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As doctors or people in high stakes
jobs who people really depend on, we

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are used to having to come up with
the right answer as the consequences

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of getting it wrong can be fatal.

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But being the smartest person in the room
or even having the most relevant expertise

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isn't always helpful when we want to make
changes in a system that's struggling.

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This week I'm speaking with
Dr. Richard More, an expert in

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leadership within clinical teams.

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In this episode, we talk about the
various different forms of power we can

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cultivate when we want to change things,
even if you don't feel you have the

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seniority or the ear of the right person.

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This isn't just a string of
buzzwords or loads of jargon.

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Richard's got loads of really
practical advice on managing conflict,

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delegating without dumping, and
understanding the only two things

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that are truly in your control.

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If you're in a high stress, high stakes,
still blank medicine, and you're feeling

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stressed or overwhelmed, burning out or
getting out are not your only options.

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I'm Dr. Rachel Morris, and
welcome to You Are Not a Frog.

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I'm Richard More.

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I come to you having been a GP for about
25 years, uh, spending more and more

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time trying to change the way that things
work and try and reduce frustrations.

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And now doing that full-time.

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brilliant to have you
on the podcast, Richard.

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I'm gonna just go straight into it.

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Can we change an organization
in which we work?

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I can give you a definite maybe on that.

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Uh, and obviously some organizations
are easier than others, some of

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our capabilities to do change
are, uh, are better than others.

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Sometimes we are on form as
individuals and sometimes we're

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just not on form at others.

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Certainly, it's always a job of work,
uh, and it never happens by accident.

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And sometimes a, a prudent and wise person
would go too difficult, too difficult,

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but you don't wanna be doing that all
the time because that just ends up with

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you being, uh, at the, the mercy of,
uh, other people's wins and so forth.

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Much better to, to change things,
how you want them from time to time.

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You do have to pick your battles.

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Yeah, you do.

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So what I'm seeing at the moment
is, is that people go into their

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roles quite enthusiastically.

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You know, they take on the role of
say, PCN clinical director, or they

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take on clinical, their practice or
clinical lead for their department.

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And they have all these good intentions,
but it just feels so hard because the

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changes they're trying to make, everyone
agrees with needs to be done, but then

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when they try and go up a level, they're
often managed by people who don't even

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work in their department or their line
manager is someone across the other side

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of the hospital or even in a completely
different, different place altogether.

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Or if you're in a general practice,
you are line managed by the ICB or

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whatever that, that, that actually
seem to be in the pockets of

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secondary care and aren't actually
looking at, at, at what's going on.

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So it, it just feels like we don't
have any power to make any change.

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Is that true or not true?

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uh, again, a definite maybe on that.

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Uh, I think what you've done
there is opened the eyes to the

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idea of team building and change.

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And I think, uh, more so in my
generation, perhaps less so in generations

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coming around, as the rule medics
aren't that good at team building.

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They, they think they are, but there
is sometimes an element of, uh,

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the idea of a well run team, as my
father used to say, is everybody

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doing exactly as they're told.

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And, and that, and that
doesn't really work anymore.

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So, or we talked about the effort of
achieving change and whether the effort

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is worth it, but haven't you already
opened the door to, well, there are some

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individuals, some sources of power that
we need to know what's going on here.

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And so that's the source of the energy
is getting out of our consultation

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room, getting out of our clinic and,
and, and getting out there and going,

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Hmm, if person A is very important
and, and usually the easiest person

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to identify is the person with the
checkbook, that that's a person.

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It's not the only person, but it's
a person with the checkbook, uh, and

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identify and go what works for you?

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And, and that sounds a bit symatic,
but if you throw the question round

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and say it, it's actually understanding
what doesn't work for them.

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So repeatedly making proposals that
don't work for the hold of the checkbook

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is just not going to get you anywhere.

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I think there is something about doctors,
um, and another senior healthcare

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professionals, we are really good
at solving problems, we are really

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good at caring for people, we are
really good at being responsible and

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we are really good at fixing things.

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And then we try and apply
those same skills to, service

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development, change, you know,
doing it and it then doesn't work.

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What is going wrong?

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Well, I think there's a
couple of drivers into that.

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Um, one of which is that most of us
are natural scientists, and if you get

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a group of a hundred of us and say how
many's got A grade A Level physics,

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you'll get about 95 hands in the air.

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So there's this concept, there's always
the right way of doing it, and anything

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apart from the right way is clearly the
wrong way, and if you do it the wrong

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way, you are clearly a bad person.

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And within that they are very used to,
uh, deploying what we call expert power.

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We like to think about the
different sorts of power.

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And of course you'd expect that you walk
in and, and, and I'm sure you and I have

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been unwell in our time and, and we've
gone to see an expert and the expert has

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said, I recommend you do this and, and
you go and do it most of the time, and

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that's because we respect their expertise.

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But the, when, when, when sitting
down over a cup of tea and sit talking

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with people going, where are we?

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Whoa, whoa.

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What needs to happen here?

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We would think also about
other sorts of power.

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We would think about reward power.

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Um, broadly speaking, that's money,
actually in this day and age,

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there's coercive power, that's often
the sort of hierarchical power.

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Go and do this because I say so.

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Coercive can have an
element of bullying in it.

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There's charismatic power.

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There is that, there are some of
us individuals who can get other

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people to do things, uh, by, by their
interpersonal behaviors, by saying,

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please, a lot of the time, by having
a reputation for being successful.

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And then there's the legitimate power,
which for those people that live in

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hierarchies where there's perhaps a
finally judged balance where there's

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pros and there's cons and someone says,
look, we're gonna have to call this.

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We can't do either or anymore.

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We are going to do it this way.

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I, I'm the boss that's going to do it.

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I think.

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All, all those powers
can be very relevant.

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We've discussed the, sometimes the, the,
the, the enormous power of reward power

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as a self-employed GP, I know that I don't
understand the position of my consultants,

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colleagues that are employees.

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I don't get that.

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I haven't been an employee since I was 26.

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I don't get that.

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But I know there is legitimate power
that says we will do this, we do that.

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So when you start to talk like that, they,
they, they, they become important things.

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The challenge I see is that many medical
staff are so used to deploying expert

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power in the consulting room where they
spend 95% of their time, that somehow

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they think just because they've said
it, that's the right thing to do.

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And there is an evidence base on
how to achieve change successfully.

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Uh, we talked about the pain of
achieving change earlier, but the,

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but there is a more painful and
a less painful way of doing it.

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But it's taught in the business schools,
it's taught in the schools of psychology,

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it's not taught in the medical schools.

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And, and I think that goes to a
great deal of frustration of our

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colleagues who just don't understand
what's worked so well for them.

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In the past 20 years, deploying expert
power suddenly doesn't work at all.

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Yes, and we, we see that, don't we?

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Where you, you'll be a clinician in a
meeting and you know that this would

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be the best thing for the patient,
and then suddenly that's all derailed

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and suddenly there's something
that's completely bonkers based on

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something with no evidence behind it.

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And you know that's not gonna work and
you've said it's not gonna work, and then

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there's nothing more you can say apart
from the fact that that's not gonna work

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and it's not gonna be good for patients.

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And then suddenly you don't understand
why people aren't, taking that on board.

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And, and what I'm seeing is
that things have shifted.

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So not only are things not good
anymore for patients, but we're

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saying and you will lose staff.

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So you can't argue for staff,
you can't argue for patients.

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Are we really in a position where we
absolutely just have to argue about

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money, resources and people's empires?

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Not just, no, but you do have to
craft solutions that work in this

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world or pack up and go home.

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Uh, and, and sometimes that
can be a, a sensible choice.

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Sometimes it can be a,
an insensible choice.

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I'm, I've certainly done it
and I dunno if you've done it.

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I've certainly, um, slammed the door
after I've worked outta meetings.

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Perhaps that means that my analysis
hasn't been entirely rational

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and more emotional, but that's,
that's frustration or whatever.

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Um, but, but everybody else lives
in this world of constraints.

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We are perhaps extraordinary fortunate,
uh, working in healthcare in England

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where we don't really worry that
much about resource constraints.

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We are used to not worrying at all.

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And I think, uh, I, I, I, I think
if, if we wanted to learn about that,

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I'd suggest taking your local vet out
for a beer, because I think the vets

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will tell you that the people walk
through the door going healthcare's

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free, and this will be 5,000 pounds.

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And they'll go, don't be
silly, it's only a rabbit.

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Well, that's how much a
titanium rod costs into a leg.

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And we just don't do that in this country.

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And how does that hinder us
then, in terms of being able

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to, to change your organization?

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Uh, we have two options.

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Uh, we either stay with the organization
we have or we go and find another one.

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Uh, and those with as individuals,
that's actually within our control.

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Our challenge of course.

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And it's, isn't it changing, isn't
it changing, that as a monopoly

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purchaser, and there's a posh word
for that, I think it's monopsony,

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um, the NHS is, is such a majority
employer, we've got no one to jump to.

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But it's becoming both less and more.

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What do I mean by that?

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One of the joys when I went into
general practice was the press about

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being independent was the freedom.

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Uh, and so broadly speaking, if
you wanted to be independent, you

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had to practice general medicine.

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If you didn't mind that you wanted
to practice specialized medicine,

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you had to be an employee.

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There was no, no third world.

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But the independence of
general practice has gone down.

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Don't we know that?

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I mean, the contract gets
bigger and thicker every year.

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§§§§ But actually I think the independent
sector is growing and growing and growing,

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so there will be places to jump to.

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And, and what's interesting is that
I know several people that have yes,

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jumped ship and gone off to do private
general practice or do different

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things, and yet the grass isn't
actually very greener on the other side.

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In fact, it's sometimes a
lot worse because it's even

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harder to influence things.

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The, the, the decisions are taken by
head office over there who has absolutely

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no idea where things are happening.

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At least you know, when, if you're
working for your, your local GP

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surgery, your decisions are taken by
your partners or, or, or, or people

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nearby or your local hospital trust.

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And then, then you start to see what
actually it's like working in a business

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with usual business constraints.

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But we have been brought up in
an era where yeah, there, there

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aren't, and we, we never have had
to think about the financials and

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the resources really very much.

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it's always very interesting when someone
talks talking, uh, doesn't necessarily

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what talk about going well in real life,
what, what they normally refer to is

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that those private sector constraints
that you've just, just referred to there.

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But I tend to kick back and going,
oh, that's interesting because the NHS

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consumes something like 30% of GDP.

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How big is your sector?

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Oh, it's about 3% of PDP.

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So, which one's reality again?

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You know, it is such a monster.

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It is such a monster.

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It, it, it's, it influences the
nation and the way that people behave.

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It's, it's, it's slightly
scary from that point of view.

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'cause I put it to you,
it's slightly outta control.

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Yes, yes it is.

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And we all know there's so
much inefficiency, isn't there?

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But, but no one seems to have a solution.

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I remember I went to see Rory Stewart,
um, at, at, at talking the Coin exchange

223
00:11:41,495 --> 00:11:44,375
here in Cambridge, and somebody asked
me about the NHS and he said, well,

224
00:11:44,675 --> 00:11:48,117
it's one thing coming up with all these
good ideas for it will ever, but what

225
00:11:48,117 --> 00:11:52,017
no government's ever managed to work out
is actually how to change it properly.

226
00:11:52,632 --> 00:11:53,082
We do.

227
00:11:53,142 --> 00:11:53,617
We know how to do it.

228
00:11:54,077 --> 00:11:54,347
Okay.

229
00:11:54,347 --> 00:11:54,797
Tell me

230
00:11:54,857 --> 00:11:57,227
you, you, and only one sentence please.

231
00:11:57,437 --> 00:11:59,357
Um, uh, it's all healthcare process.

232
00:11:59,457 --> 00:12:02,127
You look at the organizations, the teams.

233
00:12:02,337 --> 00:12:04,467
The trouble is, if you use the word
companies, everyone gets wrapped up.

234
00:12:04,467 --> 00:12:06,027
It's for private or, or, or whatever.

235
00:12:06,177 --> 00:12:08,667
But if you talk about a company
being a collection of individuals,

236
00:12:08,672 --> 00:12:12,057
a, a corporation, working to
do something, you look at those

237
00:12:12,057 --> 00:12:14,427
organizations that have been successful.

238
00:12:14,620 --> 00:12:18,940
Uh, and, and the classic that everyone
talks about is Toyota and cars.

239
00:12:19,540 --> 00:12:21,700
Uh, and, and how did they do it?

240
00:12:21,940 --> 00:12:26,320
You look at their processes, you, you
take whatever you can, which having done

241
00:12:26,320 --> 00:12:31,030
it is about 80%, because we talked about
how general practice was independent

242
00:12:31,030 --> 00:12:33,010
was varied, but it's now standardizing.

243
00:12:33,190 --> 00:12:36,220
There's an awful lot of
standardization in general practice.

244
00:12:36,400 --> 00:12:40,510
And then you do it, and then
you do it year after year, and

245
00:12:40,510 --> 00:12:42,370
then you do it time after time.

246
00:12:42,700 --> 00:12:46,660
Clearly, that absolutely challenges the
model that you are talking about earlier,

247
00:12:46,660 --> 00:12:49,000
about, uh, fatigue, frontline clinicians.

248
00:12:49,495 --> 00:12:52,345
You can't do it at nine o'clock
when you've done, you've done a

249
00:12:52,345 --> 00:12:54,205
nine till nine and then you'll
do it from nine to midnight.

250
00:12:54,205 --> 00:12:57,895
It don't work, but you've got
to have that understanding of

251
00:12:57,985 --> 00:13:00,085
reward, good things happen.

252
00:13:00,595 --> 00:13:01,675
You define what good is.

253
00:13:01,675 --> 00:13:02,935
And it's not for me to
define what good is.

254
00:13:02,935 --> 00:13:05,275
Each individual team is to
define what good is for them

255
00:13:05,755 --> 00:13:07,315
and it's worth the investment.

256
00:13:07,975 --> 00:13:11,610
When we first started doing this in
my own practice, 'cause poor, the

257
00:13:11,610 --> 00:13:15,235
poor, poor guys and girls got used as
a few Guinea pigs from time to time.

258
00:13:15,415 --> 00:13:17,245
I think I asked them, but
not entirely all the time.

259
00:13:17,245 --> 00:13:18,295
We just tried a few things.

260
00:13:18,445 --> 00:13:21,835
A mu much easier to try things and fail
among friends than it is among enemies.

261
00:13:22,285 --> 00:13:26,155
Um, and one of my colleagues looked at
the proposal, slammed the papers down

262
00:13:26,155 --> 00:13:31,030
on the desk and said if I have to work
half a day longer for each month, for a

263
00:13:31,030 --> 00:13:33,850
year to get outta this mess, count me in.

264
00:13:34,057 --> 00:13:34,267
That.

265
00:13:34,267 --> 00:13:35,647
That's a, that's a great sentence.

266
00:13:35,677 --> 00:13:38,827
But you've gotta understand, and,
and there is this J shaped curve,

267
00:13:38,827 --> 00:13:41,107
your effort, effort before reward.

268
00:13:41,467 --> 00:13:43,177
Um, so you've gotta, and
you've gotta have it.

269
00:13:43,507 --> 00:13:44,317
You've just gotta have it.

270
00:13:44,317 --> 00:13:46,596
It's no good saying
work after nine o'clock.

271
00:13:46,596 --> 00:13:48,756
You, you've got to get
that one in good and early.

