How to navigate organisational change when you feel like you don't have the power or resources to make a difference.

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

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

of getting it wrong can be fatal.

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

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

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

leadership within clinical teams.

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

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

seniority or the ear of the right person.

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

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

delegating without dumping, and understanding the only two things

that are truly in your control.

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

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

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

I'm Richard More.

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

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

And now doing that full-time.

brilliant to have you on the podcast, Richard.

I'm gonna just go straight into it.

Can we change an organization in which we work?

I can give you a definite maybe on that.

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

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

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

just not on form at others.

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

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

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

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

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

You do have to pick your battles.

Yeah, you do.

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

roles quite enthusiastically.

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

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

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

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

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

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

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

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

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

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

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

Is that true or not true?

uh, again, a definite maybe on that.

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

idea of team building and change.

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

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

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

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

doing exactly as they're told.

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

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

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

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

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

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

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

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

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

identify and go what works for you?

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

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

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

is just not going to get you anywhere.

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

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

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

we are really good at fixing things.

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

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

What is going wrong?

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

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

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

you'll get about 95 hands in the air.

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

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

way, you are clearly a bad person.

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

We like to think about the different sorts of power.

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

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

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

that's because we respect their expertise.

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

with people going, where are we?

Whoa, whoa.

What needs to happen here?

We would think also about other sorts of power.

We would think about reward power.

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

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

Go and do this because I say so.

Coercive can have an element of bullying in it.

There's charismatic power.

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

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

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

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

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

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

We can't do either or anymore.

We are going to do it this way.

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

I think.

All, all those powers can be very relevant.

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

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

colleagues that are employees.

I don't get that.

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

I don't get that.

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

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

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

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

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

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

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

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

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

it's not taught in the medical schools.

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

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

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

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

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

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

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

something with no evidence behind it.

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

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

and it's not gonna be good for patients.

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

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

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

saying and you will lose staff.

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

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

money, resources and people's empires?

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

world or pack up and go home.

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

Sometimes it can be a, an insensible choice.

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

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

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

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

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

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

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

We are used to not worrying at all.

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

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

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

free, and this will be 5,000 pounds.

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

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

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

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

to, to change your organization?

Uh, we have two options.

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

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

Our challenge of course.

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

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

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

But it's becoming both less and more.

What do I mean by that?

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

being independent was the freedom.

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

had to practice general medicine.

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

you had to be an employee.

There was no, no third world.

But the independence of general practice has gone down.

Don't we know that?

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

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

so there will be places to jump to.

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

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

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

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

harder to influence things.

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

no idea where things are happening.

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

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

nearby or your local hospital trust.

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

with usual business constraints.

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

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

the resources really very much.

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

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

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

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

consumes something like 30% of GDP.

How big is your sector?

Oh, it's about 3% of PDP.

So, which one's reality again?

You know, it is such a monster.

It is such a monster.

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

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

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

Yes, yes it is.

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

But, but no one seems to have a solution.

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

here in Cambridge, and somebody asked me about the NHS and he said, well,

it's one thing coming up with all these good ideas for it will ever, but what

no government's ever managed to work out is actually how to change it properly.

We do.

We know how to do it.

Okay.

Tell me

you, you, and only one sentence please.

Um, uh, it's all healthcare process.

You look at the organizations, the teams.

The trouble is, if you use the word companies, everyone gets wrapped up.

It's for private or, or, or whatever.

But if you talk about a company being a collection of individuals,

a, a corporation, working to do something, you look at those

organizations that have been successful.

Uh, and, and the classic that everyone talks about is Toyota and cars.

Uh, and, and how did they do it?

You look at their processes, you, you take whatever you can, which having done

it is about 80%, because we talked about how general practice was independent

was varied, but it's now standardizing.

There's an awful lot of standardization in general practice.

And then you do it, and then you do it year after year, and

then you do it time after time.

Clearly, that absolutely challenges the model that you are talking about earlier,

about, uh, fatigue, frontline clinicians.

You can't do it at nine o'clock when you've done, you've done a

nine till nine and then you'll do it from nine to midnight.

It don't work, but you've got to have that understanding of

reward, good things happen.

