Tag Archives: NHS

Is profit the best way to motivate and manage people?

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At a time when the fundamental tenets of capitalism are being closely re-examined  this question is now more relevant and urgent than ever.  So those interested in EB-HR should welcome a unique, real-time experiment that is now underway in the UK’s NHS (National Health Service) because it will inform this debate like no other.  Here, a privately-run, profit-making business will be running a ‘free’ health service, in a taxpayer-funded hospital, within a not-for-profit health system.  What an unusual mix of systems and ethos?  Yet its success could fundamentally re-shape our notions of the most appropriate organisational entity to create the greatest value from the motivation and capabilities of human capital.

At the very least it challenges the simplistic distinction usually made between the profit and not-for-profit sectors; which creates a false dichotomy suggesting very different motives and psychological contracts at play.  Such a distorted view was always in danger of reinforcing misguided assumptions about the different levels of performance and value achievable by different types of organisational entity.  In private companies the goal of financial rewards is expected to drive high performance while in the governmental/public sector employees are expected to have a vocation and be more publicly spirited: the two do not have to be mutually exclusive.

Recent events have certainly reminded us that whilst the most powerful drivers of ambition and greed can result in very successful and valuable businesses they can equally cause huge failures and misery.  But there is also plenty of evidence, certainly in the UK, that public sector management often performs particularly poorly.  It is unfortunate therefore that there are so few examples to show us what non-profit organisations are really capable of or whether they can offer a better alternative to compete with the best of the private sector.

If you read the article you will see that reference is made to the ‘John Lewis Model’, which is one of the few examples where a more socially-inclined enterprise has competed directly and successfully with ‘hard-nosed’, market driven, publicly quoted companies for nearly a century.  It is based on the very obvious notion that employee ownership (or at least partnership in the John Lewis case) should create an environment where employees have the greatest personal motivation to give of their best. This is why some politicians are heralding it as not only one way forward  for companies but as a model for economic progress and social cohesion

Of course the world will be watching this experiment with great interest and, if it succeeds, most management textbooks will have to be re-written to cope with a completely different type of organisational entity, founded on a very sophisticated psychological contract, that can see great good coming out of the combined goals of profit and public service – otherwise known as value to society.

For a more complete answer to my own question see The Value Motive

Postscript.

Union resistance to NHS plans

Decline in nursing compassion?

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EBM – Doing it for real – Lesson 12 – 31* Best Organisation Design Principles

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In organisational anatomy terms how we structure the organisation is obviously the skeleton from which everything else hangs. Following that analogy, if we keep changing the structure or playing around with the skeleton we need to ensure we are keeping the joints as supple and flexible as possible, rather than causing them to become worn or arthritic.  Organisations that constantly change their organisation chart are not only revealing something about their poor planning but also about a cultural problem that thinks it is OK to keep changing everyone’s roles without fully considering the extra stresses and strains this inflicts on people.

Organisation design includes many elements in addition to structure – systems, processes and culture are already on the framework – but the first question the organisation designer asks is what shape would suit us best – silo, matrix, cluster?  Each of these has its advantages and disadvantages.  In a silo you know where you stand, but god help you if you want to stand in someone else’s territory.  In a matrix things loosen up a bit but don’t be surprised if you end up with divided loyalties between two bosses.  In a cluster?  Well they come in all shapes and sizes don’t they?  The main issue here is having enough evidence to give you the confidence that of all the options and permutations available your structure is the best for you.

Lesson 12

Following the best organisation design principles.

Practical application

There are plenty of examples of poor design around and, as a general rule, the larger and more complex the organisation the more disastrous any inherent, structural weaknesses will prove to be.  Consider these glaring UK examples of extremely poor design : -

  • The UK NHS has 1.3 million employees but has still not decided who runs it – clinicians, managers or politicians?  It has the added problem that comes with being a public sector body without a market mechanism – it therefore employs thousands of commissioning staff to match demand with supply  – a cost the NHS could sorely do without.
  • The financial stability system (sic) in the UK before the 2008 credit crunch was split between the Bank of England, the Treasury and the Financial Services Authority – a veritable dogs dinner of design that resulted in no single body holding overall accountability, which is only now being addressed.