272
00:13:49,045 --> 00:13:52,765
The challenge we come across in
disillusioned, uh, uh, teams,

273
00:13:52,765 --> 00:13:56,725
not just clinicians, is how
do you expect me to do more?

274
00:13:56,725 --> 00:14:00,055
Or how do you expect me to
achieve more doing it this way?

275
00:14:00,448 --> 00:14:01,978
How about doing it a different way?

276
00:14:02,098 --> 00:14:03,628
Sorry, don't understand what you mean.

277
00:14:03,988 --> 00:14:05,338
Well, hang on, let's unpick that.

278
00:14:05,668 --> 00:14:08,548
And once you start to unpick
that, people start to make choices

279
00:14:08,548 --> 00:14:12,208
about what they do, they choose to
take a sense of direction about.

280
00:14:12,598 --> 00:14:16,468
But it's certainly not far and forget,
it's certainly not read two sides of

281
00:14:16,468 --> 00:14:20,098
a four and this is how to run a, a,
a multi-billion pound health service.

282
00:14:20,458 --> 00:14:22,768
It is fragmented, it is clinical teams.

283
00:14:23,018 --> 00:14:25,448
The unit of change is that clinical team.

284
00:14:25,448 --> 00:14:28,478
So that's who can that person,
that frontline nurse, that

285
00:14:28,478 --> 00:14:31,508
frontline radiographer, who are
they going to talk to today?

286
00:14:31,715 --> 00:14:34,715
And I think the thing that think
people just get really sick of

287
00:14:34,715 --> 00:14:38,306
is the change for change's sake,
which actually makes things worse.

288
00:14:38,336 --> 00:14:40,546
I think the, the German
word is verschlimmbesserung,

289
00:14:40,687 --> 00:14:43,422
Well, I, I'm, I'm very impressed
'cause I only came across that word

290
00:14:43,422 --> 00:14:46,242
last year, had me working in this,
this last month, not last year.

291
00:14:46,512 --> 00:14:48,642
Uh, and I, and I certainly
dunno how to say it.

292
00:14:48,642 --> 00:14:49,812
My wife's the linguist, not me.

293
00:14:50,145 --> 00:14:51,975
We used to teach on
the, on the Red Whaler.

294
00:14:51,975 --> 00:14:54,465
We did a Working at, working at
scale course, and I came across it

295
00:14:54,465 --> 00:14:56,035
on a podcast, verschlimmbesserung.

296
00:14:56,055 --> 00:14:59,295
it's like, you know, they, I think
they changed the Coke logo at

297
00:14:59,295 --> 00:15:01,125
some point, which was much worse.

298
00:15:01,125 --> 00:15:04,155
So, yeah, so we had all these,
these, uh, examples of things

299
00:15:04,155 --> 00:15:05,475
that were just much worse.

300
00:15:05,505 --> 00:15:09,465
I think the post, the post, they
changed themselves to Insignia, sent

301
00:15:09,555 --> 00:15:11,625
the raw mail, just made things worse.

302
00:15:11,625 --> 00:15:11,980
Whatever.

303
00:15:17,915 --> 00:15:18,635
Yeah, exactly.

304
00:15:18,635 --> 00:15:21,065
And it, it's, for me, it's working out.

305
00:15:21,155 --> 00:15:25,175
If you're making changes that are,
that, that JS shaped curve is really

306
00:15:25,175 --> 00:15:27,605
important, like you said, it takes effort.

307
00:15:27,605 --> 00:15:31,597
Like no one, everybody I know
who's working on the frontline

308
00:15:31,747 --> 00:15:33,247
in the NHS, they're not stupid.

309
00:15:33,277 --> 00:15:36,397
If they knew that they had to work half
a day more for the next year to make

310
00:15:36,397 --> 00:15:38,557
things much better, they would do it.

311
00:15:38,827 --> 00:15:39,967
We're grafters.

312
00:15:39,967 --> 00:15:41,287
We know how to do that.

313
00:15:41,647 --> 00:15:44,347
The problem is you work half a day more
and things are actually worse, and then

314
00:15:44,347 --> 00:15:45,817
that Half day more just becomes the norm.

315
00:15:45,817 --> 00:15:47,547
And then suddenly what you've
done is increased your workload.

316
00:15:47,547 --> 00:15:52,297
So you've got, you've got no output the
other end and so many changes are this

317
00:15:52,297 --> 00:15:55,177
verschlimmbesserung, which things are
getting you, you're asked to do a change,

318
00:15:55,177 --> 00:15:57,217
which you know is gonna make things worse.

319
00:15:57,277 --> 00:16:00,367
And it's being able to distinguish when
you're at the dip of that Js shape curve,

320
00:16:00,496 --> 00:16:04,036
is it gonna be going upwards or is it
just gonna go down into a cul-de-sac?

321
00:16:04,036 --> 00:16:08,266
How on earth do I know if this is gonna
be better or if it's gonna be worse?

322
00:16:08,296 --> 00:16:11,206
'Cause I'm happy to put time and
effort, it's gonna be better, but

323
00:16:11,206 --> 00:16:13,396
I'm sorry, I have run outta energy.

324
00:16:13,741 --> 00:16:15,256
To do this if it's gonna be worse.

325
00:16:15,653 --> 00:16:17,693
Uh, you don't, even if you had
all the energy in the world, you

326
00:16:17,693 --> 00:16:18,683
still want to do it in worse.

327
00:16:18,953 --> 00:16:25,133
I think the J cape curve, uh, is a J
shaped curve, but I think it's, um,

328
00:16:25,223 --> 00:16:27,293
flat if you look at it close enough.

329
00:16:27,503 --> 00:16:32,003
So zoom in and zoom in and zoom in,
and suddenly it becomes a flat line.

330
00:16:32,183 --> 00:16:33,743
It doesn't mean you're getting worse.

331
00:16:34,163 --> 00:16:38,423
So when I say zoom in, I mean get
down to a really small change.

332
00:16:38,633 --> 00:16:41,603
I'd like to go back to what you're
saying, uh, you opened up the

333
00:16:41,603 --> 00:16:45,644
conversation about, about motivation,
uh, and, and why would I do this?

334
00:16:45,729 --> 00:16:49,814
I, I think we are motivated to do things
when we are likely to be successful.

335
00:16:50,139 --> 00:16:52,579
And, uh, what that means is.

336
00:16:53,179 --> 00:16:57,439
Your first elements at achieving
change, and especially in a high

337
00:16:57,439 --> 00:17:01,969
risk environment, should be as
small as you can possibly make it.

338
00:17:02,299 --> 00:17:06,499
Now, I think there's something again
that, uh, clashes with the heroic model

339
00:17:06,499 --> 00:17:07,999
of leadership that healthcare has.

340
00:17:08,269 --> 00:17:11,359
We do this and I've saved a hundred lives
and this is wonderful and the whole line.

341
00:17:11,679 --> 00:17:16,069
A, actually, um, let's talk
about, um, where we put the

342
00:17:16,069 --> 00:17:17,389
prescriptions in the morning.

343
00:17:17,735 --> 00:17:22,805
Uh, one of our practice managers, bless
him, getting top of the leaderboard on, on

344
00:17:23,135 --> 00:17:25,535
saving a, a day, a week of reception time.

345
00:17:26,075 --> 00:17:27,935
And, and that's pretty cool, really.

346
00:17:28,145 --> 00:17:29,885
And everyone's going,
what was your secret?

347
00:17:30,125 --> 00:17:30,425
What, what?

348
00:17:30,605 --> 00:17:31,685
Tell us the secret sauce.

349
00:17:31,685 --> 00:17:34,325
If we can bottle this and sell
it, we'll all be rich and famous.

350
00:17:34,415 --> 00:17:34,835
Yeah.

351
00:17:35,015 --> 00:17:36,275
I, I moved the fax machine.

352
00:17:36,335 --> 00:17:36,995
Dates the story.

353
00:17:37,175 --> 00:17:39,755
I moved the fax machine from the
third, floor down to the first floor.

354
00:17:40,025 --> 00:17:42,935
It's not sexy, it's not
glamorous, it's not exciting.

355
00:17:43,115 --> 00:17:45,695
It just involves, let's have
a little think about what

356
00:17:45,695 --> 00:17:47,435
we're doing and let's do, its.

357
00:17:47,670 --> 00:17:50,040
So achieve those wins,
don't drop the ball.

358
00:17:50,040 --> 00:17:52,440
This is not the time for
the long ambitious pass.

359
00:17:52,592 --> 00:17:53,072
It's interesting.

360
00:17:53,072 --> 00:17:58,112
I've got a friend who an A&E consultant,
and she said, if, if the trust would

361
00:17:58,112 --> 00:18:03,482
just employ one person to keep the
cupboards stocked up, so I didn't have

362
00:18:03,482 --> 00:18:09,092
to go to five different consulting
rooms to find enough equipment to put

363
00:18:09,092 --> 00:18:13,892
in a chest drain or, or, or do this,
it would be everything much better.

364
00:18:13,892 --> 00:18:15,032
But then that is quite a big thing.

365
00:18:15,032 --> 00:18:16,202
You'll employ someone or whatever.

366
00:18:16,202 --> 00:18:20,577
So how would she make a tiny, how would
you start with a tiny thing there?

367
00:18:21,169 --> 00:18:24,259
Uh, we call that five s, and I
can't do it off the top of my head.

368
00:18:24,349 --> 00:18:29,749
It's something like sort, standardize,
shine and something, and I've got.

369
00:18:29,869 --> 00:18:33,709
And it's uh, and I went through a phase
of being really grumpy going, why a

370
00:18:33,709 --> 00:18:38,539
highly paid consultants sorting out
things because very highly paid clinicians

371
00:18:38,779 --> 00:18:40,759
are wasting time looking for stuff.

372
00:18:41,356 --> 00:18:44,656
And I, we started to use that much
more when we were talking about

373
00:18:44,656 --> 00:18:49,786
bringing, uh, new, um, federations
together and larger multi-site working.

374
00:18:50,056 --> 00:18:53,176
As the story I tell my mate who's a
jet two captain, he doesn't get into

375
00:18:53,176 --> 00:18:56,626
a 7, 5, 7 and go, Hmm, I wonder where
they put the throttles on this one.

376
00:18:56,641 --> 00:18:57,601
There are enough butter here

377
00:18:57,676 --> 00:19:01,666
Yeah, Yeah,  But, but
somehow that's acceptable.

378
00:19:01,906 --> 00:19:06,226
And I think it goes back to that
time about, which many doctors are

379
00:19:06,226 --> 00:19:09,106
very sniffy about valuing time.

380
00:19:09,926 --> 00:19:12,116
When they put it in pound,
shillings and pence, somehow

381
00:19:12,116 --> 00:19:13,796
that's the nasty commercial.

382
00:19:13,976 --> 00:19:17,726
But when it's not going home
on time, then that's valid.

383
00:19:17,726 --> 00:19:19,706
But actually it's the same thing.

384
00:19:19,886 --> 00:19:23,666
And so you've given us a lovely
example there of wasting time.

385
00:19:24,086 --> 00:19:28,226
A a lot of the work we do, um,
people, uh, at the end of it a are

386
00:19:28,226 --> 00:19:29,966
delighted I would say that wouldn't I?

387
00:19:30,176 --> 00:19:35,426
But we are really pleased that, uh, 70%
of the practices we work in say don't go.

388
00:19:35,516 --> 00:19:37,076
We're in them up for up to six months.

389
00:19:37,196 --> 00:19:38,306
And they say, you've got to come.

390
00:19:38,336 --> 00:19:40,706
You just don't go, not come
back later, just don't go.

391
00:19:41,126 --> 00:19:45,176
But, but they will be going, when's
the really, really clever stuff?

392
00:19:45,416 --> 00:19:49,976
The clever stuff that's so clever that
I as having practiced medicines for

393
00:19:49,976 --> 00:19:52,016
15 years couldn't work out for myself.

394
00:19:52,436 --> 00:19:54,356
Well, all you had to do was
study improvement science

395
00:19:54,356 --> 00:19:55,520
for a month and you'd got it.

396
00:19:55,778 --> 00:19:57,398
But you studied medicine 15 years.

397
00:19:57,458 --> 00:19:59,168
That means you don't know it.

398
00:19:59,318 --> 00:20:00,278
So, but that's okay.

399
00:20:00,638 --> 00:20:02,018
You are not actually
supposed to know everything.

400
00:20:02,078 --> 00:20:02,618
Yes, I am.

401
00:20:02,618 --> 00:20:03,218
I'm a GP.

402
00:20:03,308 --> 00:20:05,258
I'm supposed to know everything
that walks through the door.

403
00:20:05,378 --> 00:20:06,608
I run my own business.

404
00:20:06,938 --> 00:20:08,438
Nah, that's not gonna work very well.

405
00:20:08,754 --> 00:20:12,864
So what do we, what is the thing that
you learned in that month that you hadn't

406
00:20:12,864 --> 00:20:14,514
learned in 15 years of general practice?

407
00:20:14,688 --> 00:20:19,878
We, our shortcuts are, we have
great questions and we tend to

408
00:20:19,878 --> 00:20:22,638
ask, but not always questions,
knowing what the answer is.

409
00:20:22,878 --> 00:20:26,028
And people will say, how that
earth, did you know that you've

410
00:20:26,028 --> 00:20:27,258
only been in the building an hour?

411
00:20:27,588 --> 00:20:30,618
Because it's the same as the other
500 practices we've been in this year.

412
00:20:31,018 --> 00:20:34,858
And then we have other tools and
techniques about what I would say is

413
00:20:34,858 --> 00:20:39,958
making visible what's currently invisible
so that smart people make smart choices.

414
00:20:40,288 --> 00:20:43,828
So going back a decade, when we first
started doing this in my own practice,

415
00:20:43,828 --> 00:20:46,738
we closed the practice and it dates
it because we had green prescription

416
00:20:46,738 --> 00:20:49,888
cards, we spent hours chasing green
prescriptions around the place.

417
00:20:50,308 --> 00:20:52,508
And then my head receptionist
stands up and goes.

418
00:20:52,508 --> 00:20:56,018
And then we read the, we, we look
at the prescription request and we

419
00:20:56,018 --> 00:20:58,148
open the letter from the last clinic.

420
00:20:58,388 --> 00:21:00,698
And the doctors all go, oh no.

421
00:21:01,238 --> 00:21:04,268
And the head receptionist goes, uhoh,
this is gonna lose trouble later.

422
00:21:04,328 --> 00:21:05,288
What have I done?

423
00:21:05,858 --> 00:21:07,408
And the docs say, we do that.

424
00:21:07,956 --> 00:21:10,021
And the, we suddenly make this visible.

425
00:21:10,021 --> 00:21:13,201
So the smart people go, okay, I'm
not sure we both need to do it.

426
00:21:13,531 --> 00:21:14,821
Which one of us should we do it?

427
00:21:14,941 --> 00:21:17,161
So that would give you
an example of a choice.

428
00:21:17,311 --> 00:21:19,921
I choose to do this, or I choose
to ask my receptionist do it, or my

429
00:21:19,921 --> 00:21:22,503
receptionist choose to ask me to do
it, to, to get us where we need to be.

430
00:21:22,503 --> 00:21:24,063
So we, we've saved a minute.

