Gerry believes that the solutions to problems in business are often found at the grass roots level. Do you agree?

Yes I believe that is true because I think at the end of the day nobody knows how to do the job better than the people doing the job. I think what Gerry underestimates is that the complexity of the job of health care, which never involves one individual. If it was as simple as one person doing something different to make a difference, then it would be wonderful, because I think we’d get a lot of innovation, a lot of things done. But when you’re working in a theatre, you’re working as part of a huge multi-disciplinary team, each of whom may also be required to change their practice in order to accommodate the proposed innovation, and sometimes this may actually compromise patient safety.

Because nobody works in a vacuum, and everybody is an interdependent part of the team, unless the solution satisfies all members of the team, it’s incredibly difficult to get the team to actually change. Now this is where Gerry would start talking about holding people to account and getting them to do things differently, perhaps under direct orders, which is fine in theory, but often the points that other members of the team make are also valid.

Gerry tried, for example, to improve Ophthalmology productivity. But every time people came up with a ‘good idea’, there were often other members of the team who would point out “but if we did that, there would be this knock-on consequence for patient safety”. And at the end of the day we have to do things that are safe for patients. To some extent, what Gerry experienced was why we go about things in a particular way, which people, like him, find incredibly frustrating, very bureaucratic, but what it attempts to do is take on board all those views right from the outset so that we don’t end up going down a lot of blind alleys.

Now, I might like to impose those changes, but if you impose changes without taking due regard of other people’s views, and of the risks that might be being created by those changes, you run the risk of endangering patient safety.

The whole process is much more complicated than the TV programme ever can demonstrate. Having said that, there can be little doubt, and I prove it in the programme, that if a chief executive goes into an area and says I want this sorted, and I want it sorted now, things definitely move a lot quicker.

How can you make change happen?

I know that Gerry’s right in that I can make a difference and I’m absolutely committed to doing much more of what Gerry suggests, which is going out and being more demanding of people and asking them to get on with change. But, it works better in some areas than others. It works better if you’re working with a group who already work as part of a team. That tends to have a much, much faster impact, change happens more quickly then. But in parts of our service they don’t really work as teams. There are different groups of staff, all reporting to different management structures, that therefore have to work together in a team-like way but they’re not part of a team, and they all have very different views about what’s right and what’s wrong.

Whilst this is clearly an anachronism to Gerry, this is the way the NHS is structured. Consultants operate to rules and standards set by their own Royal Colleges, and which are designed to ensure safe practice – every clinical specialty has it’s own Royal College, as do the Nurses, and each of them works to a different set of rules, guidelines, working practices etc. I may not like this, but that is the way it is, and even as Chief Executive I have no real power to influence the guidelines under which these professions operate. So I have to work with them.

So encouraging one group to change doesn’t necessarily mean you can get the other to change, and that certainly is one of our problems. Theatres is one of the most complex of environments in which that occurs because you’re dealing with anaesthetists who come from one profession, surgeons from another profession, and then the theatre staff who are generally all nursing staff who also work to a different code of practice as well. And they’re not accountable to one another in that team.

Ideally the structures would be different, but we are very subject to tradition and history and all standards that the medical profession, in particular, reserves the right to determine for themselves. So I can’t make an anaesthetist work on a patient in a different way than the Royal College of Anaesthetists said they must, and the same with the surgeon, so trying to get the two of them to agree on what we might do to speed things up can actually be quite difficult, because we don’t have that degree of control.

So it’s not surprising when in the film the question is asked, “Who do you think runs the NHS?” I run the hospital but the consultants determine the practices they operate in line with their code that they subscribe to as being part of a Royal College. And of course the Government is constantly imposing things on us, over which we have no control. So, I might be chief executive in title but I actually don’t have a huge amount of control over these external forces which have such a profound impact upon the organisation. So it’s not surprising that there are different views as to who is in charge of the NHS.

Content last updated: 05/01/2007

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