What happens when a consultant surgeon embeds agile ways of working into the messy reality of an NHS operating theatre?

In this episode, Joe sits down with Rob McAdam, a Consultant Upper GI and Bariatric Surgeon who also happens to be a qualified Scrum Master. Rob is a rare example of a practitioner who hasn't just read the theory - he has spent years embedding agile ways of working into the heart of the NHS.

For Rob, the "stable team", the "prioritised backlog" and the "retrospective" aren't just agile buzzwords - they directly map onto the most important parts of surgical practice. In this deep dive, we explore how he moved his department away from rigid, linear planning and toward a model that values human collaboration over top-down protocols.

Rather than asking clinicians to work harder inside a rigid system, this work asks a different question: What if we trusted teams to redesign how the work gets done?

In this conversation, we explore:

• Why the pandemic forced a shift to 24-hour sprints - and what was lost when things "returned to normal"
• How a theatre list already resembles a Scrum team, and what that unlocks
• Why traditional list planning produces garbage-in, garbage-out results
• What surgical story points look like in practice, and how they've increased capacity without burning people out
• How proper retrospectives surface the invisible frictions a debrief never catches
• A real example of a tiny AI-assisted fix that's now spreading across an NHS trust
• Why "the HIPPO effect" still shapes medicine - and how Agile challenges it
• How psychological safety and team-led improvement could transform frontline NHS delivery

This episode is especially relevant for:

• Clinicians, surgeons and NHS leaders
• Public sector commissioners and service designers
• Continuous improvement and transformation teams
• Anyone working on adaptive, team-led change in complex systems

Stay connected:

• Follow Joe on LinkedIn: https://linkedin.com/in/joseph-badman
• Read the latest chapters from our upcoming book: https://relationalservicedesign.com
• Master the methodology: https://basistraining.co.uk/
• Partner with us: https://basis.co.uk

I heard about your work. A surgeon applying agile ways of working in the NHS to theatre practice. And this is like catnip to me.

I just absolutely had to know what was, what was going on. So tell us, tell us who you are. What are you doing?

Yeah, what am I doing? What am I doing? So my name is Ron McCallum.

I'm a consultant, general upper GI and bariatric surgeon based at a trust halfway between Liverpool and Manchester. So not far from where we are today in Media City. Yeah, it's an odd thing to get into. I think I'm possibly.

Me and my mate are possibly the only clinicians who are also qualified Scrum masters as well. And we both got into it because we started a few years ago now, pre pandemic, looking at a project around digital consent.

He's an anaesthetist, I'm a surgeon and we thought this is an obvious thing to be looking at. Now, that project didn't go anywhere and that's fine.

But what we did do is worked with some software developers and they used an online kanban board trello that I think quite a lot of people have heard of and ran the project because we were distributed all around the country using that.

And although the project didn't get anywhere, I thought this really makes a lot of sense, you know, meeting every couple of weeks and seeing how the project's progressing and bringing everything together, making it very visual. So I kind of asked the software developer, where does this come from? And he said, oh, it's agile working, we use it all the time in software.

I'm being somewhat curious.

I, I started, you know, picking up a few books and I, I think the, the gateway to all this was the, the Sutherland Red Book, you know, how to do twice the work in half the time, which for, you know, hard pushed NHS consultant seems, seems a good place to start. So we kind of. Yeah. And I found that really accessible. I thought it was a really well written book and, and kind of went from there.

So that was the, that was the kind of gateway into it. And the first practical use really was at a time when I was clinical Director of General Surgery at mitrust. Now it sounds very grand, it's not.

It's the lowest level of kind of medical management. But it does mean your line manager for maybe 60 doctors. Right.

Which is a reasonable chunk of people and certainly a reasonable chunk of additional work.

And one of the things that NHS England dropped on us at short notice, which was they tended to do, was that they needed a pathway for particular patients, some of our sickest patients that come in needing major surgery, major abdominal surgery, and the way they leverage these things or tend to is to say, unless such and such is done, the tariff that the hospital receives is. Is not going to be the full tariff. You're going to lose a bit of money. We want you to do something and we're going to incentivize you in this way.

So this was a bit of a burning platform, but it was a really complex project in as much as it involved people in A and E, people in icu, anaesthetists, surgeons, geriatricians, because it was all around older patients. And we were really, really struggling to get everybody together. Everybody was busy and we couldn't get a date in the diary.

So whilst that was going on, I actually set up an online Kanban board and online Trello board, and we worked as a disparate team and collaborated using that, I guess, agile approach.

And in the meeting that eventually got scheduled when everybody could make it, we presented the divisional director with the finished product that we'd already iterated two or three times and agreed on. So this was a bit of a kind of mic drop moment. It's kind of like, well, we've all got together, let's discuss this project.

And the team went, no need, we've done it. Where did that come from? You know, that was. That was. And what's this?

So that was my first introduction, if you like, to using it in an NHS environment.

And I found it really accelerated some of the stuff that goes on behind the scenes that patients don't need or don't want to see, but sits behind all the services that we provide.

So tell me about some of the other experiments that you've run, because I think they're so tangible and would, I think, make sense to people that are working outside of healthcare as well. So talk to me about some of the experiments that you've run since and what the outcomes of those experiments have been.

Yeah, well, we've done a number of different things.

I can talk about our pandemic experience, if that's of interest, because the next thing along the lines, having done the work that we did in developing pathways and standard operating procedures, we presented that we were the first hospital to present at a national meeting and get it published in abstract form to kind of resounding indifference, I think it's fair to say I never actually met. It was a meeting in Telford. Nothing against Telford, but I couldn't make it, actually. And the slot where one of My colleagues was presenting.

It was one of my junior colleagues was like 9 o' clock on the day after the night out and I think it was him, you know, a couple of stray dogs and that was about it. You know, there wasn't, there wasn't a huge amount of, to, you know, no ripples. But you know, we were there first.

But things really came into their own during the pandemic when everything was, you know, turned upside down in a heartbeat.

So from running a department of 60 people in a traditional way with traditional rotors and forward planning and all that, we suddenly lost about 25% of our staff in a heartbeat. Not always the same 25%.