431
00:21:24,543 --> 00:21:28,563
Uh, and again, in the process change
work we do in practice, um, I would say

432
00:21:28,563 --> 00:21:31,863
haven't had a chance to say it recently,
we won't find anything that will get you

433
00:21:31,863 --> 00:21:36,483
home 45 minutes early, but I'll put good
money on the fact we'll find 45 things

434
00:21:36,483 --> 00:21:37,623
that'll get you home a minute early.

435
00:21:37,923 --> 00:21:42,783
And we have certainly come across teams
where we have had to say sorry, they, they

436
00:21:42,783 --> 00:21:44,523
don't have the capacity to do the change.

437
00:21:45,003 --> 00:21:47,103
You and I have agreed earlier,
and we'll continue to agree.

438
00:21:47,133 --> 00:21:48,183
It requires effort.

439
00:21:48,483 --> 00:21:49,383
There's no fuel in the tank.

440
00:21:49,383 --> 00:21:51,693
There's no fuel in the tank and no can do.

441
00:21:51,857 --> 00:21:55,607
Yeah, no, and I think, I think the problem
is yes, that the workforce is really

442
00:21:55,607 --> 00:21:57,317
heading towards collective burnout.

443
00:21:57,317 --> 00:22:01,547
And actually we've had a, a survey,
um, reported by some, someone we

444
00:22:01,547 --> 00:22:02,807
worked, they surveyed their doctors.

445
00:22:02,807 --> 00:22:06,047
50, 50% of them are working
actually in burnout.

446
00:22:06,437 --> 00:22:11,427
However, I think the people that are not
in burnout that would say, yeah, actually

447
00:22:11,427 --> 00:22:14,367
if I had to put a little bit more to,
I don't have any time, but I could find

448
00:22:14,367 --> 00:22:17,967
that if, if I knew it was going to be
better, I think there are people that

449
00:22:17,967 --> 00:22:22,527
are motivated to do that, particularly
as they spend so much time doing, doing

450
00:22:22,527 --> 00:22:26,787
just busy work that actually doesn't
move the needle on anything anyway.

451
00:22:27,377 --> 00:22:30,686
But it, it's very difficult when,
when, when the perception is that

452
00:22:30,686 --> 00:22:33,476
there's no money in the system and
there's no more people in the system,

453
00:22:33,476 --> 00:22:37,196
it's very difficult to work out
well then what changes could occur.

454
00:22:37,196 --> 00:22:39,656
Because when I say to people,
you know, if you wave a white

455
00:22:39,656 --> 00:22:40,586
magic wand, what would happen?

456
00:22:40,586 --> 00:22:43,526
It's always what I get more funding, I
get more resources, I get more people.

457
00:22:43,922 --> 00:22:46,732
But maybe that's just, if you limit
yourself to things can only change.

458
00:22:46,732 --> 00:22:49,192
If that's what I get, then presumably
you're missing out on a, on an

459
00:22:49,192 --> 00:22:52,552
awful lot that could change without
necessarily needing more money or

460
00:22:52,767 --> 00:22:55,762
I, I, I put it to you in the,
in the spirit of debate, that

461
00:22:55,762 --> 00:22:56,812
that's actually not a change.

462
00:22:56,902 --> 00:22:57,772
That's just more of the same.

463
00:22:57,945 --> 00:23:00,345
Um, and, and what, what we
are talking about is changing.

464
00:23:00,525 --> 00:23:05,505
So we go back to that, that implicit
sentence, how do I do things differently?

465
00:23:05,801 --> 00:23:08,964
Well, what do you do is stop
doing stuff that's wasting time.

466
00:23:09,354 --> 00:23:11,364
How do I identify that?

467
00:23:11,409 --> 00:23:14,864
You, you, you use some tools and
techniques to surface what's going on.

468
00:23:14,864 --> 00:23:17,294
You heard my example about
talking to your colleagues.

469
00:23:17,294 --> 00:23:18,374
Are you duplicating work?

470
00:23:18,494 --> 00:23:19,994
Stop duplicating work.

471
00:23:20,369 --> 00:23:24,768
But that's a systematic review of what's
going on and it's what the engineers

472
00:23:24,768 --> 00:23:26,298
would call catastrophic failure, isn't it?

473
00:23:26,298 --> 00:23:29,418
Is each little failure cause more
strain on the next part of the system

474
00:23:29,418 --> 00:23:30,738
which caused the next bit to go down.

475
00:23:30,902 --> 00:23:33,387
And so many people working in, in
so many very, very different ways.

476
00:23:33,427 --> 00:23:37,238
I, I have a friend who had a sort of
salary job at two different practices.

477
00:23:37,398 --> 00:23:39,798
Pretty much the same area, pretty
much the same demographics.

478
00:23:39,798 --> 00:23:41,538
One was hugely stressful to work in.

479
00:23:41,538 --> 00:23:44,920
One was a joy to work in, and
the difference was just in the

480
00:23:44,920 --> 00:23:47,440
way that they did things and
the way they organized things.

481
00:23:47,540 --> 00:23:49,820
But again, it is down to time
and it's down to somebody who

482
00:23:49,820 --> 00:23:51,740
has the wherewithal to do it.

483
00:23:51,740 --> 00:23:54,680
And that's why people think,
I feel that they can't do it,

484
00:23:54,680 --> 00:23:55,580
and they feel really helpless.

485
00:23:55,762 --> 00:23:59,392
I'm gonna change your language, I think,
uh, and say it is down to time, of course,

486
00:23:59,572 --> 00:24:02,212
but, but time is only a unit of currency.

487
00:24:02,302 --> 00:24:04,282
You talk about investment,
it's a matter of investment.

488
00:24:04,522 --> 00:24:08,662
Um, back in the old days I used to chair
a finance and audit subcommittee with PCG.

489
00:24:08,932 --> 00:24:12,398
The director of finance there, who,
who's my management oppo, uh, said

490
00:24:12,398 --> 00:24:16,058
something which has really stuck with
me is money is a currency, Richard.

491
00:24:16,208 --> 00:24:18,368
You swap it for useful things like nurses.

492
00:24:18,725 --> 00:24:20,111
You keep saying you want more money.

493
00:24:20,381 --> 00:24:22,001
What is it you want to swap it for?

494
00:24:22,152 --> 00:24:27,069
Now, most people who are educated
by their experience and experiential

495
00:24:27,069 --> 00:24:30,745
learning will sort of go, well,
more of this, because it's all

496
00:24:30,745 --> 00:24:32,005
they've got in their mental model.

497
00:24:32,202 --> 00:24:35,352
Yeah, there's nothing like
going to actually see it.

498
00:24:35,352 --> 00:24:38,502
And, and I think, you know, when some
work with sort of PCN directors and

499
00:24:38,502 --> 00:24:41,562
things like that saying, well, we
can't get this practice involved, and

500
00:24:41,562 --> 00:24:43,632
they, they're on board with this and
whatever, and we said, well, what did

501
00:24:43,632 --> 00:24:44,922
they say when you spoke to them about it?

502
00:24:45,222 --> 00:24:46,632
Oh, well we, we haven't done that.

503
00:24:46,752 --> 00:24:48,162
They just don't come
to any of our meetings.

504
00:24:48,162 --> 00:24:50,562
Like, why have we actually
gone into their practice?

505
00:24:50,562 --> 00:24:52,662
Said, show me what it's like round here.

506
00:24:53,052 --> 00:24:54,312
Show me what's going on.

507
00:24:54,462 --> 00:24:57,522
Not let alone just seeing what's
happening, but there's that building

508
00:24:57,522 --> 00:24:59,232
relationships, there's that touch point.

509
00:24:59,354 --> 00:25:01,739
And, and haven't you gone
back, I think there and touched

510
00:25:01,739 --> 00:25:02,939
on what we talk about power.

511
00:25:02,954 --> 00:25:06,494
The hypothetical PCN director was
just assuming that their expertise

512
00:25:06,494 --> 00:25:10,844
was so respected that all they had
to do was say something and, and the

513
00:25:10,844 --> 00:25:15,459
power and authority, uh, that that
necessary was just self-evident.

514
00:25:15,602 --> 00:25:16,916
And why aren't they doing it?

515
00:25:16,916 --> 00:25:17,816
I've told 'em twice now.

516
00:25:17,816 --> 00:25:19,046
What, what is it they're not getting?

517
00:25:19,046 --> 00:25:20,246
Shall I email them as well?

518
00:25:20,306 --> 00:25:21,896
Shall I tell them the same thing again?

519
00:25:22,376 --> 00:25:23,816
Well, probably not.

520
00:25:24,102 --> 00:25:26,602
What we didn't say when we had talked
about power is, power can never

521
00:25:26,602 --> 00:25:28,492
be, um, never be bought or gained.

522
00:25:28,492 --> 00:25:29,242
It can only be given.

523
00:25:29,567 --> 00:25:32,177
I can, I can only give you
authority over my actions.

524
00:25:32,355 --> 00:25:34,965
Even hierarchical power,
I choose to accept.

525
00:25:35,241 --> 00:25:38,391
I always think though, that with power,
people say, oh, I haven't got the

526
00:25:38,391 --> 00:25:39,621
hierarchy, I haven't got the power.

527
00:25:39,621 --> 00:25:42,651
Well, you know, if you're having to
invoke the hierarchy, you've lost the,

528
00:25:42,741 --> 00:25:43,971
you've lost the battle, haven't you?

529
00:25:44,331 --> 00:25:48,020
If the only way you can invade hierarchy
is putting somebody in jail or saying, I,

530
00:25:48,020 --> 00:25:50,390
you know, I, you do it 'cause I said, so.

531
00:25:50,420 --> 00:25:53,549
I mean, you've lost, because yes,
that person might do that tiny thing,

532
00:25:53,549 --> 00:25:55,379
but they're not gonna do anything
else that you need them to do.

533
00:25:55,589 --> 00:25:59,549
There are very rare, uh, a certain
when it, that is the right thing to do.

534
00:25:59,759 --> 00:26:04,499
Um, I, the, and I think your, we, we, we
talked yesterday when we talked a little

535
00:26:04,499 --> 00:26:06,329
bit about different styles of leadership.

536
00:26:06,629 --> 00:26:10,229
So if we took, go back to power for
a moment and we talk about power

537
00:26:10,229 --> 00:26:13,739
as the ability to get an individual
or an organization to do something

538
00:26:13,739 --> 00:26:16,994
it wouldn't otherwise have done,
so, and, and we can talk about

539
00:26:17,144 --> 00:26:18,704
whether that's control or influence.

540
00:26:18,734 --> 00:26:19,364
Not helpful.

541
00:26:19,424 --> 00:26:20,714
Let's just talk about it as power.

542
00:26:20,894 --> 00:26:24,914
And we've mentioned the five power basis,
reward power, coercive power, charismatic

543
00:26:24,914 --> 00:26:26,864
power, legitimate power and expert power.

544
00:26:27,524 --> 00:26:31,604
Uh, but then I flip that round and I,
because we talk about leadership and,

545
00:26:31,604 --> 00:26:35,599
and I say that leaders are people that
deploy power, and, and they can use

546
00:26:35,599 --> 00:26:37,549
a multitude of, of, of those skills.

547
00:26:37,729 --> 00:26:41,089
And we've hinted in when we talked
about this, uh, in this hypothetical

548
00:26:41,089 --> 00:26:45,229
PCN director that was having challenge,
they were not making any attempt

549
00:26:45,229 --> 00:26:46,609
to pull down the charismatic power.

550
00:26:46,849 --> 00:26:49,519
They didn't drive over
there and say, please,

551
00:26:49,641 --> 00:26:49,861
Yes,

552
00:26:50,331 --> 00:26:50,841
They did.

553
00:26:51,231 --> 00:26:53,481
They didn't drive over there
and say, look, there, there's

554
00:26:53,481 --> 00:26:54,771
a RS funding coming through.

555
00:26:54,771 --> 00:26:57,441
If you do this, there's a
big apply slice the cake.

556
00:26:57,561 --> 00:26:58,341
Reward power.

557
00:26:58,461 --> 00:27:00,441
They didn't do any negotiating.

558
00:27:00,841 --> 00:27:03,121
I think another way of looking at
what we talked about, the way doctors

559
00:27:03,121 --> 00:27:06,361
behave is, at the risk of alienating
the whole profession in one half hour,

560
00:27:06,691 --> 00:27:10,471
um, I think there is something about
their behavior that they think they're

561
00:27:10,501 --> 00:27:12,061
always within their zone of control.

562
00:27:12,826 --> 00:27:16,186
And actually the only zone of
control is controlling everything

563
00:27:16,186 --> 00:27:17,146
they say and everything they do.

564
00:27:17,363 --> 00:27:18,653
That is absolutely it.

565
00:27:18,803 --> 00:27:21,173
Everything else, they're trying
in their zone of influence.

566
00:27:21,372 --> 00:27:24,732
And if they're looking at influence, they
need to just chew the end of the pencil,

567
00:27:24,732 --> 00:27:28,015
have a cup of tea, glass of scotch, stare
at the wall and go, I know it sounds

568
00:27:28,015 --> 00:27:31,315
incredibly negative, but we've discussed
saying, please, is a cool thing to do.

569
00:27:31,765 --> 00:27:35,275
What can I do to influence the
people I need to influence?

570
00:27:35,485 --> 00:27:38,215
Clearly, before you do that, you need
to work out who you need to influence.

571
00:27:38,485 --> 00:27:41,005
So if you stay to doctors, you
have you done stakeholder mapping?

572
00:27:41,005 --> 00:27:42,565
They go, oh, it's all manageable bullshit.

573
00:27:42,826 --> 00:27:46,172
Um, but then you go, well, okay,
how's this going to work then?

574
00:27:46,232 --> 00:27:47,372
Well, I'm just gonna tell 'em to do it.

575
00:27:47,462 --> 00:27:48,572
Well, that's not gonna work, is it?

576
00:27:48,572 --> 00:27:49,682
How well has that gone so far?

577
00:27:50,012 --> 00:27:51,032
Uh, it hasn't worked at all.

578
00:27:51,122 --> 00:27:52,322
Should we do something different?

579
00:27:52,322 --> 00:27:52,622
No.

580
00:27:53,015 --> 00:27:57,475
And so a lot of the work I do is raising
cognitive dissonance with people.

581
00:27:57,550 --> 00:28:02,681
I, I have to make them say mutually
contradictory sentences, phrases

582
00:28:02,681 --> 00:28:05,891
within the same sentence, and then
I go and have a cup of tea and

583
00:28:05,891 --> 00:28:07,211
work out how they're going to.

584
00:28:07,451 --> 00:28:10,061
And what that often means is they have to
prioritize something in their own mind.

585
00:28:10,456 --> 00:28:14,101
I, I, I, I remember doing some team
coaching for a practice a long time

586
00:28:14,101 --> 00:28:17,901
ago, and the practice manager was at
the end of her tether and I doing a

587
00:28:17,901 --> 00:28:20,891
sort of one-to-one coaching with her,
and she's going we really need some

588
00:28:20,891 --> 00:28:24,841
new nurses 'cause we're not hearing our
QOF targets um, for, for vaccinations,

589
00:28:24,841 --> 00:28:26,231
you know, we are, we are short staffed.

590
00:28:26,231 --> 00:28:29,141
But I keep asking the partners
and they just keep going, oh,

591
00:28:29,141 --> 00:28:30,401
we'll think about it later.

592
00:28:30,401 --> 00:28:31,121
We'll think about it later.

