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Understanding the NHS: observations from an outsider

​Having recently returned home to England from a nine-year stint across the pond, I've spent the last few months reading articles, asking questions and drawing diagrams. 

Earnestly I’ve been trying, and more often failing, to get my head round the various NHS organisations and how their remits intertwine and overlap as they desperately strive to work together to provide and improve health and care across England. My first observation is that it’s complicated, so complicated in fact that at times I’ve found myself scratching my head and repeatedly muttering to myself one of President Trump’s most astute and truest statements, ‘Who knew healthcare could be so complicated?’

I’m also surprised at how rapidly things are changing as departments, divisions and entities are frequently subsumed into others.  Mergers happen, teams are disbanded, new ones are formed; to keep up with it all could easily be a full-time job itself.

This seemingly constant restructuring creates an uncertainty that often immobilises decision making and improvement.  How could one suggest let alone test and implement a simple plan or improvement initiative when the agency or department itself is facing an existential crisis?

In this shifting environment, conversations around how best to influence senior leaders locally or nationally dominate and managers are too consumed by day to day noise to be able to focus on and structure learning for their organisations.  Data sets that should be mines of information are left untapped and positive deviants are undiscovered – their secrets not spread beyond their limited silos.

​Moreover, in our current environment conversations around reflection and learning often come across as Pollyanna or even naïve. The American healthcare system is also complex, but the best leaders I worked with there were able to rise above the fray and reflect on what has been learned and challenge their colleagues to make predictions about what is likely to be the most effective next step and the impact it might have.

Despite the complicated and changing environment, I’ve also been struck by how well intentioned, thoughtful and wise so many of the NHS staff are, be they clinicians on the front lines or managers and administrators.

Despite the complicated and changing environment, I’ve also been struck by how well intentioned, thoughtful and wise so many of the NHS staff are.

I am however sadly reminded of the wise words of Edwards Deming that a bad system will beat a good person every time.  And too many of the people I’ve met are burnt-out, desperate and tired of offering a sub-par service when they know that we can and should do better. As my colleague Joyce Lee once wrote, “no doctor ever said I want to deliver fragmented, uncoordinated, expensive, bad quality care” – and yet here we are…

Working in such a system can feel relentlessly hopeless, but given we are here what can we do?  Based on my observations, here are five ideas that some combination of which might offer some hope or a starting place to those feeling frustrated and powerless.

  • Seek joy in your work. While it might sound a bit cultish, Kaleidoscope’s recent report points out that “caring and healing are inherently joyful practices because there are few things in the world that can make us feel so needed, so useful”. Take a look at the report and the five things that can bring joy to your colleagues right away.
  • Value and support learning. Take time to reflect on your experiences with colleagues and use data to support your reflections.  Learn from positive deviants and try to support and help (not judge and punish) poor performers.
  • Prioritise relationships. Organisations might be coming and going but good people will endure (albeit with different email signatures). Take the time to invest in relationships. Good collaboration takes time and too often it is viewed as an extra-curricular rather than an integral part of an effective work week.
  • Find and foster psychologically safe environments.  Attend a Schwartz Rounds, join the Q Community or attend a Melting Pot Lunch. There are plenty of positive places both online and offline.  Make sure you make the time to not only visit and appreciate them but also contribute to them.  It’s the little things that make an environment feel safe, make a big difference and change culture: ask how your cube mate is doing, smile at your colleagues, suggest you eat together.
  • Take time to work smarter and break some rules. Ask yourself and your colleagues, if you could break or change any rule in service of a better care experience for patients or staff, what would it be? Then think about how to carefully and strategically break some. Who knows, you might discover the bicycle book of your institution?

It is clear that there is a lot that needs to be changed in the NHS and my ideas (nor anyone else’s) won’t transform the system at the rate we need it changed.  However, despite all of its challenges, when recently catching up with my American colleagues, I can’t tell you how proud I was to be able to say that, when judged on the value of equity, there is nothing that can be compared to our NHS.

…we’ll let you in on a secret about Kaleidoscope’s funding. Spoiler alert: it’s not a secret. We’re a business. We design and support collaborations, run events, and help to develop strategy and policy. Our work is shaped by our clients’ challenges. We’d love to hear about yoursfind out more.

George Dellal23 November 2018