There was a significant chunk of people who for chronic disease reasons never came into work for about six months, but others who were either acutely ill or self isolating because there was somebody in the family that was, that was testing positive and you forget what that was like. I think we've all been rewinded this week because the reports just, just dropped of how really challenging it was at that time.

And we sadly lost one of our orthopedic middle grades early on in the, was one of the first healthcare associated mortalities from, from COVID So it was a really, really difficult and dark time and challenging to keep things going.

And what I found was the obvious thing seemed to do would be to flip to an agile way of working because nobody was really quite sure what resources you were going to have at short. So instead of doing all the traditional forward planning, we flipped and we had daily stand ups.

We had a daily meeting at 8am where we looked and saw who was in that day and then we fairly ruthlessly prioritised our workflow. First job was obviously to keep the doors open and keep an emergency service going.

Second thing was to make sure we were looking after safely the existing patients that we had on the ward. The third priority was actually looking after our staff. So if somebody looked exhausted or had been working over the odds, we'd send them home.

The next thing we did was adopt some of the principles of self organizing teams. So we said to the, to set to our most junior doctors instead of doing the kind of traditional this is what I want you to do.

Said, well you're, you're all a bunch of bright sparky 22 year olds, go and find some useful work to do and work out between you. And they were like yeah, fine, you know, no problem with that.

And then we were able to have some staff left over that we were donating some juniors to our Intensive care unit and our emergency department because we were fairly well organized. And lastly, we've got some really, really excellent colorectal surgeons who were desperate to keep their cancer service going.

And with the assistance of the way we were working, we were able to free them up, plus middle grades to go and assist them. So fairly uni weekly, we actually maintained our colorectal and some other cancer services going throughout the pandemic.

And I'm tempted to quote the words of one of your colleagues, Matt Barnaby, kind enough to give us a seat at the, a couple of us a seat at the training that basis offers. And one of the things that he said that really resonated with me was when the situation is more unstable, the cycles need to be shorter.

So we were essentially running our service in 24 hour sprints, 24 hour cycles, because we couldn't realistically predict what, what resources we were going to have, you know, from one day to the next. So why try?

And the penny dropped really for me when I, when I met one of the other clinical directors of a similar sized department in the corridor shortly, so midway through the pandemic and he said, how are things going for you? And I said, well, obviously challenging, but okay, yeah, we're keeping our heads above water.

And he said, I'm having an absolute shocker of a time because I do one rotor and I then rip it up the next day. Yeah, and then I do another one and then I rip it up the next day. And it just dawned on me, I was like, well, why are you doing that?

Yeah, why, why, why even do that?

But I think this speaks to the, the kind of mind shift that you get if you start thinking in agile terms, then you start realizing that that doesn't actually make a lot of sense in a really chaotic and unstable environment to be to me doing all that forward planning only to discard it. So that for me was the moment at which I thought, right, okay, this really has something to offer. But thankfully we're not mid pandemic very often.

Maybe we'll come onto it. There's some stuff that we learned that we possibly have lost and should be adopting a bit more.

But that led me to get in touch with JJ Sutherland via LinkedIn and in a slightly embarrassing sort of fanboy moment. Just write you a message saying, I really like your book and by the way, it's really helped.

Just for your FYI, you've written a book that's actually really contributed to some tangible things that made difference for patients.

And he was good enough to answer me and we've ended up sort of, I wouldn't say working together, but he's put me in touch with some of his colleagues at Scrum Inc. And for the last six years or so we've been trying to see how agile might work in some aspects of the nhs, which I think we all know really needs some major interventions at the moment if it's to survive in its current form.

If you're still here, my assumption is you're finding this conversation useful.

We're recording these interviews because we think it's important to share stories of people who are leading and designing more human impactful and relational public services. And we'd like as many people as possible to see them.

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You can leave us a comment and let us know why you stuck around, or you could subscribe to the channel. And honestly, I've got no good reason for that other than it would cheer me up. Okay, back to the interview.

Well, I'm interested to talk about some of those interventions because most of our work, as you know, is in. Is in local government. We do some work in healthcare as well.

And I think almost universally the people that we talk to that are interested in working in an agile way are frustrated because during the pandemic the penny dropped for so many people. Oh, wow. It doesn't really make sense to work in this linear way when we're dealing with so much turbulence.

We really do need to shorten the feedback loops and they just sort of acted themselves into a new way of thinking, started working in a much more agile way, but then have seen working practices revert back to how they were pre pandemic now that the context has changed. But what's really interesting about you is that you've taken that momentum and you've tried to do experiments.

I mean, I hesitate to say in stability, but relative stability by comparison with the pandemic. So let's talk about some of those other interventions that you've tried since that point.

Yes.

So the significant thing for me was when I was organizing some slides actually for an introduction to Agile for some of my senior leadership team at my trust. So I talked about how useful we'd found it in the pandemic and on the back of that I organized a webinar.

Being slightly pushy and not knowing my limits, I just kind of phoned Whitehall and said, you guys seem to be doing some interesting stuff in Agile.

Which I'd come across in a meeting where a guy called Mike Waring, who is Director of Defense Design was, was presenting and I thought it was really, really interesting.

So he and Rear Admiral Paul Beattie came on a call and my senior leadership team joined that and I had to something of a newbie, sort of introduce the subject and I thought, I'm just going to embarrass myself here. I don't really, you know, these guys have been implementing Agile throughout a massive organization.

They've got loads of experience and loads of stor to tell. I've just got, you know, sort of the naivety of the, the enthusiast to, to introduce.

So I thought, well, most of my audience are sort of largely, I would imagine, ignorant of Agile and Scrum, so I'd probably need to need a graphic. So I pulled one of those graphics, you know, the sort of thing that looks secular, you know, feeding into a loop and a Scrum team and the rest of it.

And so I thought just sort of explain this.

So as I was making my slides it kind of, it dawned on me that the stable Scrum team, the objective done, you know, the things that are completed and the definition of done, the working from a prioritized backlog that draws from a, from a, from a longer backlog and is, and is prioritized according to business need actually really reminded me of the best bit of my job, which is the time I spend in theatre.

Yeah.

Because it maps across reasonably well that the. When we come together for a theater list, we've got a stable team that stays together for the duration, half a day, whole day.

We work off a, a list that's been pulled together. That's right sized if you like, for the, for the team and the time. And that is pulled in turn from a, from a wider backlog.