593
00:28:31,121 --> 00:28:33,071
Said, I really need a decision
on this 'cause they're not

594
00:28:33,071 --> 00:28:33,761
gonna be at the targets.

595
00:28:33,761 --> 00:28:35,441
I said, well, what have you told them?

596
00:28:35,441 --> 00:28:37,571
She said, well, in the practice
meeting I say, the staff are already

597
00:28:37,571 --> 00:28:40,331
overworked, you know, we need
somebody else, blah, blah, blah.

598
00:28:40,331 --> 00:28:43,481
I said, well, what, you know your
senior partner, what, what's his,

599
00:28:43,541 --> 00:28:45,341
what's he really motivated by?

600
00:28:45,341 --> 00:28:48,371
And she said, well actually he's
really worried about practice finances.

601
00:28:48,791 --> 00:28:50,951
I said, have you gone to him and
told them how much money you're

602
00:28:50,951 --> 00:28:52,391
gonna lose if you don't hit targets?

603
00:28:52,725 --> 00:28:53,585
Oh no, . Did.

604
00:28:53,645 --> 00:28:55,475
They got a new nurse next week.

605
00:28:55,985 --> 00:28:59,825
So we, we, that's a really tangible
thing, but also doctors think, well,

606
00:28:59,825 --> 00:29:02,795
there's no point because I've given
them it, it's a logical decision and,

607
00:29:02,795 --> 00:29:06,165
and, and maybe there's not a lot in
it for them logically, but I remember

608
00:29:06,165 --> 00:29:09,255
hearing about something about the stock
market, about, you know, the stock E

609
00:29:09,285 --> 00:29:13,245
even sort of stockbrokers, financial
traders, they make decisions largely

610
00:29:13,245 --> 00:29:18,555
based on emotions and feelings, not
really on, on, on any actual logics.

611
00:29:18,675 --> 00:29:22,035
If they do that, then, then there's
no hope for the rest of us being

612
00:29:22,035 --> 00:29:23,385
vaguely logical, is there really?

613
00:29:23,618 --> 00:29:26,583
So there's, there's, there's place
for both But I think what we do as

614
00:29:26,583 --> 00:29:30,483
doctors is forget the place of the, the
non-logical stuff and the, the emotions

615
00:29:30,844 --> 00:29:33,004
Well, and, and selfishness self-interest.

616
00:29:33,138 --> 00:29:33,948
Yes.

617
00:29:34,078 --> 00:29:40,858
get very, it's somehow considered infra
dig to think about who's important in our

618
00:29:40,858 --> 00:29:47,673
little world and work out what works for
them if we don't judge that as being of.

619
00:29:48,003 --> 00:29:49,893
I don't know what the word is, purity?

620
00:29:49,923 --> 00:29:50,673
Virtue?

621
00:29:51,091 --> 00:29:51,481
You know?

622
00:29:51,691 --> 00:29:51,931
Oh.

623
00:29:51,931 --> 00:29:54,181
It means that the organization
will make more money.

624
00:29:54,211 --> 00:29:56,361
Ah, now I exaggerate, of
course, the purpose discussion.

625
00:29:56,511 --> 00:29:57,381
I'm very pure.

626
00:29:57,381 --> 00:29:58,341
I don't care about money.

627
00:29:58,680 --> 00:30:01,170
And I had a terrible run in
with all my dear friends.

628
00:30:01,380 --> 00:30:03,720
We were talk about setting up
an X-ray department in rural

629
00:30:03,720 --> 00:30:05,550
Kenya as a charity with support.

630
00:30:05,820 --> 00:30:07,860
And I'm going, what's the business case?

631
00:30:07,860 --> 00:30:10,380
And he's going, oh, you're always talking
about bloody money these days, Richard.

632
00:30:10,380 --> 00:30:10,620
Really?

633
00:30:10,620 --> 00:30:11,040
I don't know.

634
00:30:11,400 --> 00:30:11,940
Okay, fine.

635
00:30:11,940 --> 00:30:13,500
So we had that, I had
another glass of beer.

636
00:30:13,860 --> 00:30:17,400
And I, and I go back and say, so, so
how many patients are we gonna see?

637
00:30:17,640 --> 00:30:18,480
Ooh, I think a dozen.

638
00:30:18,480 --> 00:30:19,470
What's this gonna save them?

639
00:30:19,590 --> 00:30:22,410
Well, a, a trip, four hour trip
to the nearest hospital, eh?

640
00:30:22,590 --> 00:30:23,880
So this is the business case.

641
00:30:23,925 --> 00:30:25,155
He goes, no.

642
00:30:25,495 --> 00:30:28,825
Uh, and, and, and, and it's just, Wayne
introduced to the concept of that, that

643
00:30:28,945 --> 00:30:33,085
the idea of a business case he did not
view as virtuous and was not gonna engage.

644
00:30:33,365 --> 00:30:36,545
And the problem is that people are always
thinking about what's in it for me.

645
00:30:37,114 --> 00:30:39,784
Always like is that if it's not
about how much money is it, it's

646
00:30:39,784 --> 00:30:41,284
like how much extra work is it?

647
00:30:41,314 --> 00:30:42,904
'cause money and, and time is money.

648
00:30:42,904 --> 00:30:44,794
And so, but they can't say that.

649
00:30:44,914 --> 00:30:47,944
So then they'll come up with
all sorts of other reasons that

650
00:30:47,944 --> 00:30:50,764
are more virtuous and pure about
good for the patients and stuff.

651
00:30:50,764 --> 00:30:53,254
But actually what's underlying
it is like, I don't wanna work

652
00:30:53,254 --> 00:30:56,374
extra, I want a better work life
balance, or I, I need more income.

653
00:30:56,374 --> 00:30:58,062
And that is the problem.

654
00:30:58,062 --> 00:31:01,722
You know, with, with all, with all this
stuff, whether it's the NHS, whether

655
00:31:01,722 --> 00:31:05,652
you're a charity or a B Corporation
or just an organization trying to

656
00:31:05,652 --> 00:31:10,973
make ends meet, you need money to pay
your staff to have any sort of impact.

657
00:31:11,108 --> 00:31:11,918
In this world.

658
00:31:11,948 --> 00:31:12,338
Yes,

659
00:31:12,496 --> 00:31:12,863
this world.

660
00:31:13,178 --> 00:31:16,448
in this world, other worlds may be
different, but in this world, yes.

661
00:31:16,658 --> 00:31:19,838
Yeah, but it, but it's only a
currency and we swap it for time.

662
00:31:19,978 --> 00:31:20,548
Yes.

663
00:31:20,548 --> 00:31:21,268
Totally.

664
00:31:21,380 --> 00:31:25,040
so it's both totally
unimportant and completely utter

665
00:31:25,040 --> 00:31:26,870
important at the same time.

666
00:31:26,917 --> 00:31:27,065
Yes.

667
00:31:27,155 --> 00:31:28,925
If you don't acknowledge it, it's not

668
00:31:29,030 --> 00:31:29,360
Hmm.

669
00:31:29,735 --> 00:31:30,100
It's not gonna work.

670
00:31:30,500 --> 00:31:31,880
And, and then you surface down.

671
00:31:31,880 --> 00:31:35,270
I mean, I'm, I'm, I'm your experience,
this area is greater than mine, but I've

672
00:31:35,270 --> 00:31:37,580
seen some fantastic say yes and do nos.

673
00:31:37,750 --> 00:31:37,960
Oh, yeah,

674
00:31:38,630 --> 00:31:42,080
They, I mean, and that's the problem
with working with smart people.

675
00:31:42,080 --> 00:31:44,570
You go, how did you get
there in only four steps?

676
00:31:44,900 --> 00:31:45,860
That's amazing.

677
00:31:46,130 --> 00:31:49,190
A and, and, and what would, it's
classic media training that's

678
00:31:49,190 --> 00:31:51,110
surfacing, uh, and hiding the root.

679
00:31:51,275 --> 00:31:54,320
And, and I'm sure you use root cause
analysis in five whys more than I do,

680
00:31:54,710 --> 00:31:59,178
but it can get quite tense, making
people say what's really driving them.

681
00:31:59,478 --> 00:32:00,618
And then there's the cathars.

682
00:32:00,618 --> 00:32:03,198
There's actually, the world doesn't
stop turning when someone says, I'd

683
00:32:03,198 --> 00:32:04,488
like to earn more money next year.

684
00:32:04,668 --> 00:32:06,048
The world still keeps turning.

685
00:32:06,168 --> 00:32:07,308
Okay, let's work on that then.

686
00:32:07,428 --> 00:32:07,878
How much?

687
00:32:07,878 --> 00:32:08,478
Yeah, absolutely.

688
00:32:08,523 --> 00:32:11,298
And, and that's the whole basis,
the length only five dysfunctions

689
00:32:11,298 --> 00:32:13,068
of a team, which I just love.

690
00:32:13,068 --> 00:32:16,398
And it's so helpful 'cause there's
not enough conflict in teams in the

691
00:32:16,398 --> 00:32:19,518
NHS, there's a lot of conflict between
different teams, but not within teams.

692
00:32:19,518 --> 00:32:23,763
We do not like raising issues that
we think are gonna, well, they're

693
00:32:23,898 --> 00:32:26,298
gonna make us uncomfortable, might
make someone else uncomfortable.

694
00:32:26,298 --> 00:32:29,478
And if you don't raise it, you can't get,
um, consent, you can't get commitment,

695
00:32:29,478 --> 00:32:31,818
then you can't get accountability, then
you don't get the results that you need.

696
00:32:31,906 --> 00:32:32,956
I can't agree with you more.

697
00:32:32,961 --> 00:32:36,706
And, and I'm smiling because last week
my director of finance says, right,

698
00:32:36,771 --> 00:32:39,406
we, we need to have a different con
difficult conversation with this person

699
00:32:39,406 --> 00:32:41,716
and actually with the relationship,
Richard, you are the person to do it.

700
00:32:42,256 --> 00:32:45,166
And by the way, you'll it 'cause
you'll rubbish a conflict.

701
00:32:45,556 --> 00:32:47,266
And I go highly trained professional.

702
00:32:47,416 --> 00:32:49,426
I don't know how you can say such a thing.

703
00:32:49,835 --> 00:32:52,505
Retired after the meeting, cup of
tea in the game, inside the kitchen.

704
00:32:52,505 --> 00:32:52,625
Go.

705
00:32:52,865 --> 00:32:54,125
I'm just gonna wind down from that.

706
00:32:54,395 --> 00:32:56,621
I, I, I was appalled how bad I was at it.

707
00:32:56,780 --> 00:32:57,500
We are all for that.

708
00:32:57,500 --> 00:33:00,680
I had to have a very difficult
conversation with someone a few

709
00:33:00,680 --> 00:33:03,470
months ago where I was essentially
having to, to let them go.

710
00:33:03,890 --> 00:33:06,860
My Apple Watch, actually it
was a while ago, uh, my Apple

711
00:33:06,860 --> 00:33:08,150
watch, it was five minutes.

712
00:33:08,150 --> 00:33:08,930
I was preparing for it.

713
00:33:08,930 --> 00:33:10,490
How can I do this compassionately?

714
00:33:10,760 --> 00:33:13,280
Whether writing it all out,
thinking, what do I wanna say, what

715
00:33:13,280 --> 00:33:14,420
do I wanna make sure I get across.

716
00:33:14,690 --> 00:33:17,240
My Apple Watch had alert,
alert call 9, 9, 9.

717
00:33:17,360 --> 00:33:18,680
I've detected a pulse rise.

718
00:33:18,680 --> 00:33:19,370
It's not normal.

719
00:33:20,750 --> 00:33:21,770
I teach this stuff.

720
00:33:21,830 --> 00:33:23,990
We go around teaching it, but
it doesn't mean that you don't.

721
00:33:24,050 --> 00:33:24,830
And then still did it.

722
00:33:24,830 --> 00:33:26,396
And actually it was
better than we thought.

723
00:33:26,396 --> 00:33:29,366
My colleague said, Sarah Coope, who
you know very well, uh, Richard,

724
00:33:29,726 --> 00:33:34,466
she always says, you know, we, we
underestimate the impact of not having

725
00:33:34,466 --> 00:33:38,126
the conversation and we overestimate
the impact of having the conversation.

726
00:33:38,456 --> 00:33:44,096
And often that's one of my overwhelm
amplifiers for, for doctors is we are so

727
00:33:44,096 --> 00:33:46,466
conflict avoidant that we don't have it.

728
00:33:46,466 --> 00:33:47,606
We don't have it, we don't have it.

729
00:33:47,606 --> 00:33:50,966
And eventually we have it and it all
goes pear shaped 'cause it's built up

730
00:33:51,236 --> 00:33:54,146
and or we haven't had the, and and of
course there's problems for everybody.

731
00:33:54,146 --> 00:33:56,726
It would've been so much quicker
and easier just to have had that

732
00:33:56,726 --> 00:33:58,706
conversation at, at the beginning.

733
00:33:58,979 --> 00:34:03,059
What one of my consultants, uh, said about
one practice, um, the problem with her is

734
00:34:03,059 --> 00:34:05,669
that doctors confuse their relationship
with their patients, with that, with

735
00:34:05,669 --> 00:34:07,319
their employees, and it doesn't work.

736
00:34:07,457 --> 00:34:10,397
Uh, and of course, uh, my
generation had from time to time

737
00:34:10,397 --> 00:34:13,577
and that, that, that raised a few
tensions is having your employees

738
00:34:13,577 --> 00:34:14,597
registered with you as a patient.

739
00:34:14,794 --> 00:34:19,269
You, you end up writing a sick note for
stress at work for your own organization.

740
00:34:19,449 --> 00:34:21,099
No conflicts of interest there are there.

741
00:34:22,102 --> 00:34:23,452
Oh my goodness, a hundred percent.

742
00:34:23,452 --> 00:34:27,472
So Richard, I, I a hundred percent agree
with everything, but I've got a lot of

743
00:34:27,742 --> 00:34:31,612
things in my head going, yes, but yes,
but yes, but yes, but okay, because I

744
00:34:31,612 --> 00:34:34,262
think it's, when we hear all this, we
go, yes, of course, yes, of course.

745
00:34:34,262 --> 00:34:35,552
You've gotta get to the motivation.

746
00:34:35,792 --> 00:34:40,266
Yes, of course I need to exert what work
out how I can exert this, this softer

747
00:34:40,266 --> 00:34:44,766
power that's not due to hierarchy and
all that, but either I'm too young,

748
00:34:44,766 --> 00:34:46,656
I'm a registrar in the department.

749
00:34:46,896 --> 00:34:48,066
You know, I had this at a conference.

750
00:34:48,066 --> 00:34:50,856
I was talking back, I was talking
about conflicts, and this registrar

751
00:34:50,856 --> 00:34:54,096
stood up and said, yes, but I need
to get a job next year in this

752
00:34:54,096 --> 00:34:55,716
department with these consultants.

753
00:34:55,746 --> 00:34:58,056
If I raise this issue, I'm
just not gonna get this job.

754
00:34:58,386 --> 00:35:03,576
Or, um, we, we just say, well, I,
I don't, I genuinely don't have the

755
00:35:03,576 --> 00:35:05,106
time, I don't even have five minutes.

756
00:35:05,106 --> 00:35:06,006
'cause we need burnout.