You define what good is.

And it's not for me to define what good is.

Each individual team is to define what good is for them

and it's worth the investment.

When we first started doing this in my own practice, 'cause poor, the

poor, poor guys and girls got used as a few Guinea pigs from time to time.

I think I asked them, but not entirely all the time.

We just tried a few things.

A mu much easier to try things and fail among friends than it is among enemies.

Um, and one of my colleagues looked at the proposal, slammed the papers down

on the desk and said if I have to work half a day longer for each month, for a

year to get outta this mess, count me in.

That.

That's a, that's a great sentence.

But you've gotta understand, and, and there is this J shaped curve,

your effort, effort before reward.

Um, so you've gotta, and you've gotta have it.

You've just gotta have it.

It's no good saying work after nine o'clock.

You, you've got to get that one in good and early.

The challenge we come across in disillusioned, uh, uh, teams,

not just clinicians, is how do you expect me to do more?

Or how do you expect me to achieve more doing it this way?

How about doing it a different way?

Sorry, don't understand what you mean.

Well, hang on, let's unpick that.

And once you start to unpick that, people start to make choices

about what they do, they choose to take a sense of direction about.

But it's certainly not far and forget, it's certainly not read two sides of

a four and this is how to run a, a, a multi-billion pound health service.

It is fragmented, it is clinical teams.

The unit of change is that clinical team.

So that's who can that person, that frontline nurse, that

frontline radiographer, who are they going to talk to today?

And I think the thing that think people just get really sick of

is the change for change's sake, which actually makes things worse.

I think the, the German word is verschlimmbesserung,

Well, I, I'm, I'm very impressed 'cause I only came across that word

last year, had me working in this, this last month, not last year.

Uh, and I, and I certainly dunno how to say it.

My wife's the linguist, not me.

We used to teach on the, on the Red Whaler.

We did a Working at, working at scale course, and I came across it

on a podcast, verschlimmbesserung.

it's like, you know, they, I think they changed the Coke logo at

some point, which was much worse.

So, yeah, so we had all these, these, uh, examples of things

that were just much worse.

I think the post, the post, they changed themselves to Insignia, sent

the raw mail, just made things worse.

Whatever.

Yeah, exactly.

And it, it's, for me, it's working out.

If you're making changes that are, that, that JS shaped curve is really

important, like you said, it takes effort.

Like no one, everybody I know who's working on the frontline

in the NHS, they're not stupid.

If they knew that they had to work half a day more for the next year to make

things much better, they would do it.

We're grafters.

We know how to do that.

The problem is you work half a day more and things are actually worse, and then

that Half day more just becomes the norm.

And then suddenly what you've done is increased your workload.

So you've got, you've got no output the other end and so many changes are this

verschlimmbesserung, which things are getting you, you're asked to do a change,

which you know is gonna make things worse.

And it's being able to distinguish when you're at the dip of that Js shape curve,

is it gonna be going upwards or is it just gonna go down into a cul-de-sac?

How on earth do I know if this is gonna be better or if it's gonna be worse?

'Cause I'm happy to put time and effort, it's gonna be better, but

I'm sorry, I have run outta energy.

To do this if it's gonna be worse.

Uh, you don't, even if you had all the energy in the world, you

still want to do it in worse.

I think the J cape curve, uh, is a J shaped curve, but I think it's, um,

flat if you look at it close enough.

So zoom in and zoom in and zoom in, and suddenly it becomes a flat line.

It doesn't mean you're getting worse.

So when I say zoom in, I mean get down to a really small change.

I'd like to go back to what you're saying, uh, you opened up the

conversation about, about motivation, uh, and, and why would I do this?

I, I think we are motivated to do things when we are likely to be successful.

And, uh, what that means is.

Your first elements at achieving change, and especially in a high

risk environment, should be as small as you can possibly make it.

Now, I think there's something again that, uh, clashes with the heroic model

of leadership that healthcare has.

We do this and I've saved a hundred lives and this is wonderful and the whole line.

A, actually, um, let's talk about, um, where we put the

prescriptions in the morning.