In our case, what we call a PTL patient treatment list or colloquially a waiting list which is prioritized according to clinical need, not business need, but clinical needs. Obviously the people at the top of the cancer patients and people with urgent, urgent issues.

And that's constantly being reprioritized just in the way as like an industry would have A backlog that they're working from.

And the other thing that we have to do at the end of the list, it's mandatory, is a form of a debrief which is not dissimilar to the ritual of the retro.

Yeah.

So I thought, well, this is actually, you know, it's really quite, quite striking.

And this was just occurring to you as you were talking?

Yeah, yeah. I was like, this is a handy analogy. It was a bit of aha moment and it was, was like that.

And perhaps it shouldn't have been a bit of an aha moment because Jeff Sutherland, I later discovered one of the co creators of Scrum, as you know, has got a clinical background. He was actually a professor of radiology at the University of Denver or somewhere in, in the Midwest.

And some of the work that Scrum Ink has done has been in clinical environments.

So anyway, I, I, I sort of put this across as a kind of hypothesis and I, and I thought, you know, I'm super clever, I'm going to solve, solve this issue immediately by, everybody's gonna go, yeah, of course, of course. Why didn't we see this before? And so I, I did this, this kind of exposition of why I thought it was a good fit.

And then there was a pause and, and then Rear Admiral Beatty said, yeah, we find that a lot. And I was like, oh, completely deflated. I was like, oh really? It's not novel and new and exciting. No.

And he just said any kind of, any situation where people are allowed to work together and as effectively as they can tends towards this kind of organization. You know, this is just what, how humans tend to like to work together.

Yeah.

And he said we find similar little, little clusters of that kind of thing going on in successful bits of the military and successful. I mean, I guess you could, you could, you could think that through.

You know, lots of, lots of smallish teams working together for fixed periods of times are high performance teams in, I don't know, in sport and military and all these areas.

So it's, it's an insight, but it really struck me that it was a potentially important insight, particularly because it's no surprise that the, the NHS is under pressure to perform for the money that's put in.

Again this week there's been a report, isn't there, from the Commons Public Accounts Committee that says that there's not a huge amount of correlation between the amount of money that goes into the NHS and the amount of results that it produces and that's a bit sort of counterintuitive. So I looked at this and I said, right, okay, fine. This does map across quite well.

If we thought about a theater session, for example, like a scrum team, and we know that scrum teams seem to work, you know, maybe four to ten times more effectively than other ways of working. If we. If we kind of put the model of one over the other, what would we do different?

Yeah, if we said, this is like a scrum team, so what would we do different? There were two areas.

One is that we would be probably more specific about the size of the tasks that's going into that sprint planning process or the list planning for me, list planning, the better to use the time that we've got. And the second bit is at the other end of the theatre list.

We do do a debrief, but in most situations it's not particularly in depth and it's mainly focused, as it should be, on any safety issues, because obviously, if there's been an incident that needs to be reported up, and there's a whole governance pathway that sits behind that, as there will be in social care, I'm sure. So we do the right thing if there's been an incident, but we don't actually think about how we've worked.

We don't routinely just spend five minutes at the end of the list and have a conversation about how could we have done better, what little things could. Might we have changed that would have improved things. So that's our.

That's our hypothesis is that if we look at those two bits, they're the two standout bits. I'm sure you would agree in your environment and in any other environment. Don't touch the team. The team is fine.

You know, don't tell the surgeon how to do his operation or the scrub sister how to set a trolley. Whoa. Yeah, yeah, yeah, yeah. Angels Fear to dread and all that, you know, Certainly don't.

Certainly don't tell the anesthetist, you know, what kind of anesthetic to give, you know, that there's. There's lots of reasons why practitioners should be left to do, you know, what they're good at, and that's fine.

But I guess it comes down to, you know, there's been books, isn't there, sort of entrepreneurial books about saying you're spending time thinking about being in the business or working on the business, if you know what I mean.

We as clinicians are so focused on actually doing the job that we don't take a step back and ever give ourselves just the time to say, well, how did how could all of that been made a bit easier? How could that be made a bit slicker? How. How. How come we're making the same.

We're hitting the same buffers and delays and irritations time and time again. And that's the offer, I think, that Scrum has, is that if you.

If you systematize that, if you do it regularly, and if you cure some of the recurrent small issues, those things get banked, like compound completely. Next time that won't happen.

You'll surface some other things, but you'll be going a little bit faster and the day will be a little less challenging because there's nothing more exhausting than a day in theater where you're constantly firefighting and reorganizing things. And, you know, that's. That's where, you know, errors happen as well.

So I'm all for easier, more productive, you know, smoother days in theater because they're the best.

So talk about the lists and. Right. And Right. Sizing them. Because what you're talking about there is, I suppose, using some kind of collecting collective intelligence to estimate.

Yes.

How.

Yes.

Long we think these things are gonna take. So what was happening before what happened.

This is really interesting because we have a. A list planning process, we have an admissions process, everything big.

Hospitals, you know, clearly have to have different departments that do different things. So the. The standard way, even now, of.

Of estimating how big an operation is going to be or how much time it's going to take is literally a tick box on the back of a listing form to the nearest half hour.

And who's doing that?

Whoever is seeing the patient and listing them. So it could be me, or it could be somebody quite junior that my secretary's rung up and said, you know, so and so's called in sick.

Could you spare an hour in clinic? And they've come down and it's the first time that they've done my clinic.

And they don't know too much about what I do, but they're confident enough to put. So there's all sorts of errors starting to creep in beforehand.

And then you get on to things like pooled patients because it's a bit like, you know, the queue in a. The queue in the post office. You know, it's. It's easier to have one pool queue and then pull people into the event.

That's much more efficient than sitting in individual queues. So we have quite a few patients for common operations that are pooled amongst surgeons. And then they're.

That backlog is pulled through into the next available list. So there's no guarantee that you or your team even has seen patients.

So we're all working off information that's fed into the system right at the beginning. And if that's slightly or even grossly wrong, that just gets propagated, sort of garbage in, garbage out principle.

And when you say wrong, you mean this is actually going to take way longer or way less.

Yes, exactly.

So we did a little study on that because allegedly all, you know, surgeons and clinicians are scientists, so respond to data more than, more than anecdote. So we thought, well, what's the best way of looking at this?

