NHS Primary Care News And Comments Roundup


Worth working for…

Sweltering in the heat?  Not for you languid lunches on a sunlit terrace.  No shady palms.  No rattan sun loungers.  No fluffy towels neatly folded by the pool.

For you it’s the sweltering heat on the train, no time for lunch, no seats on the bus, no fluffy towels, just a pile of ironing to do.  The only pool in sight is the sweaty pool… and that’s you. 

You are the one left behind.  You are the one who is not on holiday!  You are holding the fort, being the backstop.  You are the only one left on the grid.

Make the most of it!  It could define the rest of the year.

Yes, I know it’s impossible to arrange a meeting because everyone is away.  Anyway, you probably couldn’t get the data you need because… everyone is away.

Most people will receive an average of 122 emails a day.  When people are away, it’s likely you could double that with ‘out-of-office’ messages.  Your inbox is full of junk.  Great, press delete.

One of the best bits of advice I ever had was; do the job you least want to do first… then the rest of the day will be a breeze.  Now is the time to do the job you least want to do and the rest of the year might just be a bit easier.

Whatever has been propping up your to-do-list, get it done.

There is an interesting Prof, from Georgetown Uni, Cal Newport, who talks about ‘shallow work’;

‘…the brainless tasks that occupy our day, like responding to email – is often necessary to avoid getting fired.’

But, he goes on to say, the secret to attaining disproportionate professional success is our ability to engage in what he calls “deep work.”  He’s written a book about it.

When everyone is on holiday generally meaningful email traffic drops, meetings will fizzle out and you will be left with ‘a window’.  

Not a window to sit, gazing out of, thinking of Sangria.  A window of time when you might be able to get something serious, done!  

Most of us just about keep up with day-to-day workloads and I find the prospect of ‘deep work’ and the opportunity to do it, interesting.  In fact, I developed the idea of this eLetter, all those years ago, one August, whilst everyone was away, on holiday.

I think it was Henry Ford who said;

 ‘…people get ahead during the time that others waste.’

Being really productive, in the quiet periods when everyone else is on holiday is like being give a 54 week year.  

You have ‘two extra weeks’ where you could actually do something memorable.  Stay focussed whilst everyone else is distracted with gelato and sardines.

It’s time to get your stuff off the back burner, turn-off the cruise control and be busy.

… and cheer yourself up with the thought that vacations outside the school holiday periods are a shed-load cheaper, flights are a third-off, airports are less crowded, you won’t have to fight for a sun-lounger.

That’s worth working for! 

Have a good weekend!

Not a lot of it about…

There is a word we are all interested in, even if we pretend we’ve had enough of it!  I’ll bet even the most casual observer will secretly want to know… how’s the negotiation going.

You know; ‘that’ negotiation.  The one that might leave us with ration books and spam sandwiches.  Are they serious?

We are all experts at negotiation.  We negotiate with the other half, the boss, the people we work with, the neighbours and the kids at bed-time and the older kids about coming home on time.  Buying a car or a souvenir on holiday… you’ll be doing it.

There some good old basic rules. 

Get the timetable on your side.  You can’t negotiate in a hurry.  That’s where ‘you-know-who’ has gone wrong.  Triggering Article 50 before we had a plan.  We are running out of time.  March is about 32 weeks away, just over 200 days.  We’ll buy extra time but at what cost?

Clarity of purpose and outcome.  That’s where NHSEmployers and the Unions have gone wrong, sorting out the pay-rise.  The complex mess that has left staff, expecting a pay-rise, worse off.  Why?

Who makes the decisions?  Are they on the other side of the table.  NHSEmployers might be the employers but they don’t write the cheques, the DH does. 

What happens after the negotiations?  Never forget; there’s life on the other side of the outcome.  What happens next?  The mess the pay deal has got into will undermine confidence in the Unions and faith in Employers for years to come.  Look at the resentment that still smoulders over the junior doctor’s fiasco.

There will be life on the other side of Brexit.  Not just for us but the 27 nations we leave behind.  How will they feel about that. 

Understand the other side has problems, too. European bureaucrats cannot allow the breakup of the EU, neither can they watch as access to our markets for their manufacturers and others grind to a halt, any more than we can.  

Mutual-needs reframe negotiation.  What is it that both sides need to take home?