Uh, one of our practice managers, bless him, getting top of the leaderboard on, on

saving a, a day, a week of reception time.

And, and that's pretty cool, really.

And everyone's going, what was your secret?

What, what?

Tell us the secret sauce.

If we can bottle this and sell it, we'll all be rich and famous.

Yeah.

I, I moved the fax machine.

Dates the story.

I moved the fax machine from the third, floor down to the first floor.

It's not sexy, it's not glamorous, it's not exciting.

It just involves, let's have a little think about what

we're doing and let's do, its.

So achieve those wins, don't drop the ball.

This is not the time for the long ambitious pass.

It's interesting.

I've got a friend who an A&E consultant, and she said, if, if the trust would

just employ one person to keep the cupboards stocked up, so I didn't have

to go to five different consulting rooms to find enough equipment to put

in a chest drain or, or, or do this, it would be everything much better.

But then that is quite a big thing.

You'll employ someone or whatever.

So how would she make a tiny, how would you start with a tiny thing there?

Uh, we call that five s, and I can't do it off the top of my head.

It's something like sort, standardize, shine and something, and I've got.

And it's uh, and I went through a phase of being really grumpy going, why a

highly paid consultants sorting out things because very highly paid clinicians

are wasting time looking for stuff.

And I, we started to use that much more when we were talking about

bringing, uh, new, um, federations together and larger multi-site working.

As the story I tell my mate who's a jet two captain, he doesn't get into

a 7, 5, 7 and go, Hmm, I wonder where they put the throttles on this one.

There are enough butter here

Yeah, Yeah, But, but somehow that's acceptable.

And I think it goes back to that time about, which many doctors are

very sniffy about valuing time.

When they put it in pound, shillings and pence, somehow

that's the nasty commercial.

But when it's not going home on time, then that's valid.

But actually it's the same thing.

And so you've given us a lovely example there of wasting time.

A a lot of the work we do, um, people, uh, at the end of it a are

delighted I would say that wouldn't I?

But we are really pleased that, uh, 70% of the practices we work in say don't go.

We're in them up for up to six months.

And they say, you've got to come.

You just don't go, not come back later, just don't go.

But, but they will be going, when's the really, really clever stuff?

The clever stuff that's so clever that I as having practiced medicines for

15 years couldn't work out for myself.

Well, all you had to do was study improvement science

for a month and you'd got it.

But you studied medicine 15 years.

That means you don't know it.

So, but that's okay.

You are not actually supposed to know everything.

Yes, I am.

I'm a GP.

I'm supposed to know everything that walks through the door.

I run my own business.

Nah, that's not gonna work very well.

So what do we, what is the thing that you learned in that month that you hadn't

learned in 15 years of general practice?

We, our shortcuts are, we have great questions and we tend to

ask, but not always questions, knowing what the answer is.

And people will say, how that earth, did you know that you've

only been in the building an hour?

Because it's the same as the other 500 practices we've been in this year.

And then we have other tools and techniques about what I would say is

making visible what's currently invisible so that smart people make smart choices.

So going back a decade, when we first started doing this in my own practice,

we closed the practice and it dates it because we had green prescription

cards, we spent hours chasing green prescriptions around the place.

And then my head receptionist stands up and goes.

And then we read the, we, we look at the prescription request and we

open the letter from the last clinic.

And the doctors all go, oh no.

And the head receptionist goes, uhoh, this is gonna lose trouble later.

What have I done?

And the docs say, we do that.

And the, we suddenly make this visible.

So the smart people go, okay, I'm not sure we both need to do it.

Which one of us should we do it?

So that would give you an example of a choice.

I choose to do this, or I choose to ask my receptionist do it, or my

receptionist choose to ask me to do it, to, to get us where we need to be.

So we, we've saved a minute.

Uh, and again, in the process change work we do in practice, um, I would say

haven't had a chance to say it recently, we won't find anything that will get you

home 45 minutes early, but I'll put good money on the fact we'll find 45 things

that'll get you home a minute early.

And we have certainly come across teams where we have had to say sorry, they, they

don't have the capacity to do the change.

You and I have agreed earlier, and we'll continue to agree.

It requires effort.