So let's look at 50 patients listed for common operations, keyhole removal of the gallbladder, which is probably the commonest one that as upper GI surgeons we do. And what we found is that consultants tended towards underestimating the time that it would take them. No false modesty. You see, that's the thing.

It will be out in a heartbeat. Yes, that's right.

So there was a tendency for them to underestimate, but there was a tendency for junior doctors, can't call them junior resident doctors. To overestimate.

Yeah.

And because there's more of them than there are of the consultants, if you get a sort of mixed list, you, you know, it becomes largely guesswork. Yeah, roughly ballpark. But it, but you can get big errors.

And the best example of this and was a list that I did, it was a whole afternoon, so 1:30 till 5:00 clock that we had two cases on and we were finished by half past three. Now I'm a relatively quick surgeon because I've, you know, been around the block a few times and had a quick anesthetist with me that day.

And we just, we actually went back to the original listing forms and said, we're just wasting precious time. You know, you've paid for the, you know, the heating, the lighting, the staff, everybody, everybody's paid to be there.

And yet we're utilizing probably 45% of the available operating time. You know, that's a luxury we can't afford.

So we went back to the original listing forms and one procedure was listed for one and a half hours, the other for two hours. Now admissions will book a list for three and a half hours.

You know, the data, a sea of data and a swamp of data. Everything you do in theaters is tabulated and entered into, into a management system. We must be able to use a bit more logic and a bit more science.

So that led us down the route of starting to look at large volumes of data, plotting histograms for common operations, and actually doing some kind of rational work about, you know, let's, let's be realistic about this. Let's plan a list according to what actually happens for this particular surgeon under these circumstances.

If you do that, you actually find that you're far more effective at filling the time.

So you're looking at the literal time surgeons have taken to do these operations in the past and then using that data to informalist planning in the future.

Yeah, exactly that. And interestingly, every single. And we're very embryonic stage, so we watch this space. But all the hallmarks are from the original.

The early work is that this is going to be quite powerful.

Every single surgeon that I've shown this to wants to know, because I think surgeons are naturally curious and then also favorite subject is very often themselves. Put myself in that way. That's very rude about surges. But they are, you know, they are reflective and invested.

You know, God knows you shouldn't be doing the operation if you're not those two things. And if you show people their own data for their own work, they are really curious about it and want to know and want to be a part of that process.

Because sometimes with the best will in the world, the data that the NHS collects is, should we say, not of the highest quality. And ultimately we, we carry the, you know, the responsibility for using those resources.

I mean, this, this whole project was kicked off by the fact that my, one of my colleagues in management sent me a kind of jokey text saying, I'm gonna have to have a word with you because all your list running. And I was like, well, this is confusing. I, I only do what the, the management put on the list. They've got the hospital books for me and I'm.

But I am probably a bit quicker than many surgeons and, and that's, and the errors are compounding. And it means that I'm, I'm under running and I'm not using my resources. And that comes back to me. So where are you getting your information from?

You know, when, when these things are booked and the information was just coming from these bits of paper. So if we can, if we can get better data, I think we can do better planning. And of course, the, the way in the 21st century to.

To do that is to not necessarily run the numbers yourselves, but to utilize artificial. In artificial insemination, then I wouldn't use. I don't think that's a very. That's a really bad idea to use artificial insecure. Yeah, that's right.

I mean, reading between the lines, I think you were going to say AI.

Yes, quite. I was building up to it, then. I was building up to it.

So. And I think you're experimenting with this, aren't you, within a closed sort of data set within the Trust?

Yes, yes, yeah, we absolutely are. And the interesting thing is that if you can think of your operative times as a.

As a normal distribution, as, you know, everybody who does practical things knows sometimes the thing that you do will be dead straightforward and other times you'll struggle and things will slow you down. But that's not as chaotic as you might think. You know, if you do enough of them, you'll begin to show that skewed normal distribution. And we're not.

I'm not for a moment suggesting that we schedule everything so tightly that you only work off. Off the mean of all these, These procedures.

You can, you can build in some comfortable gaps by perhaps using the mean plus 1 standard deviation or 2 standard deviation, however you want to do it. We're just. We're just tweaking those things at the moment because. And this comes full circle back to some of the principles of SCRUM that we were.

We were talking about. I'm all for utilizing really precious NHS resources as well as I possibly can, but not at the cost of, of the staff, if you know what I mean.

You know, the, the surgeons, I think, will be fine with it, but we've got to remember that we're working with human beings who scrubbed in theater, who've got other stuff going on. The, the anesthetic assistants, the operating department practitioners, they've got to. They have a voice as well. And it's.

They're equally important as to have you had a good day? And really, interestingly, all the evidence suggests that the sense of satisfaction that people get from a.

From a slick list that's gone well and has been well planned and fills the time appropriately is. Is significant. And people like that.

I think the general principle that people like to come to work and do a good job and feel, you know, at the end of the day that, that things have gone really well and have flowed nicely is what we're aiming for. So we're starting to roll this stuff out and do some actual kind of structured trials.

And we are looking at what they call, you know, the operational research is called balancing metrics. So, you know, we're going to measure staff satisfaction and make sure that that's not compromised.

We're going to measure on the day cancellation rates to make sure that we're not bringing people in and then canceling them at the last minute because actually, we got it all wrong. Yeah. And all of those kind of things are, I think, super important. So we're not. We're not pursuing efficiency at all costs.

We're doing it gently and proportionately and responsibly. But I think there's, there's the prospect of some real breakthrough gains.

So what are the. What are the initial. Initial findings? Are you finding that you're able to do more surgeries? Yeah.

Well, this is where it gets interesting and it again draws on, on the. The SCRUM principles. You may find it slightly strange, as I do, that the nhs, the way the NHS analyzes operating lists is by. Largely by time.

So they've got this concept called capped utilization. In other words, you can't just keep operating all night and do 120%. It's capped at 100%.

But the target is that overall, a department should be delivering maybe 85%, 75, 85% utilization of the resources. But what there hasn't been, historically, is any attempt at quantifying the actual work delivered.

So you get into the really strange paradoxical situation whereby If I do three cases and finish 20 minutes early, it's under run.

Yeah.