The most basic principles of organisation design were neglected.  So this Lesson is simply a Checklist of Best Principles for Organisation Design which I have been developing for over 20 years.  It is not intended for sterile, theoretical or purely academic debate: it is born out of business savvy and hard-won political nous, not naivete. The more these principles are followed the more weight of evidence you will have that your organisation is well-structured for achieving its strategic objectives.

Even if you are not allowed to follow these principles in practice; for reasons of politics, turf wars or other forms of in-fighting, it will nevertheless make you acutely aware of what bad design looks like, highlight the consequent risks and enable you to produce an evidence-base for explaining the benefits to be gained from a better alternative.  Forewarned is fore-armed and getting a new CEO on board is the best possible time to make your move.

*There are 31 principles on the list so far but there may be many more – I am still learning this highly skilled and very valuable discipline – if you know of any others please add them as a Comment.

For personal development linked to this topic visit the Consummate Professional Series

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NHS – A terminal case of management cancer. Part 2.

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Part 1 was not the most popular read on this blog-book (currently at position 28 in the EB-HR league table). I guess partly because the UK’s NHS (National Health Service) is of little concern to international readers but also – who wants to read about cancer – management or totherwise?

Treating patients badly is not the sort of subject for a bit of light relief or jokes.  It was probably the most serious piece I have written and it named names because there is no point pretending you are interested in evidence-based management unless you are prepared to hold people to account.  It is definitely not for the faint-hearted.

When I wrote that piece back in October 2010 I called it Part 1, hoping that I would never have to write Part 2, because surely the management tumour that had engulfed the NHS might show signs of shrinking and go into remission under a new Government?  Little did I realise how soon I would be called back to duty.  This story about doctors having to prescribe water for patients, because such basic care was absent, demanded action but I am already worried that there will be many more parts before I am finished.  Or maybe the NHS will be finished before me?

Can you imagine what would happen if any large, commercial concern treated its customers in this way?  How quickly would we be baying for the blood of the CEO of Wal-Mart or Tesco if checkout operators ignored us and said they were too busy?  How soon would riots break out if you pulled into a gas station and the counter clerk couldn’t be bothered to activate the pumps?  I cannot, for the life of me, understand why NHS CEO, Sir David Nicholson is still in post today if accountability is to mean anything (Update May 2013).

Of course pernicious, systemic problems of this order do not suddenly appear overnight; the primary source of the cancer can usually be traced back a long way, deep within the system . My particular interest is in HR strategy, especially in super-large organisations like the NHS (1.3 million people) and Wal-Mart (2.1 million), so I have been studying what has passed for HR strategy in the NHS for many years.

Let us go back to the early 1990’s when a relatively young, ambitious and fast-track civil servant called Hugh Taylor was given the task of writing an HR strategy for the NHS – it was pitiful and senior UK civil servants today know no more about this crucial aspect of modern management thinking than they did then.  It does not stop people like Hugh Taylor rising through the ranks to become Permanent Secretary at the Department of Health though and being knighted; having shown complete incompetence in this key aspect of his management role.

We might want to criticise the nurses and healthcare assistants who failed to provide water but what about the attitude of the doctor who thought he (or she) had held true to the tenets of his Hippocratic Oath by writing a prescription without ensuring the problem would be resolved?  Why didn’t he just grab the nearest glass, turn on a tap and then put in place a system to ensure it never happened again?  Is that the sort of physician the NHS has been breeding all these years?  The NHS has declared that it is learning from companies like Toyota, copying aspects of ‘lean thinking’, but they have obviously misunderstood the whole concept if they cannot get the basics right.