There's no fuel in the tank.

There's no fuel in the tank and no can do.

Yeah, no, and I think, I think the problem is yes, that the workforce is really

heading towards collective burnout.

And actually we've had a, a survey, um, reported by some, someone we

worked, they surveyed their doctors.

50, 50% of them are working actually in burnout.

However, I think the people that are not in burnout that would say, yeah, actually

if I had to put a little bit more to, I don't have any time, but I could find

that if, if I knew it was going to be better, I think there are people that

are motivated to do that, particularly as they spend so much time doing, doing

just busy work that actually doesn't move the needle on anything anyway.

But it, it's very difficult when, when, when the perception is that

there's no money in the system and there's no more people in the system,

it's very difficult to work out well then what changes could occur.

Because when I say to people, you know, if you wave a white

magic wand, what would happen?

It's always what I get more funding, I get more resources, I get more people.

But maybe that's just, if you limit yourself to things can only change.

If that's what I get, then presumably you're missing out on a, on an

awful lot that could change without necessarily needing more money or

I, I, I put it to you in the, in the spirit of debate, that

that's actually not a change.

That's just more of the same.

Um, and, and what, what we are talking about is changing.

So we go back to that, that implicit sentence, how do I do things differently?

Well, what do you do is stop doing stuff that's wasting time.

How do I identify that?

You, you, you use some tools and techniques to surface what's going on.

You heard my example about talking to your colleagues.

Are you duplicating work?

Stop duplicating work.

But that's a systematic review of what's going on and it's what the engineers

would call catastrophic failure, isn't it?

Is each little failure cause more strain on the next part of the system

which caused the next bit to go down.

And so many people working in, in so many very, very different ways.

I, I have a friend who had a sort of salary job at two different practices.

Pretty much the same area, pretty much the same demographics.

One was hugely stressful to work in.

One was a joy to work in, and the difference was just in the

way that they did things and the way they organized things.

But again, it is down to time and it's down to somebody who

has the wherewithal to do it.

And that's why people think, I feel that they can't do it,

and they feel really helpless.

I'm gonna change your language, I think, uh, and say it is down to time, of course,

but, but time is only a unit of currency.

You talk about investment, it's a matter of investment.

Um, back in the old days I used to chair a finance and audit subcommittee with PCG.

The director of finance there, who, who's my management oppo, uh, said

something which has really stuck with me is money is a currency, Richard.

You swap it for useful things like nurses.

You keep saying you want more money.

What is it you want to swap it for?

Now, most people who are educated by their experience and experiential

learning will sort of go, well, more of this, because it's all

they've got in their mental model.

Yeah, there's nothing like going to actually see it.

And, and I think, you know, when some work with sort of PCN directors and

things like that saying, well, we can't get this practice involved, and

they, they're on board with this and whatever, and we said, well, what did

they say when you spoke to them about it?

Oh, well we, we haven't done that.

They just don't come to any of our meetings.

Like, why have we actually gone into their practice?

Said, show me what it's like round here.

Show me what's going on.

Not let alone just seeing what's happening, but there's that building

relationships, there's that touch point.

And, and haven't you gone back, I think there and touched

on what we talk about power.

The hypothetical PCN director was just assuming that their expertise

was so respected that all they had to do was say something and, and the

power and authority, uh, that that necessary was just self-evident.

And why aren't they doing it?

I've told 'em twice now.

What, what is it they're not getting?

Shall I email them as well?

Shall I tell them the same thing again?

Well, probably not.

What we didn't say when we had talked about power is, power can never

be, um, never be bought or gained.

It can only be given.

I can, I can only give you authority over my actions.

Even hierarchical power, I choose to accept.

I always think though, that with power, people say, oh, I haven't got the

hierarchy, I haven't got the power.

Well, you know, if you're having to invoke the hierarchy, you've lost the,

you've lost the battle, haven't you?

If the only way you can invade hierarchy is putting somebody in jail or saying, I,

you know, I, you do it 'cause I said, so.

I mean, you've lost, because yes, that person might do that tiny thing,

but they're not gonna do anything else that you need them to do.