If somebody in an extra theater does two cases exactly the same as the kind of thing that I was doing and finished exactly on time, it hasn't underrun. And therefore that list gets a tick and mine gets a. Gets across against it.

So in the same way that SCRUM encourages people to do that kind of planning poker thing at the beginning and actually talk about the quantum of effort that's required to do something, we're starting to introduce the idea of if surgical story points, you know, surgical points.

Yeah.

Which is getting the experts in the room, the surgeons, to say, right, okay, how big an operation is this? How much bigger is this operation and that one in relative terms, and do that relative sizing exercise.

Importantly, that's not so that one surgeon can say, I'm doing 50% more work than you. It's so that we can start sort of rationally planning those lists in the same way that SCRUM teams can do.

So as a kind of pathfinder with this, I've said, well, I put my money where my mouth is. Let's look at the kind of things that I do in my practice and assign them some, some points. So a small umbilical hernia would be three points.

The massive parasophageal hernias where half your stomach's in your chest and, you know, all that kind of thing that takes half a day to do laparoscopically, 21 points. And we use the Fibonacci scale like it's recommended.

And what's really interesting over the course of this year is doing that I've started to move towards, with my booking clerk saying, right, okay, instead of as well as time, let's look at the amount of points that we're actually delivering to the work that we're delivering, not just the time that we're using. And if you do that and you, you slightly push the envelope and say, that was comfortable. Can we go a bit further?

I've gone from an average of 15, 16 points per session, half day, session, up to 21 points per session. Now, if you just looked at utilization, you wouldn't necessarily notice that, but it's.

I'm doing possibly the same amount of cases, but they're more complex or they're the same complexity. And there's one more on the list than there would have been, you know, around Easter time.

And I'm trying to, I'm trying to get people to adopt this and they are starting, and certainly the surgeons are starting to, to get it.

There will possibly be a bit of friction having that, you know, having the conversation about, you know, relative sizing, relative, you know, for procedures. You know, some people will do something, some people would do others. But that conversation is going to be really interesting.

Well, that's where the interesting conversation, I think, is to be had, isn't it?

Yeah, I think.

And it's in the difference that we get closer to the reality.

Absolutely, yeah.

So we are, we're going to start having those conversations in different specialties and say, okay, for orthopedics, so for standard, total hip replacement is 8 points. What's a revision hip replacement? What's. What's a reverse shoulder? I'm not an orthopedic surgeon, so don't be.

Anyway, all these kind of super complex stuff. Where, where does that sit? And again, importantly, it's not, as I'm sure you, you would agree in. It's not about comparing apples and pears.

It's not comparing Mr. Pink with Mr. Brown with Mr. Blue. It's about an individual's team saying, right, this is comfortable for us. That was okay.

We, we tried to push it, that wasn't great. So let's drop back down again. And it's kind of yesterday's weather thing. How did it go when we did such and such? Yeah, that was fine.

Give you one very brief example. I did a list this Monday, so what, five days ago?

Yeah.

And we've, we've kind of gently increased the, the story points, the surgical points. And this was a three session day, so it was 8am to 8pm now. Right.

That's really, as you might imagine, it's much more difficult to, to predict a list that's, you know, 12 hours long than it is three and a half hours. That's easier, the errors go up the longer you, you're predicting for.

But I, I looked at it and I thought, well, let's go, let's see if we can get 21 points done per, per session. And we did, we finished absolutely bang on time. But our operating department practitioner had gone because his list, his day's work finished at five.

So we all, at the end, we had a proper debrief like we were talking about. Yeah, let's have a proper debrief. How's it gone? Yeah, great. It's been a really good day. We've got loads done and it's marvelous.

And I just said, I said I thought our ODP looked a bit too busy. And the person who'd come in to replace him said, well, before he went, he told me that he's only had 20 minute break the entire day.

So that was it makes two points. One is you can't push the team too hard. There's solutions to that.

We might be able to say, look, if we're going to do this, we need an extra ODP or he needs to have lunch relief or something. But also, if we hadn't had that, that detailed debrief, that would never have come to light. Of course, that would never have come to light.

That would have been gossip and probably possibly a bit of grumbling in the tea room.

Yeah.

But it would never have been surfaced. So having that formal little ritual at the end, how is everybody? Let's check in. You know, did every, was everybody comfortable with that?

If not, say so.

And this guy said, well, you know, I mentioned his name, but before he went, he said, I'm, I'm a bit shattered actually, because I've been running around like a headless Chicken all day trying to sort things, you know, get the patients. And it was all legitimate work. It was all the work that.

Because it's complex stuff, you know, when you're doing morbid obesity surgery, you have to position people and all that. So, you know, he did a great job, but I think he was shattered at the end.

Perhaps. Not sustainable?

No, absolutely not, no, absolutely.

And that's what worries me, actually, is that occasionally you get places that, within the NHS that are piloting things and a sort of trumpeting things called hit lists, high intensity theaters, and they're kind of like, wow, this is the next thing the NHS is needing to deliver in spades. This is the way we do. We're going to put, you know, 25 of these things on a list and we're going to crack through them. We're going to have a little.

And you just kind of think to yourself, is it. Is it sustainable? Is it. Yeah. Is it exhausting people? Is it burning people out? And that's a worry.

Yeah. Which. Which completely defeats the point, doesn't it? I mean, it's all. All well and good having a great day in.

In theatre, but if that's not replicable because people are burnt out or they go off on sick, then, yeah, you. You lack the consistency. And overall, over a longer period of time, then that efficiency that you gain will be.

Will be lost and it'll leak out completely. But I want to come back to the. The retrospectives, because that's a really, really great example. But just to wrap up this, the sort of idea of.

Of surgical points, what it sounds like is the early sign is that more surgeries are being done, which means, of course, people having their surgeries sooner, better outcomes for patients. But also my assumption is savings, that the list is getting done through, done much more quickly. Is that fair to say?

Yes, it absolutely is.

I mean, I think it's fair to say that most trusts are behind their activity plans and there is a strong push to try, maximize the assets that we're using. And the upside of all these things is really, really highly significant.

I do have to say, though, and I'm really heartened by this, certainly in our trust, if you talk to the finance department, they, for a finance department, they are not particularly interested in talking about finance, if I'm honest, which. And they would much rather talk about patients being treated.