Talking to friends and colleagues across Europe and a glance at EU media tells all but the wilful blind and deaf, that almost every EU nation has the same issues.  

Migration is a problem for everyone, from Italy to Germany and all the countries in between.  Access to markets worries them all and the creeping bureaucracy is something they’d all like to dump.

If it sound familiar it’s because it is…

Never say never.  Nothing is ever off the table and never use the word ‘never’.  If ‘never’ is true you’ll never be able to compromise and if you can’t compromise, you can never bargain.  If you can’t bargain, you can never negotiate.  

Red lines?  Daft.  Error one in the game called negotiating to win.

These are the basics and you can see how easy it is to get it wrong.  The problem is they are the rules that came from the era of trades union turbulence and corporations who did business with paper and pencil, flat caps and clipboards.

Today, a prescient media and licentious press drags negotiations onto the front page and that makes it even tougher.  

Negotiating in public is like being naked in the park.  You probably don’t have anything that no one has seen before, it’s just that you’d rather they didn’t see yours.

Add the whirlwind of social media speculation and it all becomes impossible.

I’m starting to think, as wise as all these rules and experiences are, if you get to the point where you have to negotiate then there will only be losers.  Negotiating is about how much are you prepared to lose.

Forget negotiating and think of setting out on a journey to agreement.

It might be better to start with the concept of what do we both want.  What can we reciprocate?  What are the things you really need and what do you want?  They don’t both have the same weight.  

Figuring out what the other side needs and wants and weighing it with your needs and wants changes the tone of the journey to agreement.  

Bargaining around what is less important to them and take that in return for something that is less important to you but more important to them.

That takes honesty, trust and skill.  There’s not a lot of it about. 

I take my hat off to them…

I have a new cap.  I know you’ll be interested…

It’s not a baseball cap.  No, no, nothing like that.  And, it’s not a ferret handlers cap, or an allotment digger’s cap.  It’s not a store man’s cap.  

Neither is it a beret style cap, beloved of the onion sellers.  It is not a cap that announces I have had an expensive holiday somewhere and I am daft enough to advertise the hotel for free.

It’s not a cap with a logo of an expensive car.

It’s a stylish chapeaux, adjustable in size, with a peak to protect me from the sun’s glare and made of a tasteful dove-blue mesh material that allows my bonce to breath and prevent the Friar Tuck patch, on the back of my head, from turning into a fried egg.

If you are follicly challenged you will want one and if you have a partner who is a baldy, it is an ideal gift.  Where can you get one?

The truth is, I bought mine at about one in the morning.  I sometimes have trouble doing what babes-in-arms can do naturally… sleep.  I take refuge in the inner recesses of the internet.  On this occasion I found the hat shop up the Amazon… so to speak.

My new hat was delivered the next day and I’m jolly pleased with it.

You don’t need me to tell you that Amazon is disrupting the supplies of hats, shoes, knickers, cravats and just about everything else.  It is the invisible wrecking ball, demolishing the high street.

Amazon, in the US, have done a deal with an on-line pharmacy.  They are doing pills and medication.  It won’t be long before they do the same here.  I’m told they only need employ the services of one qualified pharmacist and they will be legit.

No more schlepping to the high street, parking the car, handing in yer billet-doux, hanging about and palavering.  You’ll be able to have yer pills by lunch-time.  Delivered to your workplace, hotel or home. 

That’s what you call disruptive.  That leaves pharmacies in GP surgeries, maybe and the future of the high street pharmacy in doubt.  

Don’t write to me about how helpful a front-of-house-pharmacist might be and how they can save the NHS.  I know but I didn’t invent Amazon.  Write to them.

I didn’t invent Babylon but they will pull the rug on GP practices.  That’s what technology did to the lamplighter, banks, travel agents and cap makers.

It looks like there is something else that will scare the pants off the NHS.  Amazon is about to start supplying the public sector, here.  Ouch!

Reported in the Daily Telegraph (on line!);

‘Amazon has launched an assault on Britain’s public sector procurement market with a £600m deal to sell everything from paper clips to bandages to Yorkshire’s schools, social care providers and emergency services.

In its first major public sector contract in the UK, the web giant will provide a one-stop-shop from which public bodies across Yorkshire can buy a broad range of products they need to operate.