There are very rare, uh, a certain when it, that is the right thing to do.

Um, I, the, and I think your, we, we, we talked yesterday when we talked a little

bit about different styles of leadership.

So if we took, go back to power for a moment and we talk about power

as the ability to get an individual or an organization to do something

it wouldn't otherwise have done, so, and, and we can talk about

whether that's control or influence.

Not helpful.

Let's just talk about it as power.

And we've mentioned the five power basis, reward power, coercive power, charismatic

power, legitimate power and expert power.

Uh, but then I flip that round and I, because we talk about leadership and,

and I say that leaders are people that deploy power, and, and they can use

a multitude of, of, of those skills.

And we've hinted in when we talked about this, uh, in this hypothetical

PCN director that was having challenge, they were not making any attempt

to pull down the charismatic power.

They didn't drive over there and say, please,

Yes,

They did.

They didn't drive over there and say, look, there, there's

a RS funding coming through.

If you do this, there's a big apply slice the cake.

Reward power.

They didn't do any negotiating.

I think another way of looking at what we talked about, the way doctors

behave is, at the risk of alienating the whole profession in one half hour,

um, I think there is something about their behavior that they think they're

always within their zone of control.

And actually the only zone of control is controlling everything

they say and everything they do.

That is absolutely it.

Everything else, they're trying in their zone of influence.

And if they're looking at influence, they need to just chew the end of the pencil,

have a cup of tea, glass of scotch, stare at the wall and go, I know it sounds

incredibly negative, but we've discussed saying, please, is a cool thing to do.

What can I do to influence the people I need to influence?

Clearly, before you do that, you need to work out who you need to influence.

So if you stay to doctors, you have you done stakeholder mapping?

They go, oh, it's all manageable bullshit.

Um, but then you go, well, okay, how's this going to work then?

Well, I'm just gonna tell 'em to do it.

Well, that's not gonna work, is it?

How well has that gone so far?

Uh, it hasn't worked at all.

Should we do something different?

No.

And so a lot of the work I do is raising cognitive dissonance with people.

I, I have to make them say mutually contradictory sentences, phrases

within the same sentence, and then I go and have a cup of tea and

work out how they're going to.

And what that often means is they have to prioritize something in their own mind.

I, I, I, I remember doing some team coaching for a practice a long time

ago, and the practice manager was at the end of her tether and I doing a

sort of one-to-one coaching with her, and she's going we really need some

new nurses 'cause we're not hearing our QOF targets um, for, for vaccinations,

you know, we are, we are short staffed.

But I keep asking the partners and they just keep going, oh,

we'll think about it later.

We'll think about it later.

Said, I really need a decision on this 'cause they're not

gonna be at the targets.

I said, well, what have you told them?

She said, well, in the practice meeting I say, the staff are already

overworked, you know, we need somebody else, blah, blah, blah.

I said, well, what, you know your senior partner, what, what's his,

what's he really motivated by?

And she said, well actually he's really worried about practice finances.

I said, have you gone to him and told them how much money you're

gonna lose if you don't hit targets?

Oh no, . Did.

They got a new nurse next week.

So we, we, that's a really tangible thing, but also doctors think, well,

there's no point because I've given them it, it's a logical decision and,

and, and maybe there's not a lot in it for them logically, but I remember

hearing about something about the stock market, about, you know, the stock E

even sort of stockbrokers, financial traders, they make decisions largely

based on emotions and feelings, not really on, on, on any actual logics.

If they do that, then, then there's no hope for the rest of us being

vaguely logical, is there really?

So there's, there's, there's place for both But I think what we do as

doctors is forget the place of the, the non-logical stuff and the, the emotions

Well, and, and selfishness self-interest.

Yes.

get very, it's somehow considered infra dig to think about who's important in our

little world and work out what works for them if we don't judge that as being of.

I don't know what the word is, purity?

Virtue?

You know?

Oh.

It means that the organization will make more money.

Ah, now I exaggerate, of course, the purpose discussion.

I'm very pure.

I don't care about money.

And I had a terrible run in with all my dear friends.

We were talk about setting up an X-ray department in rural

Kenya as a charity with support.