Based on a long view of the evidence before us neither the Government, the NHS management nor the medical profession are capable of running the NHS at the level and cost required today.  If they all worked for Wal-Mart or Tesco they wouldn’t be there any longer – not because of hard-nosed management techniques but because they would not have any customers – we would all have gone elsewhere, if we had a real choice.

Despite all of this the British public still love the NHS because they distrust the profit motive in healthcare and most of the time they get the care they need.  But they don’t all know how much it is costing or how unsustainable it is. When they have to return to waiting lists of 18 months their attitudes will no doubt change but by then it will be too late to put it right.  So an HR strategy based on the best commercial management principles, yet not motivated by commercial gain, is probably the best alternative.  These are the sorts of questions finally being asked by the evidence-based management community (my own contribution, Chapter 13, critiques the nonsensical approach to leadership development in the NHS) and nothing will change the direction of the NHS until its most difficult people issues are properly addressed.

By the way – to all non-UK readers – if you think this management cancer phenomenon is unique to the UK, to the NHS or to healthcare – think again.

Update

4th July 2011 – The true size of the cancer is now becoming more apparent

For personal development linked to this topic visit the Consummate Professional Series

 

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NHS – A terminal case of management cancer. Part 1.

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Evidence-based managers always spell out their assumptions and those assumptions need to address any problems that are likely to occur.

When I was taught the Hay method of job evaluation years ago their tutor failed to follow this principle and made an implausible assumption that any person doing a job will be performing.  Hay knew that performance management and job evaluation have to go hand-in-hand but completely ducked the issue – assuming away the inevitable.  In the medical field this would be equivalent to a doctor assuming that a patient will always take their advice and lose weight; take the pills; get more exercise; stop smoking – knowing full well that it was unlikely ever to happen.

Only one other HR person in the room shared my concern so I presume the rest just went away and did what they were told, thereby perpetuating an inherently flawed scheme.  What they actually needed was not a scheme but a complete system because effective systems are designed to solve problems, not to pretend they don’t exist.

Hay repeated their problem avoidance technique once again when they launched the Hay/McBer competence straitjacket.  This was based on a highly simplistic theory of management competence that if you find managers who are deemed to be performing, and analyse any common competencies, then those same competencies can be used for development purposes.  Apart from the obvious fact that this is a theory based on a circular argument – ‘good’ managers must equal competence must equal ‘good’ managers – Hay again ensured that effective performance measurement and management was not a compulsory part of their scheme.

These circular arguments, which often produce vicious circles, can be seen in many areas of HR theory. In the particular case of competence theory some of its roots can be traced back at least to Prahalad and Hamel’s own circular-argument-theory of core competence (i.e. good companies have a core competence so companies with a core competence must be good companies).  Then all it takes is an academic journal, or more probably Harvard Business Review, to confer its blessing and before you know it we witness the birth of yet another fad to feed the insatiable appetites of the non-thinking, non-evidence-based manager.

If you want some stark, longitudinal evidence of the failure of competence frameworks just look at the NHS, which has been using this Hay approach for many years, or indeed any other large, public sector body that has jumped on the same bandwagon – the National College for School Leadership, for instance (but don’t ask them for evidence as educational standards notoriously shift with the tide).

Then look at the ONS (Office for National Statistics) evidence, which shows that between 1997 and 2007 a 117% increase* in spending on the NHS had produced only a 52.5% increase in healthcare output.** If this is not evidence of poor leadership and poor performance management (including the medical profession) then I don’t know what is. But an evidence-based manager does not work, primarily, off retrospective data.  They use hard evidence to predict what is most likely to happen in the future: then they design strategic, HR policies and practices to resolve the problems they have identified, in advance.  So, regardless of how badly the NHS is currently being managed, the only thing that matters now is how are they going to manage better in the future?

In 2008 I voiced these concerns in a piece for Training Zone, pointing out that the very body responsible for learning in the NHS, the Institute for Innovation and Improvement, set a very poor example by failing to learn from its own mistakes and by a very unfortunate coincidence it proved to be rather prescient as only 3 months later the Mid Staffs Hospital crisis hit the headlines.

