Don’t let your business become the NHS!

(warning: long post! But worth it)

Some of you may have noticed that my blog has been quiet recently — I’m delighted to announce that Carl Junior was born on 20th September. As he was a few weeks early, he has had to stay in hospital for a little while, and over the course of the labour and post birth care, I’ve made a few observations about the NHS.

As every business grows, new layers of staff are introduced, new systems are created, and the startup becomes a business becomes a corporate. The organisation becomes faceless, the stakeholders become disengaged, and the business becomes a machine. As anyone who has owned any kind of machine or vehicle knows, they soon wear out, and can either be serviced or replaced for a newer model. There comes a point that servicing becomes a constant uphill battle, and the beast that is the machine is beyond taming. Welcome to the NHS!

I think that there are some learnings for us all here. I’ll touch on the operational issues with action steps, and then follow with a discussion on the strategic side of things. If you just want to read my suggested solution, skip to the bottom! :-)

What can businesses learn from the operational issues at the NHS?

We often hear about NHS inefficiency, and it is often claimed that consultants are the root cause of these problems. In fact, if some of the press is to be believed, scrapping all of the management consultants and “middle management” would be the panacea for the system. The reality, in my view, is that their help is needed more than ever. Wholesale change is needed, and just some of the problems there can be easily identified and fixed by businesses to prevent the NHS-ing of a startup:

The Daily Huddle — at every change of shift, there is a “huddle” for approximately 30–45 minutes, where the team go through the condition of each patient to transfer the information. To the outside world this looks like an extended tea break, but I’m assured that valuable information is passed from nurse to nurse. So there is *some* value to a huddle… but how much?

There are a number of reasons why these are ineffective:

  • Anyone in business knows that meetings are most effective when used to discuss solutions, not share information. Anything that needs sharing should be shared before a meeting.
  • Chinese whispers are a very real problem. The number of times we have had to explain the situation to the new nurse was unreal, and evidenced the fact that the circa 5 minutes on our case was unnecessary. Often, it took longer to clear up the miscommunications than it would have done to just “fill in the blanks” on a systemised data process. Multiply that up by the number of patients and nurses across the NHS and you have a horrific drain.
  • The drain on the NHS infrastructure during these huddles is very real. Not only does it result in half hour double pay with no productivity, but also there are practical impacts: no nurses during certain times, parking issues just before handover times, even congestion in the walkways. A staggered approach with real time data flow would be a dramatic improvement.

Action step: Have a think about any unnecessary meetings or routines in your business. Don’t have a meeting for the sake of having a meeting. Think about the impact of team meetings on both your team and your customers. And consider whether data can be shared electronically rather than face to face.

Paper Records — perhaps my biggest frustration is the reliance on paper notes. You would not believe the amount of times we have been asked if we still live at the same address and have the same doctor. Perhaps unsurprisingly, we chose not to move house or change doctor whilst Sarah was in labour!

More to the point, the sheer lack of integration of these records mean that each doctor or nurse is effectively approaching their situation blindly. Rather than having a dashboard which can identify the key points, each individual involved in a case has to read through pages of notes, and we all know what doctors handwriting is like.

Perhaps worryingly, our baby has been kept in hospital for almost a week longer than necessary, due to an arithmetical error (volume of feeds not being added up correctly), and a comparison error (wrong weights being used for comparison). Whilst a few extra days in hospital might not be the end of the world for Junior, a miscalculation could very well be the end of the world for a seriously ill patient.

Action step: Think about how you can eliminate duplication and / or risk of error in your records. Every time you have more than one system for something, the risk of errors increases substantially. Your customers will notice this too — think about the times that you have been told “sorry I’m on the wrong screen” by a call centre… it always leads to their computer breaking for some reason!

Broken promises — this one is really simple. If baby can’t come home, don’t promise he can. We’ve set up home three times for him, had two discharge forms completed, and then goalposts moved again and again.

Action step: It’s really simple. Don’t overpromise and underdeliver. More importantly: don’t underpromise and overdeliver. Both show that you don’t really know where you’re at — even if deep down, you do. Why not just tell the truth, the whole truth, and nothing but the truth. That’s the only way to become truly trusted.

Blind adherance to checklists — I would wager that the number of checklists and systems in any organisation grow with a direct correlation to the number of layers of staff and management. Whilst checklists are a great way to identify completion, they are inadequate for project management — they only work on a strictly linear flow. In our case, the failure to see the item beyond the current “tick” caused delays; whereas a much more efficient model would have allowed box 4 to be ticked even if box 1 couldn’t be.

Action step: Empower your staff. Whilst checklists are good for confirming completion, allow them to do their job that they have been trained to do. Many systems are over-engineered simply as a risk management tool, and blind adherance to these systems is frustrating to all. If you don’t trust your staff, don’t employ them in the first place.