757
00:35:06,096 --> 00:35:12,186
Or, um, one thing, one pushback we
get a lot is a lot of change involves

758
00:35:12,186 --> 00:35:13,776
getting other people to do stuff.

759
00:35:14,226 --> 00:35:16,536
People go delegation,
they no one to delegate.

760
00:35:16,865 --> 00:35:19,115
end of story, there is no one to do that.

761
00:35:19,115 --> 00:35:21,905
So even if I wanted to, I couldn't do it.

762
00:35:22,265 --> 00:35:24,125
And like that's a big
conversation stopper.

763
00:35:24,125 --> 00:35:26,555
So how would you address those things?

764
00:35:26,555 --> 00:35:29,885
Because I think it's those things that
just leave us feeling really helpless.

765
00:35:29,885 --> 00:35:32,966
And that's what I'm,
observing in, in doctors.

766
00:35:32,966 --> 00:35:36,026
It's this feeling of
being completely stuck.

767
00:35:36,056 --> 00:35:38,036
'cause we think we've done
what's in our zone of power.

768
00:35:38,036 --> 00:35:40,736
We think we have tried to
control the controllables and

769
00:35:40,736 --> 00:35:42,356
it didn't get us very far.

770
00:35:42,691 --> 00:35:47,025
Well, I, I wouldn't want you to think
that, uh, everything I've said is

771
00:35:47,025 --> 00:35:49,305
a, is a, a surefire path to success.

772
00:35:49,395 --> 00:35:51,345
Uh, if, if success is
leading beneficial change.

773
00:35:51,645 --> 00:35:55,245
Um, but I think it puts you in a
position of being more likely to

774
00:35:55,245 --> 00:35:56,895
succeed than you were if you don't.

775
00:35:57,255 --> 00:35:59,535
And I think there was something,
uh, you were talking about there.

776
00:35:59,595 --> 00:36:03,465
Um, uh, because I've never been
purposeful, I've never been planful.

777
00:36:03,735 --> 00:36:07,155
Uh, and, and how I've got to where
I've got to is basically throwing

778
00:36:07,155 --> 00:36:10,905
myself at every door, collecting
a lot of bruises, and every now

779
00:36:10,905 --> 00:36:12,435
and then I've knocked one down.

780
00:36:12,585 --> 00:36:16,755
And I think what I never learned was that,
uh, uh, and, and I've got some words I've

781
00:36:16,755 --> 00:36:19,065
written down because I think the words
are, precision of words is important,

782
00:36:19,275 --> 00:36:24,445
that there is a difference purposeful
perseverance and blind persistence.

783
00:36:24,685 --> 00:36:26,905
And I think what I've done
a lot is blind persistence.

784
00:36:26,905 --> 00:36:30,835
And I would commonly say that, that I was
just too stupid to know and I was beaten.

785
00:36:31,195 --> 00:36:34,555
So I, I think I, I think we, we did
talk about planning your battles and

786
00:36:34,555 --> 00:36:38,245
I, and you know, if we've talked about
money as a currency, if we can also

787
00:36:38,245 --> 00:36:41,605
talk about power as a currency, we've
got to think about how we spend it.

788
00:36:41,875 --> 00:36:45,625
Uh, and if we keep on spending it
fruitlessly, we don't get anywhere.

789
00:36:46,045 --> 00:36:49,376
Um, but I think If that mid zone,
we've talked about an individual

790
00:36:49,376 --> 00:36:51,056
who's going change is difficult.

791
00:36:51,056 --> 00:36:55,196
I don't have a track record of success,
but I'm up for trying again, I might

792
00:36:55,196 --> 00:36:56,306
have time, I might have energy.

793
00:36:56,636 --> 00:37:01,316
I would counsel to go very
slowly and very thoughtfully.

794
00:37:01,826 --> 00:37:06,596
I think we've talked about wasted e um,
in process, we talk about waste in energy.

795
00:37:06,926 --> 00:37:10,196
We can think about that, that
power is a very scarce resort.

796
00:37:10,376 --> 00:37:13,346
Think very carefully about
how you are going to apply it.

797
00:37:13,856 --> 00:37:17,846
We talked about intuitive learning
going, does this likely to be successful?

798
00:37:17,846 --> 00:37:19,136
Does it, does it feel right?

799
00:37:19,376 --> 00:37:22,706
And of course, the more you
do, the better you get at it.

800
00:37:22,706 --> 00:37:25,016
You, you have your own
experience learning.

801
00:37:25,086 --> 00:37:26,426
You, you get a smell for it.

802
00:37:26,576 --> 00:37:29,436
And, and you can imagine people
like me in my stage of career,

803
00:37:29,436 --> 00:37:30,486
go, that's not gonna work.

804
00:37:30,846 --> 00:37:32,076
And reasonably colleagues go.

805
00:37:32,736 --> 00:37:33,366
Why not?

806
00:37:33,816 --> 00:37:35,976
Uh, and we've had to work
through the answer to that

807
00:37:35,976 --> 00:37:37,596
question is because I say so.

808
00:37:37,686 --> 00:37:39,876
No, it's not, that is not a good question.

809
00:37:39,876 --> 00:37:44,526
I say so, and I've had to say frequently
and I've got better at it with practice,

810
00:37:45,186 --> 00:37:48,816
um, hang on, give me five minutes
and I'll get back to you on that,

811
00:37:49,296 --> 00:37:53,916
because at the time of speaking, it's
that first order sort of reflection

812
00:37:53,916 --> 00:37:55,836
as Calvin talks about bang, bang.

813
00:37:56,344 --> 00:37:59,404
And, and then once we do the second
order stuff, we can then test as a team.

814
00:37:59,404 --> 00:38:02,434
Because I, it was really
interesting, all the blocks to

815
00:38:02,434 --> 00:38:06,574
change, you said, for example,
were all failures of team dynamics.

816
00:38:06,994 --> 00:38:08,524
They're all failures of teamwork.

817
00:38:08,759 --> 00:38:11,969
And so if I, I would feed that
back to a person who came to me and

818
00:38:11,969 --> 00:38:15,449
said, I seem to be stuck on, uh,
uh, and, and, and, and go there.

819
00:38:15,574 --> 00:38:15,724
Yeah.

820
00:38:15,724 --> 00:38:19,864
So that, that registrar, I can't change
'cause I'm bottoming the hierarchy and

821
00:38:20,014 --> 00:38:23,444
I've, I've gotta raise this issue with
the consultant, you would say, well,

822
00:38:23,474 --> 00:38:25,034
okay, that's a failure of the teamwork.

823
00:38:25,034 --> 00:38:27,704
That's a failure of psychological
safety, isn't it, within the team.

824
00:38:28,196 --> 00:38:30,746
So then what would you say, so what,
so would you say, what's the, what's

825
00:38:30,746 --> 00:38:32,246
a really small thing you could try?

826
00:38:32,306 --> 00:38:34,166
What, what would, what Would
you be counseling them then?

827
00:38:34,406 --> 00:38:35,366
Well, we've discussed, hasn't it?

828
00:38:35,396 --> 00:38:38,332
We, we are looking at changing the
behavior of individual A, and, and

829
00:38:38,332 --> 00:38:42,112
we need to understand what good looks
like from the position of individual A,

830
00:38:42,275 --> 00:38:43,085
Go and have a conversation.

831
00:38:43,085 --> 00:38:45,155
I mean, that's, that's one thing.

832
00:38:45,155 --> 00:38:49,349
So many people haven't actually gone
up to people and said, how are ya?

833
00:38:50,721 --> 00:38:54,029
Uh, and, and, and in my team,
we talk about, um, going off the

834
00:38:54,029 --> 00:38:56,532
record, uh, that that's our signal.

835
00:38:56,652 --> 00:38:57,732
Can we go off the record for a moment.

836
00:38:57,972 --> 00:38:58,467
That that means.

837
00:38:59,277 --> 00:39:01,797
You want to say some things you don't
want necessarily want people to be,

838
00:39:02,127 --> 00:39:06,327
to agree or it's not your position, or
you might want to deny ever saying it

839
00:39:06,327 --> 00:39:09,417
'cause you might hear yourself speak
and go, nah, no, I don't like that.

840
00:39:09,537 --> 00:39:10,407
Nah, nah.

841
00:39:10,827 --> 00:39:15,475
But haven't you just identified
that the research evidence shows

842
00:39:15,475 --> 00:39:18,025
that shows organizations with
a high level of psychological

843
00:39:18,025 --> 00:39:20,485
safety are good at making changes.

844
00:39:20,837 --> 00:39:23,702
A and it may well be that if there
is no psychological safety in that

845
00:39:23,702 --> 00:39:27,842
hypothetical situation, it is beyond
that organization to make changes.

846
00:39:28,142 --> 00:39:32,792
And then we come back to a, a macro
situation with a national health service,

847
00:39:33,152 --> 00:39:36,392
the market can't prune out the rubbish.

848
00:39:37,322 --> 00:39:39,122
Uh, I, I dunno if it's
ever happened to you.

849
00:39:39,182 --> 00:39:44,222
Um, but I know of GPs who practice
in areas where service A is very bad.

850
00:39:44,882 --> 00:39:49,382
Now in a private sector, that that
service would not be allowed to thrive.

851
00:39:49,652 --> 00:39:51,122
But it's the National Health Service.

852
00:39:51,182 --> 00:39:53,672
You have to put up with what
you're given and be grateful.

853
00:39:54,003 --> 00:39:57,033
Um, and, and again, we talked about
that young doctor, it, it's more

854
00:39:57,033 --> 00:40:01,504
difficult to look around and go, um,
actually, organization B looks to be

855
00:40:01,504 --> 00:40:03,964
really well led and, and suits my style.

856
00:40:04,129 --> 00:40:05,494
I I, it's certainly happened to me.

857
00:40:05,764 --> 00:40:06,694
I dunno if it's happened to you.

858
00:40:06,964 --> 00:40:10,654
I've been an employee in many
years back and been, uh, viewed

859
00:40:10,654 --> 00:40:12,514
as, as not very good at all.

860
00:40:12,994 --> 00:40:16,234
I've gone to a different place and
been considered more than acceptable.

861
00:40:16,684 --> 00:40:18,544
I don't believe I changed overnight.

862
00:40:18,949 --> 00:40:21,139
Uh, and, and we haven't really
had a chance to talk much

863
00:40:21,139 --> 00:40:22,729
about the concept to fit.

864
00:40:23,233 --> 00:40:25,303
We've talked really about right and wrong.

865
00:40:25,663 --> 00:40:26,863
Um, I am here.

866
00:40:26,863 --> 00:40:28,663
I don't fit, that's clearly wrong.

867
00:40:28,903 --> 00:40:32,233
And, and we haven't really had a chance to
talk about, although we talk about how you

868
00:40:32,233 --> 00:40:36,073
might achieve changing the organization so
that you are a better fit, but we haven't

869
00:40:36,073 --> 00:40:41,113
said that we might want to do that for our
own selfish purposes so it's more like an

870
00:40:41,113 --> 00:40:43,573
organization that we, we want it to be.

871
00:40:43,903 --> 00:40:47,533
And, um, I know you do
it and we try and do it.

872
00:40:47,773 --> 00:40:52,813
And part of that is modeling our own
behavior in organizations and individuals

873
00:40:52,843 --> 00:40:56,383
that we're trying to influence because
they want us to influence them to

874
00:40:56,533 --> 00:40:57,913
towards a new and better future.

875
00:40:58,698 --> 00:41:03,138
if we go back to psychological
safety and fit and actually all that

876
00:41:03,138 --> 00:41:07,518
sort of stuff, I think we have this
slightly learned helplessness that

877
00:41:07,518 --> 00:41:10,638
it's somebody else that's got to
provide psychological safety for us.

878
00:41:11,418 --> 00:41:14,178
And I, I'm thinking about that
registrar, I, I, I've given

879
00:41:14,178 --> 00:41:15,198
this example loads more times.

880
00:41:15,198 --> 00:41:19,583
I used to work with this brilliant
bloke called Al, who, um, was a,

881
00:41:19,583 --> 00:41:22,553
a co-presenter on the Lead Manage
Thrive course for me at Red Whale.

882
00:41:22,883 --> 00:41:26,453
And he came to medicine as a
graduate, I think he'd run marketing

883
00:41:26,453 --> 00:41:28,103
for a large bank beforehand.

884
00:41:28,523 --> 00:41:31,223
And I remember just chatting with
him and he said, oh yeah, we had that

885
00:41:31,223 --> 00:41:32,933
issue when I was a a house officer.

886
00:41:32,933 --> 00:41:34,733
I just went to the consultant
and went, oh, Mike, let's

887
00:41:34,733 --> 00:41:35,783
just sort it out, shall we?

888
00:41:35,993 --> 00:41:39,713
And I was like, Ooh, I could never have
done that because I felt the hierarchy.

889
00:41:39,713 --> 00:41:43,283
But he was just like, oh, let's just
have a conversation person to person

890
00:41:43,283 --> 00:41:45,158
and just, you know, sort it out.

891
00:41:45,158 --> 00:41:49,058
Whereas I know that when I was at
the GP registrar and I wasn't happy

892
00:41:49,058 --> 00:41:52,478
about something, I would go to the
practice manager, go, this is my issue.

893
00:41:52,478 --> 00:41:53,738
How are you gonna sort it out?

894
00:41:54,098 --> 00:41:57,998
And of course, immediately she was on
the back foot and you know, immediately.

895
00:41:58,028 --> 00:41:58,238
Right.

896
00:41:58,238 --> 00:41:58,898
I'm being criticized.

897
00:41:58,898 --> 00:42:01,748
The practice being criticized is, is
there gonna be a problem or whatever.

898
00:42:02,138 --> 00:42:04,874
If I'd have gone to her and gone
Can I just have a chat about this?

899
00:42:04,874 --> 00:42:05,684
How, how are you doing?

900
00:42:05,684 --> 00:42:06,614
How are things?

901
00:42:06,854 --> 00:42:08,204
How does this like look like for you?

902
00:42:08,204 --> 00:42:09,464
What, what are the issues there for you?

903
00:42:09,464 --> 00:42:12,164
This is how I'm experiencing
it, what can we do about it?

904
00:42:12,524 --> 00:42:15,704
Well, immediately I've created a
much more psychological safety.

905
00:42:15,704 --> 00:42:20,204
And the, the idea is that this is sort
of help helplessness, which I think

906
00:42:20,204 --> 00:42:23,954
is unhelpful when we are in the victim
mentality, is that the person we're

907
00:42:23,954 --> 00:42:27,524
speaking to, they're responsible for
creating the psychological safety for us.

908
00:42:27,788 --> 00:42:30,744
I, uh, and because I'm not very
knowledgeable in this area, uh, and I

909
00:42:30,744 --> 00:42:34,044
like to use old simple models, I would
go straight to transactional analysis in

910
00:42:34,044 --> 00:42:37,704
those day, in those days, I, I would start
talking about parent, adults and child,

911
00:42:38,154 --> 00:42:43,944
uh, at very aware that as a middle aged,
middle class bloke, given a fair wind, I

912
00:42:43,944 --> 00:42:46,524
will revert into parents, uh, co o, okay.

913
00:42:46,614 --> 00:42:47,664
Now we know that.

914
00:42:48,084 --> 00:42:49,974
What are we going to do about that?

915
00:42:50,124 --> 00:42:53,184
So, adult behavior for me
is a pretty learnt behavior.