Needless to say, no one at the Institute responded (even when I raised it with them directly in the light of Mid Staffs) but eventually I managed to meet with their Director of Planning and Performance and Head of Strategic HR & Organisational Development in July 2010.  At this meeting they referred to their Leadership Qualities Framework (based on Hay) as a “deficit” model.  Technically that means leaders and managers are deemed deficient but ‘deficit model’ could also be taken to mean any model that has no discernible benefit or return on investment.

The most disturbing feature of such models is that they don’t actually make up the deficit, they just mask the fact that endemic deficiencies in leadership and management are not being dealt with.  In the case of the NHS this has produced a cancerous management culture that has been eating away at its healthiest tissue – managers and medical staff with integrity – for many years.  What it leaves behind is a management husk of people with the title of ‘manager’ who actually gave up on managing a long time ago (think of the ‘managers’ who fiddled waiting lists). The ‘managers’ I spoke to do not even believe in the methods their Institute actively promotes. They willingly admit their Hay framework is not evidence-based and yet, perversely, feel they have to support the pretence that it will help the NHS “… identify £15-20 billion of efficiency savings by the end of 2013/14”

This sort of duplicitous behaviour is usually a direct consequence of a climate of fear and retribution that exists at the very highest levels.  It is a very nasty, invasive and particularly pernicious form of cancer that thrives in crisis-ridden organisations, especially those directly controlled by politicians.  Furthermore, while these ‘managers’ readily acknowledged that their methods could be taking them “down the wrong route” they could not openly admit their mistakes; thereby acknowledging that the NHS is the very antithesis of a learning organisation. This inevitably means they are destined to repeat the same mistakes in a downward spiral that might prove to be a macabre dance of death.  Only frightened management is willing to “play along” (their words) with the charade that is the “Leadership Council” created by NHS Chief Executive, David Nicholson and only the very worst type of manager has the audacity (and total lack of self-irony) to refer to himself (or herself) as a ‘leader’ (Update – not for much longer).

This council is populated by, in leadership (sic) terms, a motley crew that has included Greg Dyke (‘Is the BBC a stupid organisation?’ ), Daniel Goleman (‘Where can I get my next EI fix?’) and of course senior medical figures, which leads us to the biggest elephant left in the room – who actually ‘manages’ the NHS?  For an organisation that is entrusted with looking after the health of 60 million citizens the answer from the Planning and Performance Director at the Institute was quite chilling -

“the NHS isn’t one organisation it’s hundreds of organisations… the medical profession has huge power …. a doctor is capable of unseating the Chief Executive…. a Chief Exec can easily get kicked out if they upset the medical profession”

Evidence-based management should never be a witch-hunts or seeking to blame.  All it is concerned with is value – getting the best possible patient care at the best possible cost – and that is what the NHS should stand for.  The evidence tells us very clearly that the existing medical-management culture within the NHS just isn’t working anything like it should and, as with many patients who have just been informed that they have cancer, is in denial.  Whatever Andrew Lansley (Health Secretary) is planning for the NHS (e.g. giving more power to GP’s) he will have to install a much more benign regime if he is ever going to make any progress.

For personal development linked to this topic visit the Consummate Professional Series

*ONS – UK Centre for the measurement of Government Activity ‘Expenditure on Health Care in the UK’ April 2009 **ONS – UK Centre for the measurement of Government Activity, ‘Health Care Output 1995 – 2007’, June 2009

 

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68% of projects fail

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This flyer, (pictured) from Cranfield University’s School of Management, landed in my mail a couple of days ago and it immediately caught my eye because I wondered if Cranfield were referring to the projects run by its own alumni? Cranfield have been teaching  project management for many years and currently runs an “Executive MSc in Programme and Project Management” and one of the Core Modules on the Cranfield MBA is “Project Management Introduction” with one of its “Learning outcomes” being “able to identify a project, set it up, track it and bring it to completion”.

