I've had a few messages today asking what I mean by "culture change" in the NHS. A thread.

Ask a NHS Exec to describe their organisational culture. Ask the most experienced non-Exec clinician. Ask a new recruit. You'll get three different answers. Dare you ask a patient?

1/14 And there's the biggest bit of your problem with changing a culture, it is a different thing to every person. It's the ultimate subjective experience of your work environment.

How you you get rid of toxic bits then? Now, there's the challenge.

2/14

An elephant in the ICB room: Show me the money!

ICBs are being asked to break even, and cope with a huge CIP (cost improvement plan) of up to 5%. It's more really as that 5% is plus inflation. A HUGE cut.

Yet, ICBs are expected to be all things to all people, and quickly.

1/11 Social care rightly wants investment locally and on stuff that leads to long-term better health. There is a push to focus on Core20PLUS5, and rightly so as it's a great concept.

But, where's the money coming from to pay for it? Existing services are already on a shoestring

2/11

Micro change improvements, Day 10: Recognising and depowering toxic leaders

The NHS is hopeless at identifying and dealing with toxic leaders, but this is a core skill of a good manager. Even with dealing with toxic people further up the food chain.

A brief guide:

1/18 The British Army leadership doctrine (army.mod.uk/media/14177/21…, page 2-13) identifies the following Characteristics of Toxic Leaders:
1. Autocratic
2. Narcissistic
3. Manipulative
4. Intimidating
5. Overly Competitive
6. Discriminatory

That's about right, let's use that.

2/18

Micro change improvements, Day 9: Burnout vs Moral Injury

There is no easy answer, or one-size-fits-all, to this. Anyone who says there is one is probably trying to sell you their book or consultancy services.

It is something every NHS manager/Exec must know at this time.

1/14 This is NOT an academic paper, or a clinical one, it's an Exec/manager's guide on Twitter, don't go all technical or clinical on me please. 🙂

First, definitions:
1. Burnout in the NHS: people.nhs.uk/executivesuite…
This is close enough to what I mean.

2/14

Micro change improvements, Day 4:

You are your reputation.

Perfect timing by @DrSelvarajah in his tweet below

https://twitter.com/DrSelvarajah/status/1446006107487588354?s=20

How people see you based on past conduct is how they judge what you tell them you'll do now.

1/9 If you're an Exec and your organisation has a horrible reputation for anything, from bullying to financial mismanagement to toxic culture to incompetency, then you cannot get away with "we're now different!"

The old saying applies: Culture eats strategy for breakfast.

2/9

Yesterday, we sent out more invites to those in Barking & Dagenham who qualify for a booster COVID-19 vaccination.

There are appts available at Vicarage Field Shopping Centre and Parsloes Surgery.
@lbbdcouncil @NHS_NELCCG

A guide to vaccine qualification:

1/ First dose:

- Anyone aged 12y/o+

- Any site can do 16y/o+
- 12-15y/o clinically extremely vulnerable, or in a household with someone immunosuppressed, will be done by some sites. Take local advice.
- Other 12-15y/o, this will be started by the schools immunisation service.

2/

Micro change improvements, Day 3: Racism, bullying, harassment, sexism, and all other discrimination.

This should be a key part of the management operational model in every NHS organisation, but it's not because often reputational damage risk trumps justice.

1/9 Part 1: Recognise the problem.

Do you have a problem? How do you know?

Here's a start: Go to the NHS Staff Survey. Randomly pick a Trust. Review qs 12b/c, 13b/c, 14 and 15.

nhsstaffsurveys.com/results/local-…

Plenty of other evidence sources out there.

2/9

Micro change improvements, Day 2: Proper training.

When I joined the NHS in 2014, I was horrified at how little is put into non-clinical training. Specifically, there is almost zero MANAGEMENT training beyond legal minimums to keep some qualifications going.

1/8 Again, management is not leadership. The NHS has tons of good leadership training options, including through the excellent NHS Leadership Academy but nothing on the bare bones grunt training to teach people how to do their jobs and that of the level up.

2/8

Micro change improvements, Day 1: Mandate independent benefits analysis for any project >£10m and random for under.

Any NHS senior leader seeing business cases with clearly made-up outcomes that are only there to stop Exec level meltdowns will understand this.

1/6

https://twitter.com/CraigNikolic/status/1445024338093166594

If you promise to improve something. Show me the improvement.

If you promise to save money. Show me the savings.

If you promise more/less of something, show me the stats.

If you make clearly unachievable promises then that should impact your annual performance review.

2/6

An overdue rant:

I'm not sure some people get the morale level of general practice right now.

Repeated headline news in the Telegraph, Times and Mail about how GPs are money-grabbing slackers who refuse to see patients F2F so they can spend more time on the golf course.

1/8 The persistent narrative of anti-GP in the media is toxic. GP receptionists get unacceptable levels of abuse, clinical staff get it as well right in their faces. Practices get vandalised, and we're fortunate we haven't seen more physical violence against practice staff.

2/8

This tweet seemed to have gone down well yesterday. One of the most common replies given was that it's hard to do >2yr strategy in an environment that keeps changing. Here's my guide to why you should do it anyway.

No plan survives contact with the enemy (paraphrased)

1/8

https://twitter.com/CraigNikolic/status/1434847802312601602

The true value of writing a good strategy is in the planning.

A trivial worked example:

You plan to go on holiday to Italy. 1 week to go, the govt changes it to "red list". Do you stop, rip up all your plans and start again? No, you reuse most of it and do something else.

2/8

This is part 3 of my guide to managing burnout in your staff. I'll link parts 1&2 at the bottom.

Today, I'll be concentrating on the longer term. This is the organisationally hard part as you'll be battling both internal inertia and finances.

1/ The first two parts were:
1. Managing burnout today
2. Managing tomorrow

Each incremented up in organisational challenge, moving from operations to crisis planning, and now to future planning to help build organisational resilience

2/

This is part 2 on my guide to managing burnout in your staff. I'll link part 1 at the bottom.

Today, I'll be concentrating on the hardest bit: What happens when COVID starts to recede.

The third part will cover long-term plans.

1/ When the vacc campaign gains momentum along with other measures, COVID will recede. One day you'll get to a point your COVID appointed staff start to see patient numbers drop off, people will start to think back on what they've seen.

You must start planning for this now.

2/

As promised, here’s my guide to staff burnout management during COVID. I’ll post over several days.

First though, the basics.

As a senior NHS leader, you must manage staff wellbeing. It's your primary job. If you don't do this, how on earth are you going to deliver?

1/ Today’s thread covers the problem TODAY. Tomorrow, I’ll cover the mid-term problem

Today, you have a problem: your clinical and non-clinical staff are burning out. What tools do you have available to you?

Rest
Recovery
Reserves
Rotation
Rehabilitation

2/

Interesting but this is only half the story though. Some examples in a thread on the drivers of GP demand:

https://twitter.com/thekingsfund/status/1198876978796994560

Long waiting lists in hospitals? Patients go back to their GPs for interim care. My rough rule-of-thumb is a two month wait creates a new GP contact for interim care.