anxieties for the future of the NHS in the face of Brexit, is nothing to do with him.

Pull the other one.  The timing was perfect.  Just in time to catch the breakfast news programmes on a quiet news-day.  The work of a professional.

What are the Providers saying?  Not much.  In a word; 

'... if there is any Brexit planning going on, members of their club are not involved.'

So what?

Can you imagine the other side of the coin; 

'Our members have got enough to do without being involved in endless committee meetings, speculating about Brexit.'

What are the facts?  Here are some of the more eye-catching;

  • About 45 million packets of medicines go from here to Europe every month and 37 million come back.
  • Without a deal they could be subject to over 40 checks at the boarder.
  • Supply chain security will depend on increasing inventory and that means specialist warehouses and the cost of the stock pile.
  • The European Medicines Agency has already gone.  
  • There are 180 drugs, used across Europe that are manufactured, exclusively, here.
  • Approvals and market authorisations will have to be duplicated.
  • The numbers of EU health workers, registering to come and work here has dropped by 90%.
  • There is a concern about carting radioactive isotopes back and forth.
  • Across the whole landscape of care, about 17% of the workforce comes from outside the UK.
  • The NHS is not represented on the Cabinet Brexit Committee.

There's probably a lot more going on, that we can do without but I'm struggling to know how the Board and the Bosses of The Littleblogsworth Foundation Trust can do anything about any of it.

NHSE+I+DH+?  They can rent warehouses, stockpile medicines, crank-up training and recruitment and set-in-train all sorts for the best and worst scenarios, and...tell the Treasury what the bill is expected to be.  I'm pretty sure they've done that.

Until we know what kind of a deal we are dealing with, it's speculation.  

This week, expect the Government to publish some technical documents that may give some clarity to the 'what-if' arguments.

The truth is; you can't negotiate in public.  Pushing a disaster scenario for Brexit is daft.  Saying it will be a breeze, is equally daft.  

Whether you are Brexit or Remain, you only have to talk to EU business people and citizens (which I did last week) and you'll discover, guess what?  They are worried about their jobs and businesses if we leave.  The last thing they want is a 'crash-out'.

They asked me, politely, if we had gone mad!  

My guess; saying there will be no-deal makes a deal more likely.  That's why the likes of Fox and Hunt and others are saying it.

I passed the Astra-Zeneca factory just outside Calais, it is the size of a small town.  They have another one in Macclesfield and one in Sweden.  They are spending £40m in preparation.  My guess is, people who can get ready, are getting ready.

NHS Providers club, strategic leak is naive, adds nothing, tells us nothing, takes us no further, has no point and frankly I don't know why I'm bothering to write about them... but...

... I am... maybe that's the point.  

Don't wait for it to arrive...

Managing in tricky, changing times?  Here are The Magnificent Seven of the most underrated questions we don't seem to ask ourselves.

What has to be done?

Note to ebullient leaders;  not 'what do I want to do'.  In the context of the NHS... it's obvious.  We have to work around the debris created by the Lansley reforms and change the way the money flows through the system to make it create more healthcare. 

What's 'right' for the organisation.

It might be right to charge people for using the NHS.  Charge when they abuse it.  It might be right to subcontract chunks of it.  It might be right to ration care or ask for top-up payments.  It might be right but it wouldn't be right for the NHS.  

The ethos; skills, wisdom, virtue and goodwill.  Without it we run on fresh air.  With it, we're cooking on gas.

Have we got any idea how to do what we want to do?

This is where things, generally, start to go wrong.  The 'how to' is often settled in the Board Room, the C-suite... instead of on the shop floor.  Asking the people doing the job.

Who is making the decisions?

Decisions are no-good unless everyone involved knows what the decision is.  It's even better if everyone is involved in making the decision in the first place.  Who's taking a lead, how do people have their say, what's the deadline?  

You'd be surprised how many organisations don't get the basics right.

How are we going to tell people?

Back in the dark ages, when Florence and I came to work on the bus, communication was difficult.  We'd do newsletters, notes in pay-packets, communications days... none of it really worked.  We could never beat the gossip.  

Today, every member of staff will have a smart phone.  Every chief executive, boss and manager can communicate everyday.  

I'm still amazed at the number of organisations that don't invite staff to be on the daily up-date-text and messaging system.  Even more amazing, the number of Trusts that don't have them.

Can we exploit opportunities?

There are opportunities to save money, work smarter, be safer, improve through-put and make the work easier and more enjoyable.  

If we did a tour of your-place, we'd have ten ideas by lunch time.  Bet the farm.  Fill the gap between 'what it is' and 'what we want'... in a morning, fuelled with enthusiasm where people have the freedom and opportunity to have a say. 

The 'we' word

You'll not achieve much but 'we' can do anything.  It's a mindset.  Think 'we'.  You may have the job, the title, the responsibility and delivering is down to you but you'll not do any of it on your own.  