It transpires though that they were, of course, referring to everyone else’s IT projects and the source of the 68% figure is the Standish Chaos Report (2009) so I thought I would investigate further. The number of projects rated as “successful” between 1994 to 2009 range from 16% to 35% per year. The EB manager could challenge how they define ‘successful’ (for example, just because a project is ‘on budget’ does not necessarily mean the budget was ‘right’) but there are plenty of high profile, project ‘failures’ to support the picture presented here and so, if we take these figures at face value, there is an enormous amount of room for improvement.

‘Project management’ has become almost as much of an oxymoron joke over the years as ‘military intelligence’ or ‘leadership development’ as one large project after another has failed. Some of the biggest ones spectacularly so – take the UK Ministry of Defence’s attack class submarine – Astute – which was about £1 billion and 7 years late when it was finally launched in 2007 -

Or the NHS’s National Programme for IT (NPfIT) which is years late and well over budget. So why do projects fail so often?  What do we need to learn from these failures to make them more successful?

One commentator, Kelly Waters (who also refers to the Standish data under the heading ‘Most IT Projects Fail. Will Yours?’) concluded that some of the common reasons for project failure include “Stakeholder Management and Team issues” : – Insufficient attention to stakeholders and their needs; failure to manage expectations

  • Lack of senior management/executive support; project sponsors not 100% committed to the objectives; lack understanding of the project and not actively involved
  • Inadequate visibility of project status
  • Denial adopted in preference to hard truths
  • People not dedicated to project; trying to balance too many different priorities
  • Project team members lack experience and do not have the required skills
  • Team lacks authority or decision making ability
  • Poor collaboration, communication and teamwork

Kelly’s analysis looks sound to me but maybe an even more thorough, evidence-based, cause-and-effect analysis would have included all of the possible, human reasons behind project failure.  These would have to include: -

  1. The egos and hidden agendas of the main protagonists.  Perhaps no one wants to have to produce a clear business case because then their pet project might not go ahead and they won’t be able to embellish their CV, satisfy their personal ambition or enhance their status.
  2. Maybe the approval process is primarily a political process – for political ends (like another aircraft carrier we don’t need) – rather than to produce something worth having.
  3. Perhaps no one is skilled enough in project scoping and definition (Astute kept being re-designed as it was being built)
  4. Or perhaps no one is prepared to be held accountable and, even if they were, would they be given the authority to control every aspect of the project and its supply chain?

The list of human frailties goes on and therefore evidence-based project management, as with every other aspect of EBM, is inherently a human discipline designed to resolve human system issues, rather than a purely scientific, mechanistic or managerial one.  Only when the project management ‘profession’ accepts that organisational culture has probably the biggest impact on project outcomes will the 35% success rate have much chance of improving significantly. 

A good start, therefore, might be to ensure all project management training courses address these crucial issues at the very beginning, rather than choosing to ignore them and perpetuating the cycle of hope triumphing over experience.  Everyone involved in the project has to be allowed to air their valid concerns without fear of losing their jobs or being deemed to be uncooperative; then these crucial issues actually have to be resolved before any money is spent.  These are the very sort of powerful, ‘human capital’ indicators that EB-HR aims to develop.

I certainly hope this is item number one on the syllabus of Cranfield’s “new and exciting programme” and uppermost in the minds of those running it.  Moreover, if they have some guaranteed ways of resolving these issues I, for one, would recommend it.

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Where can I get my next EI fix?

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A week ago an email landed in my spam filter from a company called TalentSmart (based in San Diego, USA) advertising “Working with an emotional intelligence mentor”.  What a very seductive concept emotional intelligence has always been since it hit the headlines over a decade ago. It felt like emotionally intelligent executives were suddenly being described as ‘attractive and intelligent’ or ‘good in bed and a great conversationalist’ – the perfect combination. So who wouldn’t want an emotional intelligence mentor?

