4th June 2015

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Dr Mark Porter

In conversation with Roy Lilley - this is warming up to be a really good 'conversation'!

Chair of the BMA - just how relevant is the BMA; does anyone listen to them
Is the BMA a busted flush?  The British Moaners Association or the British Machiavellian Army?

Let's find out.  Health Chat at the King's Fund 18th June Details here.

It's all about the sausages  
News and Comment from Roy Lilley

The NHS is a whole system. By that I mean it is like a sausage. Squeeze it in the middle and you'll get a bulge either side. Squeeze it at the end and you'll get a bulge the other end.  And, you'll be lucky if it doesn't burst.


Thus it is; the first of the immutable laws of the squeezed sausage; if social services are slow off the mark and bed occupancy squeezed, patients will back-up on the wards.


The second absolute law is; if patients are backing up on the wards, A&E is squeezed and cannot clear people through their part of the sausage as there are no empty beds for them to be moved into.


And so, we arrive at the third unarguable law of the sausage; if A&E is choc-a-bloc ambulances cannot discharge their customers and so they bulge and wait in the car-park.


Next, we have the fourth law of the sausage. There is no point in the CQC trundling around the highways and by-ways of the NHS complaining hospitals don't, today, have enough nurses if, for whatever reason, years ago,  nurse training places were squeezed and not enough were commissioned.


We now come to the fifth unarguable law of the sausage; Monitor and their country cousins, the TDA, 'failing' organisations for not balancing the books is valueless if money is squeezed and there is not enough in the system to go around.


To be an expert in the Laws of the Sausage requires an understanding of systems thinking:


Systems thinking is a management discipline that concerns an understanding of a system by examining the linkages and interactions between the components that comprise the entirety (of the) system.




An organisation, as an entity, can suffer systemic failure. This occurs in the whole system or high-level system where there is a failure between and within the system elements that need to work together for overall success.


In other words a bit of common-sense is required. A commodity that the DH's Andrew Lansley had not a pinch and between them, the CQC and Monitor and the other lot, has not a peck.


Common-sense tells us:


Whole system success requires a performance management system that is pitched above the level of individual systems...features may include group or team-level goal-setting, development, incentives, communication, reviews, rewards, accountability. The aim is to focus on what binds individuals together and what binds systems together rather than functional silo performance.


NHS organisations don't 'fail', they become victims of the system. They are components of a wider system, the pressures from which can combine to break the component.


In whole systems, silo components can flourish; some of our bigger Trust luxuriate on commodious surpluses whilst equally vital components, elsewhere in the system, plunge into debt and its disastrous consequences.


Few politicians understand the Laws of the Sausage and even fewer plastic-managers get it. They might like to try reading Chapter 12 of this book.


Fortunately, Simon Stevens does understand the Law of the Sausage and has enough common-sense for Whitehall and the whole of the NHS.


Amongst a host of other interesting things, he told the Confed conference (news report here); NHSEngland and Tweedle Dum and Tweedle Dummer, Monitor and the TDA will move in on health economies that are struggling and deploy a 'success strategy'; '... push through determined action to ensure hospitals, GP surgeries and other NHS service providers work together much more closely to tackle deep-seated problems which previous initiatives have failed to banish." 


This is whole system management; at last somebody gets it.  Also, note the use of the word 'success' and not; failure, special measures and the other clap-trap lexicon favoured by regulators.


This move brings back a 'virtual' strategic level of management that Lansley's madness and Cameron's ignorance demolished and; pretty-well, nails down the coffin lid on the H&SCAct, tells Monitor to get real and help people work together and shows the CQC the door. They can't inspect whole systems. They spend 300k+ on taking a Polaroid of a hospital, painting a picture of a whole system will cost millions.


Tarzan was right when he said; if regulation was going to work it would have done so by now.


Shouting at Trusts 'your books don't balance', when there's not enough money in the system; screaming at them 'you don't have enough nurses', when no one does; and commissioning like it was still mid-90's, when we are in another century... is making the wrong kind of meal of it.


Now, it's all about the sausages.  


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18th June 2015
King's Fund
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