New Year, New NHS Battles

War and business analogies are often not helpful. They tend to be all blood and guts; a bit too much testosterone for the modern and diverse business world. But then again, all generalisations are wrong and in Malcolm Gladwell’s latest book, 'David and Goliath: Underdogs, Misfits and the Art of Battling Giants', there is a military analogy that might just help us better manage organisational change in the NHS in 2015.

The intensive day and night bombing of London during the Second World War from 7 September 1940 was a tragedy on a huge scale. Forty-thousand civilians were killed, and 46,000 injured. More than a million homes were destroyed. Dan McGonagle, in his poem The Blitz, highlights Gladwell’s area of interest which is the sense of calm among people during the bombings.

Antiaircraft guns are blazing, towards the sky the bullets strafing, a distant rumble just like thunder, another street is torn asunder

Bodies lying on the road, families left with no abode, among the rubble pets are lying, some in shock, others dying

Despite it all a sense of calm

This sense of calm has been ascribed to the British “stiff upper lip” but Gladwell cites examples of other cities and nationalities showing equal stoicism. His explanation is intriguing and potentially valuable for NHS leaders. Based on the work of a Canadian psychiatrist, he splits the effected population into three groups.

The first group is the people killed. Theirs is the ultimate loss. These are the 40,000 dead.

The second is the near misses. This group sees, hears and feels the direct consequences of bombing. They directly experience the horror, and suffer shock as a result. People in this group are left traumatised. These include the 46,000 injured.

The third is the remote misses. This is the crucial group for Gladwell as their experience and reaction is the direct opposite of the near misses group. They do not feel shock. The bombs have come close, but each time they remain unscathed. People in this group feel invincible and by Gladwell’s calculations they were the biggest group, numbering around 7.9 million.

Performance management

So what relevance is this to the NHS in 2015? The parallels are obvious and numerous. Organisational change, in one of its many forms, affects over 1.7 million NHS employees every day. It is relentless. It feels indiscriminate. It seemingly falls from the sky.

Some staff employ their own figurative versions of blackout curtains, hoping that if they cannot be seen they will not be affected. Others create bunkers and hide, emerging only when the change subsides.

For our purposes it is useful to address each of the three affected groups in turn. I will relabel these: the redundant, the disenchanted and the repeaters.

For the redundant, there are two obvious things we can do. First, have fewer redundancies. Second, rehabilitate those who have been discarded in the past.

Given we need to spend about the same amount money on healthcare in five years’ time as we do now, it is reasonable to forecast that healthcare organisations when taken as a whole will employ about the same number of people. When viewed alongside natural staff turnover and high retirement levels, large scale redundancy programmes, where hardworking and intelligent people are forced out of their employment, are wasteful and disrespectful. Using redundancy as a personally cheap but fiscally expensive way of dealing with underperformance is wrong. The lazy and inept can be performance managed.

Reduce redundancies

Pooling staff across organisations, producing accurate long range workforce plans and investing in retraining staff will significantly reduce redundancies.

In such a system contracts of employment with the NHS can be viewed as almost permanent in exchange for staff viewing their jobs, as they are currently established, as transient and firmly linked to performance.

The “what”, “where” and “who” of the job will evolve over time. If roles develop into something the jobholder no longer wishes to do then an improving job market will present good people with choices. Receiving a pay-off should not be one of them.

The fallout from change

I was hunted down earlier this year by the Department of Health’s legacy management team. I had apparently committed the heinous crime of employing someone who had previously been made redundant by “the NHS”. I lacked the foresight to realise that a person’s skills and experience are needed elsewhere in the system is now a crime. Bringing someone back into the fold following the failure of others to redeploy them is not an excuse to ostracise and stigmatise the redundant. Roles become redundant, people do not.

Colleagues who have suffered the fallout of relentless organisational change, sustained professional injuries or who have friends and family in the redundant group make up the disenchanted. While relatively small in number, they are the most dangerous. Due to the amount of harm suffered they are motivated to obstruct future change.

In post-traumatic stress disorder cases, patients with mild symptoms are encouraged to carefully monitor their symptoms for improvement or deterioration. This approach is called watchful waiting. It is simple but effective.

Passion for improvement

The difference between this and inaction is in the expectation that the person will recover in a few weeks. We need to create cultures where it is understood that people will become stressed by continuous reorganisation. It is demoralising to be asked to perform a role two bands lower, even if the pay is protected. Denying this is the case and ignoring the disenchanted will not work. The health service has caused this and it is responsible for helping them progress.

The repeaters are those who do not remember the past and are condemned to repeat it. For the repeaters the situation is worse; they learn the wrong lessons from the past. As a result of surviving numerous organisational changes they actually see such top-down reorganisations as universally positive and seek to replicate them at a local level.

The solution here is a person. Every organisation has at least one and you just need to find yours. From a distance, they look like one of the disenchanted. They talk about the “good old days” and the damage caused by needless and badly managed change. They are amateur historians. They were keen observers while the bombs dropped.

You can spot them because they maintain a passion for improving things and despite numerous setbacks remain positive that things can improve. When they refer to things being better in the past; they can show you the evidence and are open to adapting it with new knowledge.

Choose your battles

The trick with these people is to listen to them and empower them. Give permission for everyone to talk about the past and learn lessons from previous failures. Positivity is great but it is more effective when combined with experience.

The alternative is to bring in fresh talent from outside the NHS; people with new ideas and different experiences. The challenge will be to find someone from a sector that has not suffered its own change blitz.

Regardless of how we choose to deal with the people affected by change, the lesson we need to learn from the blitz is about the nature of the bombs themselves. They were inaccurate and ineffective. The military’s new weapon of choice is the unmanned drone.

The changes we choose to make from now on need to have the same relentless focus on carefully selected targets and causing minimal collateral damage. Choose your battles wisely in 2015.

The is an adapted and updated version of a piece originally published in the Health Service Journal (HSJ).