Normally this sort of unsolicited email would not get past my own bullshit detector but being evidence-based does not automatically make me resistant to new ideas, mean-spirited, mechanistic, obsessed with measurement or devoid of human sensibilities. So I read further and found that TalentSmart offer (apparently): -

“Everything you need to develop an emotionally intelligent workforce. From books, to selection tools, to the leading emotional intelligence assessment.”

If that is “everything” I am not sure where it leaves one’s existing personality, parental influence, genes and a host of other factors that probably have a part to play in the way someone behaves in the workplace – but let us not worry ourselves unduly about such minor details.  Also, let us not open up the eternal debate again about nature versus nurture, or whether emotional intelligence is a skill, competence, attribute or whatever.  Instead let’s just get to the logic and evidence on offer.  Here is one snippet from their “Business Case for Emotional Intelligence (EQ) 2009 Update” – which, incidentally, invokes a quote from Jack Welch in support of emotional intelligence – yes, that Jack Welch – the one who developed that emotionally intelligent system called forced ranking.

“Fortune Brands saw 100% of leaders who developed their EQ skills through classroom training, coaching, and online learning exceed the performance targets set for them in the company’s metric-based performance management system. Just 28% of leaders who failed to develop their EQ skills exceeded their performance targets. (Bradberry*, 2005).”

As with all statistics, we need to check what we are reading first. There are only 4 possible outcomes from this exercise. Some of the participants could have: -

a. developed their EQ skills and exceeded targets (i.e. the 100% referred to)

b. developed their EQ skills and not exceeded their targets (must be 0% if a. is true)

c. failed to develop their EQ skills and exceeded targets (the 28% referred to)

d. failed to develop their EQ skills and did not exceed targets (no mention of this group)

The only data we are actually given though is percentages, not actual numbers of participants. So, let us assume that for every 100 ‘leaders’ who participated, the actual numbers in each category were as follows (with the relative percentages in parentheses) -

a. 1 (1% of the total but 100% of those who developed skills and exceeded targets)

b. 0 (0% of the total)

c. 28 (28% of the total but also approximately 28% of the group who did not develop EQ skills)

d. 71 (71% of the total)

On this basis TalentSmart’s EQ approach would have a success rate of just 1% and yet would still be able to justify their claims on a purely statistical basis.  We don’t know if this was the split of course but you could play around with any other combination that achieves the same relative percentages (e.g. 20/0/23/57 – but b. will always be zero).

Regardless of the questionable statistics though, what the evidence-based manager would really take issue with is the methodology itself – the focus here is on the process of ‘developing EQ skills’ and not on any evidence of the likely causes of under or over performance. The ‘solution serum’ has been pre-prepared and injected into everyone before any evidence is offered. Of course, this approach is supported by Daniel Goleman’s** article in Harvard Business Review (March 2000) entitled ‘Leadership that gets results’ because HBR informs us that

“drawing on research of more than 3,000 executives, Goleman explores which precise leadership behaviors yield positive results. He outlines six distinct leadership styles, each one springing from different components of emotional intelligence.”

The evidence-based manager does not have to challenge this assertion so much as ask the simple question – is this just correlation masquerading as causation again? Where is the evidence that attempting to develop emotional intelligence actually gets results (and doesn’t have any side effects)?  Those who are offering EI or EQ have to do better than this.

*Bradberry is a partner at TalentSmart

** Daniel Goleman has been appointed as an adviser to the UK’s NHS Leadership Council

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Scan gel can teach us a great deal about EBM

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As someone who has often taught the ‘Toyota Way’ as a (very rare) case study of exemplary HR Strategy, the recall of thousands of its vehicles in 2010 serves as a stark reminder (not that I needed one) of the severe limitations of case studies as teaching aids.  The world can change so very quickly that it renders case study material irrelevant or just plain wrong. Whether or not these recalls should be seen as evidence of Toyota having got something fundamentally wrong or not, my informed guess is that Toyota will learn how to overcome this latest hurdle and remain at the forefront of the automotive industry, if nothing else simply because it has nurtured evidence-based habits in its people over many, many years.  Nevertheless, it just goes to show that no organisation, however successful today, can afford to become complacent. So what has all of this got to do with a tube of scan gel? (you know that stuff they smear over pregnant bellies to check the baby is OK?)