And then the quote that I get very often is, you know, we take care of the patients, the finance will look after itself.

Yeah.

And I found that really heartening. I thought that was great, you know, and I've got a lot of time for. For that attitude. So, you know, the more patients we're.

We're treating, the less people. Less time people are spending on waiting lists.

As long as we're doing it safely without burning people out and without compromising, without cutting corners and those kind of things, I. A win, win, win.

It's a win for the staff, it's a win for the patients and it's a win for the Trust and the broader nhs because, you know, this is public money that we've been entrusted with ultimately, and it's, you know, it needs to be spent wisely.

Yeah. Let's talk about the retrospectives. So how that was a great example of how something was surfaced that you can now act upon.

Yeah.

How are you. How are you going about. I mean, literally, how are you. How are you doing the.

The activity of the retrospective in a way that's different to the debrief? And then when you identify things that didn't quite go so well or small improvements that you want to make, how does.

How does that actually happen and not get lost?

Yeah. So, as I say, there are some safety guardrails part of any invasive procedure.

And one of them, they're called natsips, National Safety Standards for Invasive Procedures. And one of them is a debrief at the end. But it has to happen, but it's not specific about how, you know, what, what components there are.

And very often, too often, it's kind of like, yeah, it was everything. Anything for the debrief? No, as, you know, shouted down the corridor or somebody's getting the jacket on and heading out.

So what we, what we did, trying to. Trying to push this in.

In this initiative in a very kind of light touch way, the first thing, rather than trying to change anybody's behavior, is just to look at the. The documentation around that. Because on the back of the.

The big A3 sheet of paper, which is where the patients and what procedures they're having is, Is written on the back of that is a. Is a box that, that says, you know, what went well, what went badly.

So the first thing we thought was, well, let's just harvest that information and pull it together and see. So it's. These days, the AI can do that. AI can do that for you very easily.

So we just simply took all the information from a week's worth of debrief documentation in a. In the Trust and we fed it into the AI and, you know, immediately that gave us a kind of ranked list of Things that were problematic.

And again, this is not, this is not the, anything that was a kind of potential patient safety issue goes up a different pathway, quite rightly so governance stuff goes, goes to the government and just to reassure everyone, that happens very often and it's very, usually very minor stuff, you know, sort of. But if there's a near miss with something then that goes that way.

But this is just the kind of the, the kind of low level grumbling things, you know, the niggles, the, the, the, the got a slightly late start start because there wasn't anywhere to see the patients on this particular ward or the ward staff weren't ready or the patient was a reproductive age female and they hadn't had a pregnancy test done. And we checked and this was wrong and that swab was, it's all the kind of little, little.

And if you do that across a whole department for a week, then you, you start to create yourself. What you might say in scrum terms is a backlog that's making it real.

It's all about, you know, agile's making the invisible visible, starting to make the things that are going on everywhere that everybody kind of shrugs their shoulders and says, you know, what a shame, starting to make it more visible. And then what do you do with that?

Well, what we're hoping to do with that is to, is, is to encourage teams to fix the stuff that they can fix themselves, which is some of the things and, and obviously like everybody, there's some really resourceful people who come up with, you know, ideas and, and changes. There's some stuff that would be, you know, requires capital investment or, you know, that's never going to happen.

And you know, if somebody says, oh we, yeah, we need a, we need a helipad on top of the building so that we can, yeah, that's never good. Do you know what I mean? It's kind of like masses.

There's a, of the occasional grandiosity that's, that's in there not often, but there's that chunk in the middle that with a bit of work we might be able to address. So that's the, that's the bit that's fertile ground for, for actual traditional service improvement.

But unless you, you actually start collating and harvesting and aggregating that information, it becomes hellishly difficult to, to go to the finance director and say, please fund this. Yeah, because it's money that's dribbling through his fingers.

But he doesn't see it because nobody's showing it to him quite how much it's impacting what he can deliver for patients on a day to day basis. Just to give you one little story of how a really tiny improvement.

So as I say, I do a list that's 12 hours long, goes until 7:30, 8 o' clock at night. And we had a patient listed for a general anesthetic in the evening session, 6 o' clock at night.

He'd come into hospital sort of mid afternoon whilst we were still operating. So me and the anaesthetist had gone out to, to see him on the ward. Now this, this was a chap for a GA procedure who had learning difficulties.

He had down syndrome. And the anesthetist saw the patient and said down, I'm not an anaesthetist so I don't really going to, you know, know this, this stuff.

But he said downs, patients can have difficult airways because of, because of the kind of morphology of. And she said I'm not sure it's the right thing to be doing to be giving him a generalized.

If I get into a difficult airway problem, I have nobody else around. We're on our own here in the department, everybody else has gone home so we would ordinarily not do that. Okay, fine.

So we went and saw for this, this chap and his parents and of course he'd come into hospital, they'd taken time off to bring him, he'd fasted all day, got changed, sat in the bed and we went in and said, terribly sorry but we're not going to proceed today because it's not the right time. Which by anybody's estimation is a really poor.

Yeah.

State of affairs. And we came back and we did a proper debrief at the end of that list.

So we talked about it and we, I promise you, you may be surprised but for the most part you would, that kind of thing happens.

Most people kind of roll their eyes and shrug their shoulders and go, you know, and because there's so much else going on, you know, we don't, we don't have time to think about what, what, you know, what's, what's happened in any depth or detail.

But we, we've got into the habit by this point of having a proper, proper debrief and we've started experimenting with using AI again to kind of feed the debrief information in. Now this is all secure within an NHS environment. It's not ChatGPT, it's something that's been signed off as safe to use within the nhs.

And when we did the debrief and we Kind of recorded it. The suggestion came back is, do admissions, the admissions department, would they benefit from some guidance on when to book these patients?

I'm ashamed to say that had never occurred to me and I thought to myself, well, maybe I'll ask them.

So I actually sent an email and said, just FYI, this chat was cancelled and it's because, would it help if I gave, set out some sort of standard best practice guidelines and surprisingly, the manager emailed straight back and said that would be really helpful. Reason being is that a load of our really senior admission staff have recently retired, right.

Got a bunch of new people in and this kind of implicit knowledge that's never not documented anywhere, but people who work there for 20 years would know not to do that kind of thing. It just isn't there. It's gone with them. So, yes, please put it in.