916
00:42:53,649 --> 00:42:58,689
Um, and, and, and I can be quite
paranoid about asking my team if I

917
00:42:58,689 --> 00:43:00,519
start to slip into controlling parent.

918
00:43:00,549 --> 00:43:03,639
'cause I'll live there quite, I also live
in nurturing parent quite happily as well.

919
00:43:03,734 --> 00:43:05,319
And, and, and, and it's not good.

920
00:43:05,319 --> 00:43:08,679
We know from the research that that's
not, uh, not how teams do well.

921
00:43:08,859 --> 00:43:13,179
Why do I put the effort into behave
in a slightly cultural kind of manner?

922
00:43:13,479 --> 00:43:16,449
Because it means my team will be better.

923
00:43:16,989 --> 00:43:20,649
Not necessarily more profitable,
but, but, but happier and more

924
00:43:20,649 --> 00:43:22,249
effective, and more forgiving.

925
00:43:22,279 --> 00:43:24,019
That's a nice thing about
an adult, adult team.

926
00:43:24,019 --> 00:43:24,889
It's more forgiving.

927
00:43:25,249 --> 00:43:28,579
Uh, whereas if you've got parent
child going on, children can be,

928
00:43:28,579 --> 00:43:30,379
the child role can very unforgiving.

929
00:43:30,532 --> 00:43:33,652
Yeah, and that is the basis
of psychological safety.

930
00:43:33,652 --> 00:43:36,212
It's not that I'm just trusting you're
gonna be nice, but it's the trusting that

931
00:43:36,212 --> 00:43:40,312
if I muck up and say something really
bad to you, you're gonna forgive me.

932
00:43:40,312 --> 00:43:42,532
You're not gonna hold, you, are
not gonna hold it against me.

933
00:43:42,532 --> 00:43:45,032
And the transactional analysis,
I think that was Eric Berne,

934
00:43:45,052 --> 00:43:46,152
wasn't it, The Games People Play.

935
00:43:46,152 --> 00:43:49,742
Well, he was the, uh, mentor
for, uh, Stephen Karpman

936
00:43:49,762 --> 00:43:50,902
who did the drama triangle.

937
00:43:51,182 --> 00:43:55,322
So what I'm talking about is when we
get into victim, which then puts other

938
00:43:55,322 --> 00:43:59,732
people into persecutor or rescue, they
feel they're gonna rescue us or they

939
00:43:59,792 --> 00:44:03,272
more often they feel blamed themselves
and they go into victim, 'cause the

940
00:44:03,272 --> 00:44:07,022
minute we start blaming other people
in victim, we become the persecutor.

941
00:44:07,022 --> 00:44:11,532
And so, doctors, I think what's happening
is we are feeling so victimized, we

942
00:44:11,532 --> 00:44:14,622
start blaming everyone else, and of
course they then feel victimized.

943
00:44:14,892 --> 00:44:17,892
And what you end up having is an argument
about who's the Vic biggest victim.

944
00:44:17,892 --> 00:44:19,932
And it's, it's an argument
all the way to the bottom.

945
00:44:20,352 --> 00:44:24,762
It's not an argument going, look, hey,
I can see how difficult this is for you.

946
00:44:25,092 --> 00:44:26,022
Let me just share the impact.

947
00:44:26,022 --> 00:44:28,122
You know's the whole
nonviolent communication thing.

948
00:44:28,332 --> 00:44:29,292
This is what I think I need.

949
00:44:29,292 --> 00:44:30,972
How can we find a win-win solution?

950
00:44:30,972 --> 00:44:32,232
How can we do it together?

951
00:44:32,622 --> 00:44:35,562
The problem is we have never,
ever, ever, ever been taught

952
00:44:35,562 --> 00:44:37,002
the skills of how to do that.

953
00:44:37,069 --> 00:44:37,742
Bizarre, isn't it?

954
00:44:37,892 --> 00:44:39,362
For a profession that sows.

955
00:44:39,367 --> 00:44:41,132
We, we are really good communicators.

956
00:44:41,492 --> 00:44:42,092
Really?

957
00:44:42,302 --> 00:44:43,532
I've not met a good one yet.

958
00:44:44,487 --> 00:44:44,777
Just

959
00:44:44,802 --> 00:44:47,292
we're with patients, but like,
let's apply to the patient.

960
00:44:47,292 --> 00:44:49,902
So, so if you had a patient that comes
in yelling at you, you automatically

961
00:44:49,902 --> 00:44:51,912
go into, okay, let's unpack this hope.

962
00:44:51,912 --> 00:44:53,732
Hopefully, unless you're
thinking I'll just get lost.

963
00:44:54,454 --> 00:44:57,026
Uh, I, I, I, well, I let, let's go.

964
00:44:57,116 --> 00:45:00,386
'Cause we talked earlier about how
doctors are used to deploying expert

965
00:45:00,386 --> 00:45:03,476
power in the consulting room, and
sometimes they carry on doing, uh, uh,

966
00:45:03,476 --> 00:45:07,136
expert power, uh, outside the consulting
room even if they don't have it.

967
00:45:07,596 --> 00:45:10,112
But I think that deployment of
expert power is very close to

968
00:45:10,112 --> 00:45:11,432
behaving like a nurturing parent.

969
00:45:11,672 --> 00:45:15,422
Uh, it, it, it's, I I think this
therefore, um, off you go next.

970
00:45:15,422 --> 00:45:16,652
I, I, why are you still sitting there?

971
00:45:16,772 --> 00:45:17,282
Nine minutes.

972
00:45:17,282 --> 00:45:17,672
Off you go.

973
00:45:18,072 --> 00:45:22,482
And we know from Burne's work that
our own behaviors will tend to

974
00:45:22,482 --> 00:45:24,582
force others into the alternative.

975
00:45:24,762 --> 00:45:28,947
So if we are behaving in parent, we
will drive other people to child.

976
00:45:29,307 --> 00:45:33,087
But haven't you just described a
scenario where a grumpy registrar will

977
00:45:33,087 --> 00:45:37,227
behave childlike and that will flow
the partners into parent, 'cause they

978
00:45:37,227 --> 00:45:39,237
spend eight hours a day in parent mode.

979
00:45:39,420 --> 00:45:42,750
I mean, it's, it, it is a mutually
satisfying relationship, 'cause the,

980
00:45:42,840 --> 00:45:46,834
it's the cross ones aren't, but doesn't
that mean then that to drive to adult,

981
00:45:46,834 --> 00:45:51,314
we know that adult to child and adult
to parent creates friction and requires

982
00:45:51,374 --> 00:45:56,834
effort and planful not just chatting, but
now I need to think about my next words.

983
00:45:57,224 --> 00:46:02,357
We have a, a communication truism at
Zytal,, which is that, um, in times

984
00:46:02,357 --> 00:46:07,480
of stress, all ambiguous communication
will be interpreted adversely.

985
00:46:07,720 --> 00:46:08,530
That's rule one.

986
00:46:08,950 --> 00:46:11,860
Rule two is all human
communication is ambiguous.

987
00:46:12,290 --> 00:46:17,330
So, so if someone's determined, they,
they, you know, you can have a, you can

988
00:46:17,330 --> 00:46:20,374
have a formal complaint about saying
good morning, if you're really determined

989
00:46:20,374 --> 00:46:23,674
to get down there and manipulate
them up into controlling parent and

990
00:46:23,674 --> 00:46:25,414
then take pot shots, you can do it.

991
00:46:25,570 --> 00:46:28,900
And, and, and we know people who are
very good at it, and we know people

992
00:46:28,900 --> 00:46:30,610
who've made whole careers out of it.

993
00:46:30,964 --> 00:46:31,984
It's worked for them.

994
00:46:32,203 --> 00:46:33,918
Well, it, you say it's worked for them.

995
00:46:34,038 --> 00:46:36,678
I can't imagine they are happy
or fulfilled in their jobs.

996
00:46:36,678 --> 00:46:39,978
So you know, they've got what they wanted,
but it's not actually worked for them.

997
00:46:39,978 --> 00:46:41,058
It doesn't work for anybody.

998
00:46:41,058 --> 00:46:42,588
When you're sucking this drama, does it?

999
00:46:42,775 --> 00:46:46,165
Well, you've opened the door there to
something I don't quite know how to say.

1000
00:46:46,465 --> 00:46:50,495
Because we talked about dependency,
and clearly it goes back to

1001
00:46:50,495 --> 00:46:52,145
my own psychological profile.

1002
00:46:52,365 --> 00:46:55,605
The way I've got to as being
a partner and as being a chief

1003
00:46:55,605 --> 00:46:59,265
executive of my own organization,
I have high levels of autonomy.

1004
00:46:59,372 --> 00:47:01,065
And that's the most important thing.

1005
00:47:01,275 --> 00:47:05,785
Being in a, being in a position where I
didn't have high levels of autonomy would

1006
00:47:05,785 --> 00:47:08,225
drive me mad, Full stop, new paragraph.

1007
00:47:08,585 --> 00:47:12,645
I see the new setup of NHS as my
younger medical colleagues having

1008
00:47:12,645 --> 00:47:14,145
very low levels of autonomy.

1009
00:47:14,595 --> 00:47:16,965
And it's traditional at this
stage for people like me to say,

1010
00:47:16,965 --> 00:47:19,635
well, youngsters of today, they
have it easy, it shouldn't be me.

1011
00:47:19,785 --> 00:47:22,275
Yes, I did the one and twos,
yes, I do the one in ones.

1012
00:47:22,579 --> 00:47:24,679
But enormous levels of autonomy.

1013
00:47:24,809 --> 00:47:25,499
Absolutely.

1014
00:47:25,889 --> 00:47:26,729
It's so fascinating.

1015
00:47:26,729 --> 00:47:32,249
The other thing I think happens with
autonomy and control is people will say,

1016
00:47:32,499 --> 00:47:35,139
you know, when I talk about the zone
of power, what's outside your control?

1017
00:47:35,139 --> 00:47:36,369
What's inside your control?

1018
00:47:36,729 --> 00:47:39,069
I'll, uh, I'll, you know, they'll
say, well, what's inside my control

1019
00:47:39,069 --> 00:47:42,639
is what I eat for lunch, or, you
know, and I, and I'll push it.

1020
00:47:42,639 --> 00:47:44,589
I'll go, what time you leave work?

1021
00:47:44,859 --> 00:47:47,139
No, I'm not in control of
what time you leave work.

1022
00:47:47,169 --> 00:47:47,799
Definitely not.

1023
00:47:47,799 --> 00:47:50,185
I said, oh, well, who
is in control of what?

1024
00:47:50,185 --> 00:47:52,765
Well, the patient, the thing, the road.

1025
00:47:52,885 --> 00:47:57,235
I said, well, okay, who is in control
of when you stand up and you leave?

1026
00:47:57,235 --> 00:47:59,395
Like literally stand up off
your desk and, and leave?

1027
00:47:59,725 --> 00:48:01,765
Oh, well, I mean, that's
me, but that's not really.

1028
00:48:01,765 --> 00:48:02,305
I said, no.

1029
00:48:02,335 --> 00:48:05,935
So we get to the point where I'm saying
literally you are in control of you.

1030
00:48:05,940 --> 00:48:08,755
If, if, when you stand up and
leave that building, nobody

1031
00:48:08,755 --> 00:48:09,775
else is in control of that.

1032
00:48:09,835 --> 00:48:10,135
Oh, yeah.

1033
00:48:10,135 --> 00:48:14,047
But, but no, but I can't, I
cannot leave If there's a sick

1034
00:48:14,047 --> 00:48:15,427
patient, like a sick child.

1035
00:48:15,688 --> 00:48:17,488
And I say, well, you could leave.

1036
00:48:17,548 --> 00:48:18,598
No, I, I can't.

1037
00:48:18,598 --> 00:48:19,558
I'm a good doctor.

1038
00:48:19,618 --> 00:48:23,358
Well, actually what you are saying
is you are in control of when you

1039
00:48:23,358 --> 00:48:27,503
leave, but you don't like what the
consequences are gonna be if you do leave.

1040
00:48:27,867 --> 00:48:29,692
And this is not a moral compass.

1041
00:48:29,692 --> 00:48:31,702
I'm not saying it's the right thing
to do, to leave when you should

1042
00:48:31,702 --> 00:48:33,172
be seeing an, an extra child.

1043
00:48:33,262 --> 00:48:35,422
You know, you might be struck
off, you might lose your job.

1044
00:48:35,545 --> 00:48:37,435
But that doesn't mean
you're not in control of it.

1045
00:48:37,435 --> 00:48:41,935
And so when doctors feel helpless
and feel that they don't have any

1046
00:48:41,935 --> 00:48:45,998
control or autonomy, they do, they
have much more control and autonomy

1047
00:48:45,998 --> 00:48:49,217
than, than other health, even
other healthcare professionals.

1048
00:48:49,517 --> 00:48:53,417
But what they don't like is the
consequences of doing stuff.

1049
00:48:53,417 --> 00:48:56,927
Because either it's really significant
consequences when like someone might die

1050
00:48:57,137 --> 00:49:01,873
or something, or someone's gonna think
badly of them or they may upset someone or

1051
00:49:01,873 --> 00:49:03,853
it's going to be difficult conversation.

1052
00:49:04,202 --> 00:49:05,402
it's because it's too difficult.

1053
00:49:05,462 --> 00:49:07,292
It's because it feels too hard.

1054
00:49:07,292 --> 00:49:09,362
Because it, and it
affects our sense of self.

1055
00:49:09,432 --> 00:49:11,387
At at what the cost is too much.

1056
00:49:11,505 --> 00:49:13,695
But then they don't look at
the cost of staying the same,

1057
00:49:13,844 --> 00:49:14,679
a, a Agreed.

1058
00:49:14,911 --> 00:49:17,177
But we are all products of
our social conditioning.

1059
00:49:17,237 --> 00:49:18,437
I, I agree with everything you're say.

1060
00:49:18,587 --> 00:49:22,547
Um, and you know, I, I, you know, again,
there's a middle aged bloke, sometimes

1061
00:49:22,547 --> 00:49:25,487
I'm walking around and I'll ask staff
going, you just have to forgive me.

1062
00:49:25,487 --> 00:49:26,837
I'm a product of my social conditioning.

1063
00:49:26,997 --> 00:49:30,352
And, and, and I think if you, if,
if, if you, I, I see I seem to

1064
00:49:30,352 --> 00:49:31,612
be forgiven fairly frequently.

1065
00:49:32,062 --> 00:49:34,342
Perhaps someone's following
behind smoothing the waters.

1066
00:49:34,466 --> 00:49:36,930
But can I just say, Richard, the
difference is that you are, yeah, you're

1067
00:49:36,930 --> 00:49:39,210
productive of your social conditioning,
but you've got the self-awareness

1068
00:49:39,210 --> 00:49:44,490
to know that and then to give people
permission to tell you that and to say it.

1069
00:49:44,490 --> 00:49:46,260
And that's what psychological safety is.

1070
00:49:46,260 --> 00:49:50,340
It's, it's psychological Safety
is not always being perfect.

1071
00:49:50,666 --> 00:49:53,186
Cause we, we can't be, and
we make mistakes and we

1072
00:49:53,186 --> 00:49:54,686
accidentally offend people.

1073
00:49:54,686 --> 00:49:58,316
And if, if people are wondering about,
you know, talk Chris Turner podcast, you

1074
00:49:58,316 --> 00:50:02,156
know, the guy civility saves lives on, you
know, how to challenge unhelpful behavior.

