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In the late eighties I had a good friend, Oliver.
Oliver was a shredder. The biggest NHS supplies could find.
Whenever DH policy palaver turned up in the mail (it was before emails), our lovely administrator-in-chief, secretary and the person who actually ran the place, would just dump it all into the jaws of ‘Oliver’, and…
… we’d get on with the real job of making the services as good as they could be for the patients, residents, relatives, carers, friends and the fabulous people we worked with.
We Oliver’d everything. I figured; if it was important, someone would send it again.
Oliver?
Oliver North, who unexpectedly fessed-up to helping run the US covert Iran-Contra operation, and admitted shredding documents. He got away with it, on a technicality!
A couple of days ago, speaking at a conference, the DH+ permanent secretary Samantha Jones said, when she was running her hospitals, she;
‘... did not read policy documents’,
she was was busy;
‘... working out how to lead the team, how to do things on a daily basis.’
An outburst of Oliver North frankness is entirely unexpected from a permanent secretary, but…
… if you were at that conference;
I hope you stood up and applauded.
I hope there was an ovation.
I hope she was cheered from the rafters.
I hope (if it’s not too chauvinist to suggest it) she was inundated with flowers and champagne (or a bottle of Penderyn)…
… carried shoulder high from the podium.
She is right…
… the gap between the board and the ward? Everyone knows it exists, but very few dare say it out loud.
Spend time in Whitehall, NHSE or the policy units and you’ll be surrounded by documents;
- Strategies.
- Guidance.
- Frameworks.
- Transformation programmes.
- Roadmaps.
- Delivery plans.
- Re-organisations.
- Name changes.
- Redundancies.
Spend time on a ward and it’s a different world. Wards have their own reality;
- Patients,
- staff shortages,
- bed pressures,
- families asking questions.
- The bleep, bleeping.
- The next emergency arriving, before the last one has been sorted.
The business of hospitals is immediate and practical. It is about people, time and resources.
There’s a canyon between these two worlds.
One of my management favourites, Henry Mintzberg distinguished between two forms of strategy;
‘… the deliberate strategy, written in plans and ...
... the emergent strategy, that develops in real life as staff cope with circumstances.’
Hospitals, GP surgeries, community and all the rest, run almost entirely on the emergent version.
Michael Lipsky, in his book Street-Level Bureaucracy, argued that;
‘… the real decisions in public services are not made in ministries or headquarters but by frontline workers, who interpret policy under pressure.’
Policy arrives from the centre and collides with the reality of crowded wards... limited staff and beds in the corridor.
Frontline staff adapt. They improvise. They don’t need nincompoops redefining a corridor as a ‘non-clinical space’. They want real space.
Only one message travels reliably to the ward…
… it’s money…
… or, the lack of it.
Tariffs change behaviour. Budgets change staffing numbers. Capital investment changes how and where. The rest barely ripple the waterline of hospital life.
New structures. New names for organisations. New acronyms. New frameworks...
... they may dominate policy discussions but their impact on the ward, in the clinic… negligible.
The latest wheeze; neighbourhood services…
... what do they think GPs, district nurses, hospitals and social workers try to do every day? Give them the money and they'll show you how to do it.
No policy document required.
Oliver, symbolised something important. The endless stream of junk-mail, clogging up inboxes are meaningless to the people who actually do the real job.
For the people who play parts in the theatres of the NHS, the scene shifters at head office are irrelevant.
Some directives matter … funding or regulatory. The rest can be Oliver’d.
This isn’t cynicism. It is survival.
The health service; a complex operational, organisation. Its only purpose, its raison d’être; the instant a patient meets a clinician...
... making that moment come sooner, safer, and when it does, being sure it creates peace-of-mind... it's the only job.
Peter Drucker said;
‘… the real work of an organisation happens where it meets the customer, [the patient]. Everything else is support.
Mostly, policy has lost sight of that reality.
If the DH+ believes that hospitals are run by plans and structures, it will keep producing them.
If it understood that hospitals run through empathy, tender moments, joy, sorrow, effort, judgement, relationships, innovation, determination, inventiveness and skill...
... it might behave differently.
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