So what anybody would do in these days, you know, you ask the AI to write you a set of standard, you tweak it and you make sure it's how you send it off. Didn't take any time at all.

And just a couple of weeks ago I heard that the edict's gone out within my trust that, that please, can every surgeon do the same because they've found it so helpful. Now, that is one tiny thing is nobody's going to notice that we don't get Down's patients booked on the evening session.

Many of these things compound over time, don't they?

But. Exactly. That's one problem that we hope not to have again and then we'll move on to the next one and then we'll get it.

So it's that kind of approach, I think that's really, that's really helpful. So. So, yes, big tick for doing a debrief. Big tick, actually, for the AI, feeding it into an AI and saying, what do you suggest?

What possible things could we do to prevent this from happening again and just having a go?

I think it's wonderful.

One of the challenges that I often get when talking about working in more agile ways, particularly in services where perhaps there really is a question of life or death or we're dealing with very vulnerable people, is people's assumption is, well, surely it's just really risky to be testing and learning. And my response back is, usually, well, it's risky not to be testing and learning.

And you've got to remember that you're still Rob McAdam, consultant surgeon. All of that knowledge about what is appropriate and safe to do doesn't just go out of the window.

This is you in control and trying to identify opportunities for continuous improvement.

And that's just one very simple example of how putting this agile way of working into, into place can make small, small improvements that just compound over time. And I think, yeah, I think this, it's really, really heartening.

And also a great, a great example of a use of very safe, very safe use of AI with you in control of that process. Just, you know, using it to, to.

Optimize how quickly I do think this will be come really important and like with all AI models it gets better the more it's used.

Yeah, but I completely agree with what you're saying because the, the, the prospect of making any interventions in a social care environment would terrify me. You know, I would much rather take somebody's esophagus out than, you know, than give an opinion on, on risk in that kind of scenario.

But, but it's because, you know, you're you and I'm me. Do you know what I mean? And you become accustomed to those kind of situations.

And you know, and you're right, you know, again coming back to this with the estimation thing, you know, trust the people with the knowledge, trust the team to know what the appropriate thing to do is. There is governance around this. Absolutely, there should be governance around this.

You know, our use of AI has gone through an extremely rigorous process and it will continue to do so. And we've got all the, got all the guardrails and checks and balances in, in place. So we're doing it the right way.

But I think this could actually make a difference to, to real frontline deliveries. This is not an abstract kind of AI concept. This is actually, you know, sort of what we do on a day to day basis.

And if we integrate it well, I think it will become standard practice going forward.

I think it's a great example. Some research came out of MIT very recently which you may have seen about AI tests and it's something like 95% of tests with AI fail.

But that's okay because it's all learning and what's important is that the test is relatively small, there are quick feedback loops and we learn from it.

And this is one of those examples where, you know, it's a relatively small test, it's within your control, there are very quick feedback loops and we can scale on the basis of learning. So I think it's brilliant.

I'm interested to ask you about what feels incongruous now about the way things were done before now, you know, what you know about agile. So when you look at the environment that you work in.

You know, we gave an example during COVID of how it would sort of feel incongruous to plan lists in the way that we'd done previously despite having a very turbulent workforce during that time. Is there anything else that you see that feels sort of incongruous now?

Yeah, I'm sure it's the same in a lot of workplaces.

But I think medicine is still quite hierarchical and the one thing that does happen quite a lot, and I'm sure you come across the concept of the hippo, the highest paid person's opinion. That still is something that is strange to see and I think it will take possibly a change of generation for those things to flatten out.

But we do still see that a bit. We certainly do see the kind of. The hierarchies within medicine playing, playing out.

Can you explain that? So I'm very familiar with it, but.

Maybe some people watching insofar, you know, there's a number of, number of times in management meetings and there's, there's a lot of things that go on behind the scenes in the same.

In social care and clinical care is that what sits behind the kind of service delivery is an awful lot of meetings and service developments and conversations that sit behind all of these things and committees that all of us have to sit on. And sometimes it can be skewed a little bit because the clinician's opinion is given significantly more weight than perhaps it deserves.

But one of the, I think one of the really heartening things about agile ways of working is that assumption that, that the team is all, you know, the, the team comes together to deliver something and there is a. It's not about necessarily one person or two people or whatever. There is a real kind of team emphasis. And I must admit I've.

I've changed my way of working as a response to doing some of these things and things in this different way. And it can feel. Medicine and surgery can feel a little bit old fashioned in that regard.

There's also, I think an inbuilt feeling amongst clinicians is that management and is almost something that's done to them rather than with them. Even though there is a bit of a. There can still be a bit of residual Venus feeling.

And quite often people are promoted into line management roles with quite a lot of responsibility by virtue of sort of time served, if you know what I mean. And there's not people with a kind of burning ambition to change things.

It's just, it's my turn to pick up the baton and run the department or whatever. And most of the time, people do a really, really, really difficult job really, really well. But what I'd like to.

What I'd like to see, and this might be slightly naive, but I'd like to see that how you run your service and how you work together to run your service almost becomes part of the undergraduate curriculum for the medics. Because at the moment, a lot of the. A lot of the time, or certainly was when I went through, back in the day, when I graduated, all the.

You were judged on what would you do? You know, the questions was always where you're presented with a clinical problem. What would you do? What, what needs to be done? What.

You know, so tell me what needs to be done? What, what would you do with this kind of patient in front of you with a neck lump or this or a hernia or whatever.

And we are all judged and have to be accountable for our own actions. There's not a huge amount of emphasis placed on what, what should we do, what should. What. What should the service provide.

It's all about, this is my action, this has to be defensible, this is within my competence. Don't stray outside your competence. You know, you've got. And that. And that's clearly important. But what I'd.

What I'd really like to see for the future is an increased emphasis on. On team working. And that sounds very woolly, but I think that's where the big breakthroughs can come. It really does.

Yeah.

I don't think that sounds woolly in the slightest because particularly the continuous improvement work that you were talking about, everybody's got a slightly different perspective on what's happening there. So it's illogical to assume that one person is going to be able to observe all those problems and come up with the solutions.

That's not the kind of problem that we're. That we're dealing with, I suppose, for that team.