1075
00:50:02,306 --> 00:50:04,946
Half of us don't even know the
behavior's unhelpful at the time.

1076
00:50:05,186 --> 00:50:07,886
Unless somebody tells us, we,
we, we are not gonna know.

1077
00:50:07,886 --> 00:50:10,766
And that is the point is that when
someone says to you, that wasn't very

1078
00:50:10,766 --> 00:50:12,296
helpful, you go, oh, that's interesting.

1079
00:50:12,296 --> 00:50:13,076
Thank you for feeding back.

1080
00:50:13,076 --> 00:50:15,956
Tell me what wasn't helpful about
it and what could I do differently?

1081
00:50:16,526 --> 00:50:18,466
What could I do differently next time?

1082
00:50:18,796 --> 00:50:21,821
But while we're stuck in this
helplessness and this victim mentality,

1083
00:50:22,121 --> 00:50:23,681
we want to blame other people.

1084
00:50:23,681 --> 00:50:26,744
That feels actually, it's more
comfortable, it's more comfortable to be

1085
00:50:26,744 --> 00:50:28,574
blaming other people and to be helpless.

1086
00:50:28,574 --> 00:50:32,114
Now, this is where I have to be
really careful because I do not want

1087
00:50:32,114 --> 00:50:36,644
to resilience victim blame, and that
resilience, victim blaming is gaslighting.

1088
00:50:36,674 --> 00:50:40,064
It's saying Here, see a hundred
patients, and why haven't you

1089
00:50:40,064 --> 00:50:43,394
taken up that lunchtime offer of
some mindfulness that we gave you?

1090
00:50:43,394 --> 00:50:45,704
You know, like that is
resilience, victim blaming.

1091
00:50:45,704 --> 00:50:46,634
This is not that.

1092
00:50:46,634 --> 00:50:51,644
It's saying this is about when you find
yourself in the victim mentality, go, have

1093
00:50:51,644 --> 00:50:54,181
I really looked at what I'm in control of?

1094
00:50:54,181 --> 00:50:57,571
And what am I avoiding doing
just because it's too hard?

1095
00:50:57,976 --> 00:51:01,336
Or because it's going to, it's
gonna, my amygdala won't let me do

1096
00:51:01,336 --> 00:51:05,866
it because it, I might be disliked
the courage to be disliked, or the

1097
00:51:05,866 --> 00:51:10,276
potential of upsetting somebody, or
even it going into my own identity.

1098
00:51:10,276 --> 00:51:12,946
I, the more I work with you
know, people, the more I realize

1099
00:51:12,946 --> 00:51:16,976
that this self-sacrificial
identity is really important.

1100
00:51:17,256 --> 00:51:20,446
So if I, if I'm not telling everyone
I'm busy on the edge of burnout,

1101
00:51:20,446 --> 00:51:22,126
what does it mean about my identity?

1102
00:51:22,193 --> 00:51:27,803
I, I, think you, you, that is a variety
of the social conditioning that starts,

1103
00:51:27,923 --> 00:51:31,673
uh, I, I, with, uh, forgive me, the
lies that we teach, potential medical

1104
00:51:31,673 --> 00:51:35,183
students, that teach the same medicine's
a really wonderful vocation to join.

1105
00:51:35,813 --> 00:51:36,563
Well, it can be.

1106
00:51:36,563 --> 00:51:40,343
On the other hand, it can be a, uh,
it can be a tough and rewarding job

1107
00:51:40,643 --> 00:51:42,263
and it can be a completely shit job.

1108
00:51:42,683 --> 00:51:45,499
And just because it's tough
doesn't mean to say it's shit.

1109
00:51:45,499 --> 00:51:47,479
And, but because it's shit
does mean to say it's tough.

1110
00:51:47,509 --> 00:51:49,729
It doesn't map, map, map well map one way.

1111
00:51:49,909 --> 00:51:51,469
And that's all into rewards.

1112
00:51:51,659 --> 00:51:55,754
I was lucky in my career to be
dragged outta bed fairly frequently,

1113
00:51:55,754 --> 00:52:00,584
antisocial times to do stuff, which I
thought was worth doing in my opinion.

1114
00:52:00,961 --> 00:52:04,471
And that worked nicely for me, among a
team that would go, oh, that was cool

1115
00:52:04,681 --> 00:52:06,271
you know, with the external validation.

1116
00:52:06,391 --> 00:52:08,251
And I don't think that's
what they get at the moment.

1117
00:52:08,251 --> 00:52:09,391
They get the shift work or whatever.

1118
00:52:10,131 --> 00:52:10,581
Yeah.

1119
00:52:10,760 --> 00:52:12,740
Um, I've slightly gone
off piste, haven't we?

1120
00:52:12,740 --> 00:52:16,460
But I think this does boil down to
the question that the original reason

1121
00:52:16,460 --> 00:52:20,000
why I got you on the podcast was I'm
really obsessed with this idea of

1122
00:52:20,251 --> 00:52:24,322
people thinking nothing can change
for me until the system changes.

1123
00:52:24,892 --> 00:52:28,822
And my line is actually you need to change
what you are doing, 'cause the system's

1124
00:52:28,822 --> 00:52:30,712
way above your pay grade and my pay grade.

1125
00:52:30,712 --> 00:52:33,712
And I think you are thinking
actually you can change the system.

1126
00:52:34,234 --> 00:52:38,974
So how, how would you advise someone
who is feeling really, really helpless?

1127
00:52:39,034 --> 00:52:39,304
Really?

1128
00:52:39,304 --> 00:52:40,354
Like, I've tried stuff.

1129
00:52:40,894 --> 00:52:42,244
It's really difficult.

1130
00:52:42,314 --> 00:52:45,407
There's all these different
reasons why, why we can't change.

1131
00:52:45,407 --> 00:52:48,017
I've got, I've got no
time, I've got no energy.

1132
00:52:48,017 --> 00:52:50,897
But I hear what you're saying
and in theory that makes sense.

1133
00:52:51,194 --> 00:52:53,698
But on the ground, where do I even start?

1134
00:52:54,036 --> 00:52:57,066
So the, the first thing is to
really understand what good

1135
00:52:57,066 --> 00:52:58,986
looks like and why it looks good.

1136
00:52:59,376 --> 00:53:02,106
Um, and, and get, that doesn't have
to be written down, but you know

1137
00:53:02,106 --> 00:53:03,606
what I mean, really boiled out.

1138
00:53:03,786 --> 00:53:06,906
So the phrase better service for
patients doesn't work for me.

1139
00:53:07,206 --> 00:53:08,191
What does that, what, what does that mean?

1140
00:53:08,751 --> 00:53:09,531
Quicker, faster be.

1141
00:53:09,771 --> 00:53:10,281
What does that mean?

1142
00:53:10,671 --> 00:53:14,451
And then we cut into the how
you would do that first cut.

1143
00:53:15,021 --> 00:53:18,741
And then we go back to our conversation
earlier about is this worth the candle?

1144
00:53:19,161 --> 00:53:20,601
Because we're into risk.

1145
00:53:20,751 --> 00:53:23,421
We're talking about return
on investment or what a nasty

1146
00:53:23,421 --> 00:53:24,471
management consultant phrase.

1147
00:53:24,861 --> 00:53:27,441
Um, as you know, it looks
like that investment.

1148
00:53:27,651 --> 00:53:28,221
But hang on.

1149
00:53:28,221 --> 00:53:31,731
Now we've had to think about the what and
we think about the how you are now talking

1150
00:53:31,731 --> 00:53:35,721
to myself who ha has a team around them
that know every shortcut in the business.

1151
00:53:35,957 --> 00:53:40,517
If we redefine the how, utilizing
our shortcut, what does the business

1152
00:53:40,517 --> 00:53:43,337
case, oh, another nasty management
consultant phrase look like?

1153
00:53:43,732 --> 00:53:44,147
Ah.

1154
00:53:44,496 --> 00:53:46,308
I didn't like the first
one 'cause it looked really

1155
00:53:46,308 --> 00:53:47,748
difficult with days of labor.

1156
00:53:48,108 --> 00:53:51,528
Quite like the second one 'cause it's
got a day labor and I'd be really

1157
00:53:51,528 --> 00:53:56,358
interested in getting home earlier, making
more money, dropping the complication

1158
00:53:56,358 --> 00:53:59,988
rate, dropping the mortality, being
invited to speak to a conference.

1159
00:54:00,288 --> 00:54:03,648
I mean, how, how we can go on for half
an hour on that without even thinking.

1160
00:54:03,798 --> 00:54:07,047
But I've gotta know which one it
is, ' cause we got to prioritize and

1161
00:54:07,047 --> 00:54:09,327
focus our change to get what you want.

1162
00:54:09,686 --> 00:54:12,986
And I really, really, really,
really need to know what you want.

1163
00:54:13,346 --> 00:54:16,766
And we've worn out the old Einstein
phrase that says, if I had an hour to

1164
00:54:16,766 --> 00:54:19,736
change the world, I'd spend 55 minutes
thinking what to do in 5 minutes doing it.

1165
00:54:19,856 --> 00:54:22,946
We use it so often we've worn it
out, but the docs are all going.

1166
00:54:23,006 --> 00:54:23,366
Yeah, yeah.

1167
00:54:23,366 --> 00:54:25,826
Well if, if you could just sort this out,
I've gotta go and see Mrs. Mackins now.

1168
00:54:25,826 --> 00:54:26,216
Bye.

1169
00:54:26,966 --> 00:54:28,616
I don't even know what
we're trying to achieve now.

1170
00:54:28,616 --> 00:54:31,346
You just said you wanted something
different and flew out the door being

1171
00:54:31,346 --> 00:54:34,856
very important and playing the um,
the, the stroud waving trump card.

1172
00:54:35,336 --> 00:54:38,786
Sorry, I don't accept the stroud
waving trump card, 'cause I

1173
00:54:38,786 --> 00:54:39,956
was doing it before you were

1174
00:54:39,986 --> 00:54:40,286
What's this?

1175
00:54:40,346 --> 00:54:42,386
What's a stroud waving trump  card?

1176
00:54:43,350 --> 00:54:44,030
Shroud wave.

1177
00:54:44,090 --> 00:54:44,330
Oh yeah.

1178
00:54:44,330 --> 00:54:46,616
What is, okay, what is, just explain that?

1179
00:54:46,616 --> 00:54:51,566
It's an unjustified, unaccurate,
untrue, maliciously delivered if we

1180
00:54:51,566 --> 00:54:53,546
don't do it my way, someone will die.

1181
00:54:53,546 --> 00:54:53,816
Yeah.

1182
00:54:53,816 --> 00:54:57,896
So it, it's like the, the,
higher calling is serving these

1183
00:54:57,896 --> 00:54:59,936
patients and that is gonna trump

1184
00:55:00,023 --> 00:55:00,533
Everything

1185
00:55:00,533 --> 00:55:01,433
everything.

1186
00:55:01,548 --> 00:55:03,108
Including the risk of burnout.

1187
00:55:03,228 --> 00:55:06,288
and, and, and it leads to very
distorted risk management.

1188
00:55:06,418 --> 00:55:10,038
because you can always, always
argue that any risk will end

1189
00:55:10,038 --> 00:55:12,088
up with severe patient harm.

1190
00:55:12,088 --> 00:55:16,068
So in, in a training session, we were
debating this, when can I leave work?

1191
00:55:16,158 --> 00:55:17,448
You know, I can't get up and leave.

1192
00:55:17,448 --> 00:55:22,278
And someone said, I can't leave when
I'm on call on a Friday night, because

1193
00:55:22,458 --> 00:55:24,228
what if patients need to see me?

1194
00:55:24,708 --> 00:55:25,578
Uh, well, what?

1195
00:55:25,728 --> 00:55:26,248
Okay, well what, what?

1196
00:55:26,418 --> 00:55:29,539
She said, what if there is
a sick child in that queue?

1197
00:55:29,539 --> 00:55:33,789
And yes, the phones have gone over,
but I can't leave them to c NHS 111

1198
00:55:33,978 --> 00:55:37,188
because what if they don't assess them
properly and they don't send them, and

1199
00:55:37,188 --> 00:55:38,808
are, they're not that good in our area?

1200
00:55:38,808 --> 00:55:42,258
And I'm like, and then luckily someone
else on the, in the, in the training

1201
00:55:42,258 --> 00:55:44,855
said, yeah, but what you do on a
Sunday afternoon when there might be

1202
00:55:44,855 --> 00:55:46,235
a sick child in the queue, you know?

1203
00:55:46,235 --> 00:55:50,022
It's just this nonsensical thing of we
can always say, well, if that result

1204
00:55:50,022 --> 00:55:53,622
isn't filed, if that normal result isn't
filed, well, what happens if, if, if you

1205
00:55:53,622 --> 00:55:57,852
can always extrapolate the worst case
scenario of something dreadful happen in.

1206
00:55:57,852 --> 00:55:58,962
The problem is you do see these.

1207
00:55:59,132 --> 00:56:01,952
Isolated incidents where something
absolutely almost happened, you could

1208
00:56:01,952 --> 00:56:05,912
not have predicted or whatever, but
we use it as the shroud waiting.

1209
00:56:05,912 --> 00:56:08,402
It's, it's like this Trump card
of get out of jail free of,

1210
00:56:08,612 --> 00:56:09,452
I can't come to that meeting.

1211
00:56:09,452 --> 00:56:12,962
I can't put it in that time because
patient need and that trumps everything.

1212
00:56:12,962 --> 00:56:15,662
And I do see that with
senior clinical leaders.

1213
00:56:15,692 --> 00:56:16,622
I'm like, why?

1214
00:56:17,012 --> 00:56:21,542
If you had a choice of doing the extra
clinic or spending that time on leadership

1215
00:56:21,542 --> 00:56:23,762
and management, you should be spending
that on leadership management, 'cause

1216
00:56:23,762 --> 00:56:24,902
you've got the experience to do that.

1217
00:56:24,902 --> 00:56:28,929
And you let the people, know, you know,
who, who aren't there to, to do the

1218
00:56:28,929 --> 00:56:32,335
thinking for your department to, to
do the service delivery essentially.

1219
00:56:32,335 --> 00:56:34,910
And, and I think that's an
unhelpful, coercive power.

1220
00:56:35,024 --> 00:56:37,154
Uh, and, and, and it
leads to a negative term.

1221
00:56:37,404 --> 00:56:41,064
We then into boundary setting, uh,
into our own, uh, our own boundaries.

1222
00:56:41,244 --> 00:56:44,904
And, uh, I'm grateful for a friend of
mine with the phrase, um, the graveyard

1223
00:56:44,904 --> 00:56:46,284
is full of indispensable doctors.

1224
00:56:46,532 --> 00:56:49,442
Um, and, and, and we
talked about autonomy.

1225
00:56:49,442 --> 00:56:53,552
We talked about self-realization
that if you are into, um, being very

1226
00:56:53,552 --> 00:56:57,902
important, in fact indispensable,
being told that it will carry on after

1227
00:56:57,902 --> 00:57:00,332
your dead can be a very uncomfortable.

1228
00:57:00,482 --> 00:57:03,092
We talked about raising cognitive
dissonance, but sometimes we have

1229
00:57:03,092 --> 00:57:06,272
to raise cognitive dissonance so the
individual can resolve themselves.