Staff reward schemes — One day, the only conversation of note that we heard in the ward was between two midwifes. They were bitching about midwife number 3 winning the staff award. “She hasn’t saved any lives”. “She just runs around to make herself look busy”. Staggering to see how much jealousy an M&S voucher can cause! And perhaps, an insight into the motivations of the team.

Action step: Some well meaning staff incentives can be counter productive. But also, some staff can just be poisonous. Don’t take this as a message to cut reward schemes — just make sure that you foster a culture of pride and congratulation, not of bitching and backstabbing.

Conflicting advice and compounding of errors- now, I’m kind of allowed to say this as Sarah has a nursing background… Nurses don’t know everything! On that note, it’s OK to admit to your customer (or indeed your patient) if you don’t know. Provided that you take every step to find out, pretty quickly, and get back to them, people understand. I certainly don’t know everything about every matter that my businesses deal with — in fact, the only thing I know is that I know very little.

The conflicting advice was actually fairly simple. One midwife told Sarah to buy a “Stage 3” teat for a bottle to see if it would improve flow. Once bought, staff changed shifts, and midwife 2 accused her of negligence for buying such an advanced teat, and sent her back to get a “Stage 2”. Lo and behold, she was then told that Stage 2 was what was being used in the first place.

Now, this might not seem like much, but when combined with broken promises, and the fundamental errors, it became a huge issue in our mind.

Action step — think about the impact of errors or mistakes on your customers or your team. It’s rare that one single problem creates an issue. Most of us have a “bank of goodwill” built up over several good experiences, and we forgive a simple, innocent mistake. When a business makes too many mistakes, this bank becomes overdrawn, and that is the tipping point that can turn an advocate into a net detractor.

The (oversimplified) way to stop this becoming an issue is to stop making mistakes. Accepting human nature however; another way to approach this is to look at how you handle complaints — this is an ideal time to “top up the bank account” and bring your customers back to advocate level.

Delegating difficult conversations — this is a cardinal sin. We had to deal with junior doctors, who were simply stuck in the middle of whoever made a decision and us. They had no say, no power, and had simply been tasked to deliver difficult messages to us. When escalated, we again spoke to someone who could only be described as impotent in the grand scheme of things. The real decision makers on our case hid behind layers of staff and bureaucracy. This cowardice is so common amongst managers in business, and it is often just a case of picking up the phone…

Action step — if you have to have a difficult conversation, have it. Don’t delegate it to someone else. If they come back with an issue, and it’s more difficult than first expected, step in. Don’t just bat it back. Man up. Weakness in these situations is visible, and reduces respect from your customers and your team.

What can businesses learn from the strategy issues at the NHS?

I’ve spent a long time dissecting just some of the operational issues at the NHS. These are the ground floor, obvious faults that many of their patients will have seen, day in day out.

As I alluded to before, many see that the NHS is underfunded, and there are two schools of thought: cut costs, or increase funding. In life, nothing is as simple as a binary option like that. Chucking more staff and more cash at such a shambles is only going to magnify the issues (a hidden tip there for any business owners!). Cutting costs is also going to only go one way. It’s also not the consultants fault, nor the managers.

In fact, I’d contend that the middle management is pretty good — they do what they are told to do.

But something isn’t right. After all, we pay for the NHS. £2,000 per adult. If BUPA treated me this way, my (less than) £2,000 membership would be scrapped immediately. With the NHS, our hands are tied as taxpayers.

The one thing everyone who comments on the state of the NHS seems to miss is that there are three parts to any business — the operations, the tactics, and the strategy. Workers, managers, and leaders. Ultimately, it is the leaders who set the direction for the organisation, and in this case, it is the leaders who have failed the NHS.

We need to invest in our health system — whilst it is widely touted as the best in the world, it’s not even the best in Europe — it’s 14th (source: 2015 EHCI). But investment isn’t pay rises for junior doctors, extra cash for nurses, or more beds. Investment is a structural change in the way the NHS is run.

In business, there are two types of cost: capital and ongoing. Ongoing costs, as the name suggests, are yearly costs, that happen each and every year. Employing say 1,000 doctors at £50,000 is another £50m cost every year. If they are working within an inefficient system, then logically this is an inefficient spend.

Instead, we need to invest in the vision of where the NHS should be. Not just a service, or a “change of brake pads”, we need to redesign it with a blank canvas. The NHS needs to be technology led, commercial in its thinking, innovative in its approach to healthcare, and customer-centric in its approach to service. Whilst we can treat the symptom and employ more and more nurses and doctors, we should actually address the cause and fix the NHS — once and for all, as a “capital cost”. It’s a big cost, but a one off cost, and we need those consultants and middle managers on board to make it happen.


Originally published at Carl Reader — The Startup Coach.

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