Its site will replace a more complicated procurement system involving a number of suppliers.

With services ranging from office supplies to medical equipment, the deal covers education, emergency services, local government and social care across 13 local authority areas and is expected to be run through the new Amazon Business division.’

Blimey!  That looks like the end of Lord Bog-Roll’s endless graphs, reports and faffing about.  It puts the skids under DHL and their mysterious on-costs and makes pointless, the row they are having with Unipart.

Buying on a global basis not only makes paper clips twopence a ton it makes drugs, prosthesis and devices as cheap as chips.

Amazon, I take my hat off to them.

I like it…

The GMC have realised a lot of training doctors are hacked off. 

They’ve done a survey.  The upshot;

‘The results are stark. Long and intense working hours, heavy workloads and the challenges of frontline medical practice are affecting doctors’ training experience and their personal wellbeing.’

‘…the supply of new doctors has failed to keep pace with changes in demand.’

My guess; if you did the same survey of most healthcare workers you’d get, pretty much, the same answer.

We know; there is a global shortage of healthcare people.  Even the WHO are worried.  This is their latest.


“We expect a tremendous nursing shortage of about 500,000 people by 2030,” 

…says Professor Stefan Goerres, of the Institute for Public Health and Health Care Research at the University of Bremen. 

“Even if the profession were more attractive, there just aren’t enough young people due to declining birth rates.”

Vacancies for nurses and midwives were over a fifth higher at the end of last year compared to two years ago, with a total of 133,660 vacant posts advertised in 2017.

At the same time, the number of applications dropped by 12.2 per cent between the last quarters of 2015 and 2017, meaning this is getting desperate.


The system scientist, Russell Ackoff, in the 70’s talked about puzzles, problems and messes.  Puzzles have a solution.  Problems have have approaches.  Messes are dynamic, untidy, cluttered and muddled.  They need something different.

What?  How do we go about this?  Root and branch…  

Root cause analysis?  It doesn’t help.  The root causes; underfunded training in 2010, withdrawing the bursary, the impact of Brexit on migration.  They are legacy, policy and now structural.

It takes well into ten years to turn out an all-singing all-dancing doctor.  Nurses; three years, then a 6 months preceptorship and then if they change their mind and want to switch from, say, wards to ITU, or a specialty… start again.

Allied health professionals and care workers.  None of them come in a box from Amazon.

I we can’t fix the ‘roots’, let’s look at the ‘branches’.

What are we doing to develop the ‘branches’.  Make incremental changes and muddle through?

Muddling through is about all we have.  Charles Edward Lindblom who died earlier this year, at the ripe old age of 101 first theorised about ‘mudding-through’.

He wrote two articles, separated by 20 years: “The Science Of ‘Muddling Through'” (1959) and “Still Muddling, Not yet through” (1979).  Here.

Muddling-through is sometimes called ‘branching’; growing out, building out, bit by bit, using small practical steps, from where we are, moving towards a practical solution.

For instance, training.  Branch-thinking, asks what are we doing we can build out from, be more effective and muddle through?  

It’s quicker and cheaper to train nurses but some still turn-up on wards not knowing how to do an injection.  There is no national curriculum and nothing in their foundation course in basic prescribing, something, if all entry level nurses and AHPs could do, might revolutionise care.

Improving training; making healthcare professionals more effective, creates a more powerful, elegant, productive workforce.  It is common to find nurses trained outside England have more competencies when leaving training.  Only 5 of our nursing schools are in the global top fifty.

Branch-thinking, muddling through, says, extend the apprenticeship scheme; lower entry threshold, attractive earning-and-learning programmes and the qualifications end up the same. 

Branch-thinkers, muddling through would ask how do we improve working conditions to make the job more attractive to new-comers and re-joiners and persuade leavers to stay.

Branch-thinking, muddling through… instead of using our energy trying kill off Babylon, how do we develop distance and AI supported care.  It may not not be perfect but it will get better.  How do we accelerate its improvement.

The end game; replace people making decisions and recording stuff, with machines making decisions and recording stuff.  Ouch!

We just have to muddle through and as Professor Valerie Iles tells us;

 ‘It will be important to allow professions to ‘muddle through elegantly’ amending decisions in light of events as they unfold.’

Muddling through, elegantly.  I like it.


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