Some years ago a workshop delegate told me a story about how Toyota was so good at continuous improvement that it had reached a stage where an employee invented a plastic pencil-stub-holder to hold the old-fashioned pencils Toyota still used (they still regard pencils as ‘fit for purpose’).  The stubs were what was left after sharpening the pencil down to its last inch or so (2.5 centimetres).  The cost of the re-usable holder was seen as a worthwhile investment in terms of lower pencil costs.

Now you might not see this as clear evidence of very sophisticated management thinking and practice.  In fact it might appear like the very opposite; management declining into a sad state of obsessive, micro-management.  Can an organisation as big and as successful as Toyota really be that bothered about the cost of a new pencil? Haven’t they got more important matters on their minds?  Have they brainwashed their employees to become obsessed with minutiae? Well, whether you see this as an indictment of the modern world’s drive for perfect efficiency or not, if we ask the same question about healthcare costs perhaps it puts it into perspective?

Anyone who has ever seen a scan being performed will know that the scanning clinician will squirt a sizeable dollop of scan gel on the area to be scanned; to ensure a clear image is achieved. It suddenly occurred to me once that the clinician did not measure out a precise amount of gel and, with 60 million potential patients in the UK alone (and scan gel selling at nearly $30 per US gallon) that might amount to quite a lot of unnecessary gel being wasted.  So is this simple procedure a suitable case for considering the merits of evidence-based HR management or am I just a sad so-and-so who has nothing better to do than annoy hospital clinicians?

The evidence-based manager’s answer to this question is quite simple -we don’t know until we look at the evidence and the EB manager willingly admits their initial ignorance. Until we know how much scan gel is used each year we have no basis for deciding whether this is a priority or not. For all we know the potential saving from a precisely-measured application of  gel could be anything from £10 to £10 million per year in an NHS that spends £120 billion per annum  . So the first step for the E-B manager is to assess the cost but that immediately poses a long list of other questions: -

  • Do we have any precise data on how much gel needs to be applied in different scanning procedures?
  • Does the NHS ensure that all scan gel purchases are coded identically in the accounts?
  • Does the NHS know how and where all the scan gel is used?
  • If it knew all of this, at what level would it be able to track the use of scan gel – by hospital, department, team, shift or individual clinician?

I posed this very specific question to a group of very senior NHS managers (up to Chief Executive level) only last week and was advised that the data should be available down to department level. I suggested that only when we reached down to the individual level would we be able to speak to individuals about their own personal use of scan gel. I got the impression (without implying any criticism) that this was not likely to become a major priority overnight – which is precisely the point – managers and doctors cannot manage everything themselves.  Evidence-based management is as much about self-management as it is about senior management.  My humble guess is that, among the 1.3 million workers in the NHS, the laws of probability suggest that at least one clinician has calculated the precise amount of gel required to produce a clear image at the lowest cost.  Not because they are sad individuals but because they are totally dedicated to providing the absolutely best (fit for purpose) value the NHS can provide and they know that money wasted on scan gel cannot be spent elsewhere.

Now all the evidence-based HR manager has to do is find out where these people are and create an environment where they can teach some of their colleagues how they do it.  Of course, the key to this is actually a long-term HR strategy which genuinely aims to engage every single employee in the pursuit of perfect value for money.  If we do not explicitly and systematically encourage such a positive approach, every day of the week, it is almost impossible to engender the requisite level of commitment just as times get hard. No doubt the list of similar savings opportunities is probably endless but the evidence-based manager also realises what impact structure and culture have on an organisation. Would the clinician be allowed to use his or her own best judgement on the amount of scan gel used or would it become a very long and tortuous process of evaluating various methods; all subject to scrutiny by senior consultants? Who knows, but asking scan technicians to show some interest in the subject by providing comparative data on their own usage might be a start?