1230
00:57:06,624 --> 00:57:09,864
And then we're talk, we're into process
change, but we're into process change

1231
00:57:09,864 --> 00:57:13,134
in people so blimey, we seem to have
gone into psychodynamics without

1232
00:57:13,134 --> 00:57:15,534
actually, well, that, that's okay.

1233
00:57:15,564 --> 00:57:16,794
'cause there are no boundaries there.

1234
00:57:16,794 --> 00:57:17,754
And we're dealing with people.

1235
00:57:17,754 --> 00:57:19,854
Well, it's, it's a behavior
change model, isn't it?

1236
00:57:19,854 --> 00:57:22,404
I mean, is and, and that, you know,
coaching, I'm a big fan of coaching

1237
00:57:22,434 --> 00:57:25,044
obviously, and I'm sure, sure
you are as well, but that's what

1238
00:57:25,044 --> 00:57:27,264
helps you, you know, the coaching
can actually get you your why.

1239
00:57:27,264 --> 00:57:29,934
And what's the important thing here and
what you're trying to change, and give

1240
00:57:29,934 --> 00:57:31,554
you your why, then, then you're gonna go

1241
00:57:31,554 --> 00:57:32,154
do it.

1242
00:57:32,224 --> 00:57:35,574
And what we've done in our own
organization is done the whys and

1243
00:57:35,574 --> 00:57:36,774
laughed at ourselves when we've gone.

1244
00:57:36,774 --> 00:57:37,674
It's obvious, isn't it?

1245
00:57:37,884 --> 00:57:38,154
Okay.

1246
00:57:38,154 --> 00:57:39,414
Why haven't we been able
to explain it to me?

1247
00:57:39,624 --> 00:57:41,454
Um, and gone right down to values.

1248
00:57:41,814 --> 00:57:45,009
And then once we've done a five
whys or have 'em and it takes to get

1249
00:57:45,009 --> 00:57:49,629
down to why is that important and
capture the value we then build up.

1250
00:57:49,629 --> 00:57:54,339
So at last week's, uh, board meeting, we
are then looking at our work program and

1251
00:57:54,339 --> 00:57:57,069
cross-referencing against our values.

1252
00:57:57,208 --> 00:57:57,868
And values.

1253
00:57:57,928 --> 00:58:00,758
I think that can be a bit
of a misunderstood term.

1254
00:58:00,758 --> 00:58:03,548
It's just basically what's the really,
really important thing to you, right?

1255
00:58:03,609 --> 00:58:06,979
Um, so, uh, for example, we have
a colleague who hasn't been doing

1256
00:58:06,979 --> 00:58:08,419
their paperwork correct, correctly.

1257
00:58:08,539 --> 00:58:09,769
It's very easy.

1258
00:58:09,769 --> 00:58:11,779
I find I don't, because I don't do it.

1259
00:58:11,959 --> 00:58:14,989
Uh, Craig going, look, our
value of integrity means doing

1260
00:58:14,989 --> 00:58:16,219
what we say we're going to do.

1261
00:58:16,849 --> 00:58:19,819
You said you were going to do
this, you haven't done this,

1262
00:58:19,999 --> 00:58:21,439
so can we talk about integrity?

1263
00:58:21,529 --> 00:58:24,799
And that's, I find that very
helpful in staying a long way away

1264
00:58:24,799 --> 00:58:28,189
from you haven't done what I told
you, no change in language, and

1265
00:58:28,189 --> 00:58:29,689
therefore you are a bad person.

1266
00:58:30,049 --> 00:58:33,589
Which is exactly the medical, I hate
to use the word leadership model

1267
00:58:33,619 --> 00:58:35,839
that I see disturbingly frequent.

1268
00:58:35,989 --> 00:58:36,289
Yeah.

1269
00:58:36,289 --> 00:58:37,699
And then we use shame, don't we?

1270
00:58:37,699 --> 00:58:40,669
And, and doctors are already feeling
shame that they can't see their

1271
00:58:40,669 --> 00:58:43,129
patients in the way they want to
and all, all that sort of stuff.

1272
00:58:43,129 --> 00:58:43,579
So it's difficult.

1273
00:58:43,739 --> 00:58:45,576
I think I've already asked
you for your top three tips.

1274
00:58:45,576 --> 00:58:46,056
Keep going.

1275
00:58:46,056 --> 00:58:46,266
What?

1276
00:58:46,266 --> 00:58:48,546
So yeah, what would
you, what would you say?

1277
00:58:48,546 --> 00:58:51,336
Someone's just feeling really helpless
and stuck, but they are in a position

1278
00:58:51,336 --> 00:58:53,646
where they could influence and
change, they're not sure where to

1279
00:58:53,826 --> 00:58:57,096
I think my opening line to uh, if
they needed something would be don't

1280
00:58:57,096 --> 00:58:58,236
just do something, stand there.

1281
00:58:58,711 --> 00:59:02,202
Pause, analyze, think, don't move yet.

1282
00:59:02,322 --> 00:59:04,782
Just work out what you,
what the next steps are.

1283
00:59:05,083 --> 00:59:08,443
As I'm grateful to, one of my trainer
colleagues stood up in, uh, the Bristol

1284
00:59:08,443 --> 00:59:10,093
area, must be three or four years ago.

1285
00:59:10,423 --> 00:59:13,273
And you know what, Rich, when I first
heard you talk about this, I thought

1286
00:59:13,273 --> 00:59:16,093
it was all management bollocks,
but it really works, doesn't it?

1287
00:59:16,093 --> 00:59:18,493
And I go, yeah, it's a recent Toyota,
the biggest car company in the world.

1288
00:59:18,692 --> 00:59:19,084
it's interesting.

1289
00:59:19,084 --> 00:59:22,804
I've got a friend who's a, a, a coach
and she does a specific form of coaching

1290
00:59:23,044 --> 00:59:26,044
where they literally spend two hours
working out what the main issue is.

1291
00:59:26,427 --> 00:59:29,217
And I think, yeah, if you can actually
just work out what the main issue

1292
00:59:29,217 --> 00:59:30,777
is, that is part of the problem.

1293
00:59:30,777 --> 00:59:32,967
And I think, yes, a lot of, I'm just
thinking back to this, this session we

1294
00:59:32,967 --> 00:59:36,267
did with consultants where they were
so pissed off, so disenfranchised, and

1295
00:59:36,387 --> 00:59:38,577
we spent two hours talking about what
you're in control of, what you're not,

1296
00:59:38,577 --> 00:59:41,067
and the fact that you, you have to just
accept the stuff outside your control,

1297
00:59:41,067 --> 00:59:43,047
which they found incredibly difficult.

1298
00:59:43,047 --> 00:59:47,997
But actually when they worked out what,
what is the main issue that the one

1299
00:59:47,997 --> 00:59:50,457
thing, then you know what to change,
then you know what you can go after.

1300
00:59:50,457 --> 00:59:52,527
And everything else just that
falls by the side said, well,

1301
00:59:52,527 --> 00:59:53,637
I'm, I can put up with that.

1302
00:59:53,637 --> 00:59:57,297
I can put up with that, but this is
the thing that we really, really want.

1303
00:59:57,297 --> 00:59:58,857
And then you've got something to go after.

1304
00:59:59,048 --> 01:00:02,614
this, if you look at the original
productive general practice books, which

1305
01:00:02,614 --> 01:00:07,084
we, uh, uh, I contributed to a decade
ago, you'll find the start of each

1306
01:00:07,084 --> 01:00:10,384
module is first create your module team.

1307
01:00:10,743 --> 01:00:15,513
And I think I would advocate that
vociferously and violently because I

1308
01:00:15,513 --> 01:00:18,423
think if you do that, you can get the
average medic to do the bare minimum.

1309
01:00:19,011 --> 01:00:20,151
Okay, great.

1310
01:00:20,331 --> 01:00:21,711
So get your team around you.

1311
01:00:21,891 --> 01:00:23,721
Um, stop and pause and wait.

1312
01:00:23,901 --> 01:00:27,261
And there's one last thing I want
to ask you because I think I'm gonna

1313
01:00:27,261 --> 01:00:28,941
be asking this a lot more to people.

1314
01:00:29,301 --> 01:00:32,652
This thing about delegation, what would
you say to someone says, well, fine,

1315
01:00:32,652 --> 01:00:35,142
that's all very wanna good, but there's
absolutely no one to delegate to?

1316
01:00:35,427 --> 01:00:40,917
Well, it does reflect back to, um, uh,
team dynamics and, um, as you recall when

1317
01:00:40,917 --> 01:00:44,336
we first time I heard you saying that,
and I don't, it is probably not fair.

1318
01:00:44,366 --> 01:00:48,266
I'll take, it's not fair, but I'm
sure we can imagine a scenario where

1319
01:00:48,746 --> 01:00:53,786
someone has said this needs doing
perhaps not in a very comprehensive way

1320
01:00:54,236 --> 01:00:55,766
and just said, it's now your problem.

1321
01:00:55,916 --> 01:00:57,656
I think that's what I'm
trying to understand.

1322
01:00:58,046 --> 01:01:02,835
Um, in the delegation, there's a
difference between coordinating the

1323
01:01:02,835 --> 01:01:06,675
tasks that need to be achieved for the
team to achieve what it needs to achieve

1324
01:01:06,945 --> 01:01:08,745
and going, I'll do that, you do that.

1325
01:01:08,875 --> 01:01:12,151
And there's a difference between
that delegation, uh, which

1326
01:01:12,181 --> 01:01:13,681
refers on hierarchical power.

1327
01:01:13,741 --> 01:01:16,471
I am chief executive,
please, will you do this?

1328
01:01:16,653 --> 01:01:19,517
Answer yes, thank you very much,
because it's gonna need to be done.

1329
01:01:20,027 --> 01:01:22,337
Um, as opposed to, uh, I'm off.

1330
01:01:22,337 --> 01:01:23,237
I've gotta go and see a patient.

1331
01:01:23,237 --> 01:01:23,867
It's now your problem.

1332
01:01:23,867 --> 01:01:24,197
Goodbye.

1333
01:01:24,313 --> 01:01:27,343
And I think there's delegating and
dumping and I heard elements of dumping

1334
01:01:27,343 --> 01:01:28,933
in the first time we talked about this.

1335
01:01:28,974 --> 01:01:29,582
that's interesting.

1336
01:01:29,582 --> 01:01:30,902
And I think that's
probably what people ask.

1337
01:01:30,902 --> 01:01:32,072
Who can I dump this thing on?

1338
01:01:32,162 --> 01:01:33,722
And then they say, well, if I
don't know someone that's got

1339
01:01:33,752 --> 01:01:34,682
to, and I'm like, yeah, okay.

1340
01:01:35,032 --> 01:01:38,932
In aviation we have a phase that goes,
um, plan the flight and flight the plan.

1341
01:01:39,303 --> 01:01:43,653
And what that means is you spend the time
beforehand analyzing what is required to

1342
01:01:43,653 --> 01:01:48,303
happen for safe flight, uh, and actually
always having a plan B, always having a

1343
01:01:48,303 --> 01:01:51,153
plan B and often sees D, but that's not
what we're talking about at the moment.

1344
01:01:51,453 --> 01:01:53,823
And then you put the stress into the plan.

1345
01:01:54,633 --> 01:01:58,053
If I do all this in this
order, I am going to be safe.

1346
01:01:58,259 --> 01:02:00,869
And what you don't then have
is the cognitive bandwidth

1347
01:02:00,869 --> 01:02:01,589
of, should I be doing this?

1348
01:02:01,589 --> 01:02:02,399
Is this the right decision?

1349
01:02:02,459 --> 01:02:04,859
You don't make decisions on the hoof.

1350
01:02:05,009 --> 01:02:07,169
You do what decisions you've made.

1351
01:02:07,589 --> 01:02:11,369
And so I think going back to dumping
and, uh, delegation, if there's a clear

1352
01:02:11,369 --> 01:02:14,609
action plan, we talk about a breadcrumb
trail at work, is there a breadcrumb

1353
01:02:14,609 --> 01:02:16,469
trail that takes me from here to there?

1354
01:02:16,669 --> 01:02:19,579
And there are bits on the breadcrumb
tray, please, will you do that bit?

1355
01:02:19,669 --> 01:02:20,269
Yes, please.

1356
01:02:20,269 --> 01:02:20,929
Will you do that bit?

1357
01:02:20,929 --> 01:02:21,889
That's delegation.

1358
01:02:22,106 --> 01:02:24,506
Not just here have it and
I never wanna see it again.

1359
01:02:24,536 --> 01:02:25,076
Yeah.

1360
01:02:25,136 --> 01:02:26,576
Oh that's a much nicer way of thinking it.

1361
01:02:26,835 --> 01:02:27,705
Richard, thank you so much.

1362
01:02:27,705 --> 01:02:31,125
Now listen, if people wanna find out more
about you and Zytal, where can they go?

1363
01:02:31,183 --> 01:02:33,433
Uh, we have a, uh, a website
that's always being changed,

1364
01:02:33,433 --> 01:02:36,413
which is Zytal, uh, XYTAL.com.

1365
01:02:36,613 --> 01:02:40,723
And always, I mean, I suspect we have
the, uh, uh, the same problem, Rachel.

1366
01:02:40,843 --> 01:02:44,473
We always love chatting to people and
finding out stuff and go, oh, is that what

1367
01:02:44,503 --> 01:02:45,613
it looks like from where you are sitting?

1368
01:02:45,613 --> 01:02:48,133
'Cause where it looks like
I'm sitting, so, so the email

1369
01:02:48,133 --> 01:02:50,143
is richard.more@zytal.com.

1370
01:02:50,275 --> 01:02:52,975
it's been really fascinating for me,
Richard, and we'll, we'll get you back

1371
01:02:52,975 --> 01:02:54,355
on 'cause there's so many more things.

1372
01:02:54,355 --> 01:02:56,785
And if people have got
questions, please email in.

1373
01:02:56,915 --> 01:03:00,475
hello@youarenotafrog because we can
get Richard back to q and a perhaps.

1374
01:03:00,475 --> 01:03:03,685
And you know, I think there's a,
there's a lot of yes buts and so

1375
01:03:03,685 --> 01:03:07,701
whats, but um, I think Richard, you've
seen, you've seen it all haven't you?

1376
01:03:07,701 --> 01:03:11,901
And I think you've seen all the objections
and stuff like that and, um, this stuff,

1377
01:03:11,961 --> 01:03:15,561
this stuff really works and it, it is
not the case that everything is going

1378
01:03:15,561 --> 01:03:17,061
to shit and it will always be like

1379
01:03:17,371 --> 01:03:21,486
We find it, I find it phenomenal
that we've been in 1300 practices.

1380
01:03:21,651 --> 01:03:22,111
Absolutely.

1381
01:03:22,366 --> 01:03:23,026
So get in touch.

1382
01:03:23,026 --> 01:03:25,186
Anyway, Thank you so much and
have a good rest of the day.

1383
01:03:25,223 --> 01:03:25,683
And to you.

1384
01:03:25,683 --> 01:03:26,133
Cheery bye.

1385
01:03:27,927 --> 01:03:28,857
Thanks for listening.

1386
01:03:28,957 --> 01:03:33,417
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1387
01:03:33,507 --> 01:03:38,337
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1388
01:03:38,417 --> 01:03:42,877
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1389
01:03:42,877 --> 01:03:45,847
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1390
01:03:46,221 --> 01:03:49,741
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