Ask, 'how will 'we' do this' and then shut up and listen. 

Do you think any of this is worth doing?  Think it might work for you?  Could help you and your organisation change gear and do stuff?

I have to tell you... I have adapted the magnificent seven from the work of Peter Drucker.  

His first book 'The End of Economic Man' was written in 1939, of which J B Priestley said: 

'... the most penetrating and the most stimulating book I have read on the world crisis.  At last there is a ray of light in the dark chaos'.

The Concept of the Corporation - followed in the year I was born, 1946.  Then came the seminal, 'Practice of Management' in 1954.  

Even today, the same topics, astound us and confound;

  • The social and environmental responsibility.
  • The relationship between the individual and the organisation.  
  • The role of the top management and the decision-making process.  
  • The need for continual training and re-training of managers; the focus on their own responsibility for self-development.  
  • And, the nature of workforce relations and imperatives of community and customer relations. 

Of all the common-sense and originality, perhaps the most apposite from Drucker, at a time when every tin-manager and plastic predictor is telling us what the NHS must look like, is this advice; 

Don't ask 'What will tomorrow look like?

Ask, instead: 'What do we have to tackle today, to make tomorrow?'

Get that?  'Make tomorrow'.  Define it and do it.  Don't wait for it to arrive. 

Pragmatism...

There is a global shortage of nurses.  I have rehearsed the numbers often enough, you know them by now.  It looks to me as though nursing is in a 

state 

of 'managed decline'. 

Traditional thinking is not going to solve this, yet the NHS ploughs-on, bullying and bamboozling people into believing working under horrible pressures is ok and then wonders why they leave.

What's the point of recruiting more staff when a third leave in the first year.  

What are we to do?  

Two solutions are obvious to me.  The first, I know cuts against the grain.  I know, the roof comes in when you suggest it, because I've said it before and it did!  And, to be honest, I'm not entirely a fan of my own idea.  But, sometimes you have to be practical;

Stop training nurses at university.

There is an urgent need to get caring, thoughtful, motivated hands on the wards.  The existing apprenticeship scheme gets close to this.  We need to put the scheme on steroids... 

... make it the single entry-point into nursing.

The universities will squeal.  They need our money.  Their borrowing boom and 8% returns are a bubble and a rip-off and like all bubbles and rip-offs, will come to grief.  Some are returning to the public debt-markets to raise cash.  All the time they can charge students £9k a year for not much, they'll be OK.  It won't last.

The alternative?  Don't do it.

Apprentice training is paid for from the training levy that employers are obliged to pay.  The money is available.  The nurse apprenticeship scheme means nurses aren't saddled with debt, making entry into the profession more attractive.

Apprentice training is fundamentally ward-based.  That has the advantage of giving trainees a feel for what being a nurse is really like.  You'd know in the first month if you were in the right job.  And, anyone who has a memory of SEN, SRN training knows the benefits.

Hospitals training the nurses, like they used to.  How many of you reading this will have the silver belt buckle your Mum and Dad bought you, when you qualified.

Is it safe?  Stop kiddin' yerself... we don't do safe staffing now and there's safety in numbers.  One to 8 doesn't make me feel remotely, anything like safe.

Of course, training should still culminate in a degree but based on a national curriculum so everyone learns the same things and over a longer period if necessary.

But that's not enough.  We have to become a better employer.  

  • We hire people to work under pressure - how do we take the pressure off?  
  • We hire people to work in a regulated environment - how do we make that supportive?  
  • We hire, overwhelmingly, a female workforce - what does that mean to us as employers?
  • We hire people who are the principle carers of children and relatives - what thought do we have to give to that?
  • We hire people on shift-work.  What does that do to family life and day-to-day living.  How do we ameliorate that?

High ambition and the search for excellence, the cry to be world-class is all very well but the quest for preeminence is not a good idea when doing it causes it's own problems.

Neglecting workforce planning has left us in a hole.  We are facing a horrible future, it will impact on quality, safety, waiting times, peace of mind and staff wellbeing.  Working in the NHS will become a second choice career and then a third choice.  

We have an excess of hope and a deficit of ideas.

Donald Winnicott, in the 50's gave us the concept of 'good enough' it was about parenting but has since been translated into a management concept.  

It doesn't mean; sloppy, not good enough, or just good enough.  It means 'good enough'.  Not bad, could be better or inadequate.  It means, does the job. 

It does mean; we stop pretending.  With an austerity economy, a very uncertain future that no one can describe let alone agree on, we can't buck an international trend on healthcare workers.

It does mean; we are sensible, we don't abandon our values or sacrifice our principles, we just come at them differently.

It does mean; we recognise, somewhere between idealism and failure lies pragmatism.

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roy.lilley@nhsmanagers.net 

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Reproduced at TrainingPrimaryCare.com by kind permission of Roy Lilley.