Maybe evidence-based management is not really about pencil stubs or tubes of scan gel at all, more the means by which every single employee is enabled, encouraged, allowed and supported in working to the very best of their own ability? It is also about suppliers educating customers how to get the most value out of their products – but that is a subject for another day.

For personal development linked to this topic visit the Consummate Professional Series

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Equal opportunities can have unintended consequences

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One of the fundamental notions that underpins evidence-based management is that one should always look at the specific context before trying to apply a generic (HR) policy.  If you need convincing of this then look no further than the application of equal opportunities policies to women entering the medical profession. In the UK the number of women entering medical school rose from 492 in 1960/61 to 4,583 in 2008/09.  By 2017 the majority of doctors are likely to be women (this could of course be more to do with merit than any explicit equal opps policy). However, for very obvious reasons (motherhood being one of them) this has engendered some significant shifts in the gender profile of the medical profession as well as a disproportionate representation of genders in various areas (especially those becoming GP’s).  This is a statement of fact – pure evidence – but should not be read as the author taking a particular stance or view on equal opportunities policies, or the relative merits of male versus female doctors. However, the financial and practical implications of the present situation are significant and will have to be addressed at some stage.

I now set this difficult and complex issue as an assignment for my MBA HR Strategy class.  There are at least two main concerns.

It costs approximately £250,000 to train a doctor. For an annual intake of 10,000 that would be £2.5 billion.  If we assume that each doctor works a full career and, let us just say for the sake of argument, that their work repays the UK economy 5 times their training cost (net), in terms of better health outcomes, then we can attach a net benefit to the UK of £12.5 billion. Following this simple logic (the evidence-based manager always tries to construct a causal hypothesis) for every doctor that does not work a full career (i.e. leaves the profession, takes time out etc.) there will be a direct and causal drop in the value created from this group of doctors. In short, having more women doctors could result in a bigger fall in value than just employing men.

In addition, women doctors tend (according to the evidence) to require more flexible working arrangements than men, which places further possible strains on planning and delivering healthcare services.

So, two of the key (and deliberately provocative) questions for the MBA class are: -

  1. Should equal opportunities policies apply to the training of doctors?
  2. If so, what other strategic HR policies should be introduced in order to provide the most valuable solution?

This is not a hypothetical conundrum it is a very real and live debate that has been going on in the UK’s NHS for at least 5 years and there is no easy answer.

For what it is worth, the evidence-based manager does not have a magic wand but they do have the next best thing, a clearly thought out, coherent approach that aims to provide the most valuable answer to whatever specific objective is set.  So in this case the objective could be: -

  • The best overall care of patients (output and outcome measures) – in which case the evidence-based argument would have to include the relative performance of male versus female doctors (i.e. if women perform twice as well as men then they will produce as much value in half a career span)
  • The lowest average cost of training a doctor – a very different (input) objective – which might lead towards a policy where all doctors have to work long enough to repay their initial training cost – a very different HR policy perspective with huge ramifications (e.g. the whole principle of paying back training costs in any publicly funded role)
  • A set proportion of women in medicine – a typical diversity target – which has already led to the idea of quotas being mooted.  Jill Kirby, director of the Centre for Policy Studies was quoted in the Sunday Times (9 May 2010) as saying -“Clearly it’s unacceptable to start imposing quotas but we have to recognise this is one of the downsides of equal opportunities”.

The only thing that can be said with some certainty is that the current situation just highlights that there is no such thing as an automatically beneficial policy when it comes to HR strategy. Also, if I get any miraculous answers from the MBA class I will post them here!

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