I suppose for a change in the way teams work together in the context that you're working in to take place.

And taking into account the hierarchical nature and the Hippo effect and all the stuff that we've been talking about, it probably needs to be a bit of a focus on psychological safety and people being able to say, well, actually, this isn't working, or we could have done this better. How are you thinking about that in. In the teams that you're working in?

Yeah, I. I mean, I think that's.

That's really interesting and that is getting better, certainly with, with the younger consultants that are coming through, they are more attuned to those kind of things. So you do hear the term sort of psychological safety mentioned and people do speak up.

You know, one, one of the, one of the pleasures of being an older consultant now is that stuff that you've done, you know, however many dozens of times, is new to your trainees. So you get trainees that come in and they're like, wow, that was great. And you kind of really. Yeah.

And that next generation, you know, the, the, the Gen Z or whatever, is that what they're called? Coming, coming through are refreshing in that regard. You know, they, they really are and they're a pleasure to work with.

So I, I, I do think it's important, and I absolutely agree with you, that one person's solution can't be taken as gospel.

This is why I always find it so funny when people talk about the NHS and the first response that anybody says is, well, get rid of all the managers, all the middle managers. You've left the consultants to their own resources.

I mean, have you ever met a bunch of people, they would be fighting like rats in a sack within hours.

You try and leave the cons, something to organize a, you know, you wouldn't even to run a lemonade stall or something like that there, that everybody's got a different opinion and it's, you know, and it's all, it largely anecdote.

And this is what surprises me again, again, I've been very rude about my colleagues, but quite, quite often people are super scientific about their work.

Yeah.

And they'll say, I can't do that because there's no evidence, but show me the evidence. And then something about how they work comes up and they'll say, oh, it's obvious, it's obvious we need to employ three new consultants.

It's obvious that we need an extra wing that does this, that and the other. And it's not obvious, it's absolutely obvious.

Obvious from your perspective, but what you don't see is the fact that there's a massive backlog in this particular part. People, they're not used to thinking in terms of flow particularly.

They just see the little bit of the pathway that they, they've got in front of them and the solution, you know, table thumping the solution is obvious. We need to do this, we need, and too often we've kind of gone, well, usually he, he's got the loudest voice. Let's, you know, let's do what he says.

And lo and behold, it doesn't actually work because it was never the full story. Exactly what you said in the first instance.

Yeah, that's really interesting. Let's talk about some, some other opportunities to wrap it up.

You've got, you've identified some opportunities within your own control for self organizing agile teams to make improvements.

Looking from a slightly more helicopter view, if you were allowed to tinker with other parts of the NHS where you'd like to do some agile working, test and learn what would be some of those areas, where would you go?

It's very interesting because when we started working with the mod and we haven't worked particularly closely but they've been really helpful, then we've got some sort of commonality with some, some guys that are working with them and also we're working with us at that meeting that is when we had the webinar, we were talking about, well, how do you go through agile transformation? You know, when I was chatting to JJ Sutherland, I was saying, do you start at the bottom or do you start at the top?

He said, well, you've got to do both. And okay.

And we're talking to Mike, Mike Waring and we were talking about how you introduce agile in a at scale and he kind of, you know, sucked his teeth and went. I said, well the difference is, he said in the military we've got these things called orders and they really help.

And so it helps the military that General Jenkins, first Sea Lord, you know, read the Red Book and then phoned up, up JJ Sutherland and said we're doing this and all of a sudden the military is doing this and it's, it's working for them. There's no equivalent of that in, in medicine. There absolutely isn't.

So the way we've gone about things is, is from the bottom up we've started doing the agile for one, as Matt would call it in his, in his trainings and that's really helped people, surprisingly so.

The, the fact that just that discipline of doing, you know, creating a backlog and being realistic about what you can achieve by sizing this tasks seems to resonate with a lot of people in healthcare that are pushing themselves too hard, if honest. So I've got the, I've got the emails from people who've done the course and said, I just need, you know, weeks, sometimes months down the line.

It, the word overwhelmed is the commonest one. If you added a word cloud, overwhelmed would be number one, would be biggest because people say this has helped me to feel less overwhelmed.

So in terms of what you could do, I do Think there's a role for the kind of skills and techniques of agility for individuals. I think that would help.

Well certainly having taught the course that helps a lot of the people that come through and then, and then I, I think actually. Well, I think on practical terms I'll tell you how I think it will go because the NHS is not this kind of homogeneous organization.

There's pockets of places with issues and places with less issues. It's really different. So you get certain places that are, you know, over performing certain places where they really struggle.

So if we can show that, that using agility as a model in, in theatres will move the dial in our trust, which I should say is an outstanding trust according to CQC ratings, really good place to work, very forward looking. So perhaps it's not the right place to start because we're actually starting from a reason, you know, a really good bench base level.

But I still think we'll show some improvements. There will be pockets elsewhere so I don't know but they'll be in this area.

That urology will have a massive waiting list and if that area is eyes and in somewhere else it's knee surgery and for various historical reasons I think there will be targeted approaches to see if this kind of approach can work in those small areas and then I think it will go from there. There'll be pockets of good practice. We've already using the AI that we're piloting at the moment.

We're already talking to, and this is just by word of mouth, we're already talking to trusts in South Yorkshire, Wales and other places within the northwest who've just heard about what we're doing and curious. So yeah, I think that's the way it's going to go.

Well, I think word of mouth is selling yourself short somewhat because I think part of what's going to make it possible for other people to have the confidence to experiment is hearing stories told in a language that makes sense to them. And I heard about your work through John Dolman, a chap who works down in, does great work down in Somerset.

So the story of your work has sort of whipped around the country, found its way to me and it's finding its way to other people too. And I think that continuing to tell those stories is what's going to create the conditions for other people to experiment.

So I think you're doing really important work obviously in your day to day practice but also for making the way for other people to, to experiment with agile ways of working in the hs.

Well And I have to say I'm inspired by your work as well. Like I say, outside of you probably don't realize how terrifying the work that you guys do is to the non specialists. So yeah, fair play to you.

And I've been really encouraged by some of the stuff that I've heard from you guys as well. It's been a pleasure.

Thanks, Rob. I really appreciate it. Thanks so much for agreeing to do this today.

No worries. Appreciate it. It.