And I'm going, what's the business case?

And he's going, oh, you're always talking about bloody money these days, Richard.

Really?

I don't know.

Okay, fine.

So we had that, I had another glass of beer.

And I, and I go back and say, so, so how many patients are we gonna see?

Ooh, I think a dozen.

What's this gonna save them?

Well, a, a trip, four hour trip to the nearest hospital, eh?

So this is the business case.

He goes, no.

Uh, and, and, and, and it's just, Wayne introduced to the concept of that, that

the idea of a business case he did not view as virtuous and was not gonna engage.

And the problem is that people are always thinking about what's in it for me.

Always like is that if it's not about how much money is it, it's

like how much extra work is it?

'cause money and, and time is money.

And so, but they can't say that.

So then they'll come up with all sorts of other reasons that

are more virtuous and pure about good for the patients and stuff.

But actually what's underlying it is like, I don't wanna work

extra, I want a better work life balance, or I, I need more income.

And that is the problem.

You know, with, with all, with all this stuff, whether it's the NHS, whether

you're a charity or a B Corporation or just an organization trying to

make ends meet, you need money to pay your staff to have any sort of impact.

In this world.

Yes,

this world.

in this world, other worlds may be different, but in this world, yes.

Yeah, but it, but it's only a currency and we swap it for time.

Yes.

Totally.

so it's both totally unimportant and completely utter

important at the same time.

Yes.

If you don't acknowledge it, it's not

Hmm.

It's not gonna work.

And, and then you surface down.

I mean, I'm, I'm, I'm your experience, this area is greater than mine, but I've

seen some fantastic say yes and do nos.

Oh, yeah,

They, I mean, and that's the problem with working with smart people.

You go, how did you get there in only four steps?

That's amazing.

A and, and, and what would, it's classic media training that's

surfacing, uh, and hiding the root.

And, and I'm sure you use root cause analysis in five whys more than I do,

but it can get quite tense, making people say what's really driving them.

And then there's the cathars.

There's actually, the world doesn't stop turning when someone says, I'd

like to earn more money next year.

The world still keeps turning.

Okay, let's work on that then.

How much?

Yeah, absolutely.

And, and that's the whole basis, the length only five dysfunctions

of a team, which I just love.

And it's so helpful 'cause there's not enough conflict in teams in the

NHS, there's a lot of conflict between different teams, but not within teams.

We do not like raising issues that we think are gonna, well, they're

gonna make us uncomfortable, might make someone else uncomfortable.

And if you don't raise it, you can't get, um, consent, you can't get commitment,

then you can't get accountability, then you don't get the results that you need.

I can't agree with you more.

And, and I'm smiling because last week my director of finance says, right,

we, we need to have a different con difficult conversation with this person

and actually with the relationship, Richard, you are the person to do it.

And by the way, you'll it 'cause you'll rubbish a conflict.

And I go highly trained professional.

I don't know how you can say such a thing.

Retired after the meeting, cup of tea in the game, inside the kitchen.

Go.

I'm just gonna wind down from that.

I, I, I was appalled how bad I was at it.

We are all for that.

I had to have a very difficult conversation with someone a few

months ago where I was essentially having to, to let them go.

My Apple Watch, actually it was a while ago, uh, my Apple

watch, it was five minutes.

I was preparing for it.

How can I do this compassionately?

Whether writing it all out, thinking, what do I wanna say, what

do I wanna make sure I get across.

My Apple Watch had alert, alert call 9, 9, 9.

I've detected a pulse rise.

It's not normal.

I teach this stuff.

We go around teaching it, but it doesn't mean that you don't.

And then still did it.

And actually it was better than we thought.

My colleague said, Sarah Coope, who you know very well, uh, Richard,

she always says, you know, we, we underestimate the impact of not having

the conversation and we overestimate the impact of having the conversation.

And often that's one of my overwhelm amplifiers for, for doctors is we are so

conflict avoidant that we don't have it.

We don't have it, we don't have it.

And eventually we have it and it all goes pear shaped 'cause it's built up

and or we haven't had the, and and of course there's problems for everybody.

It would've been so much quicker and easier just to have had that

conversation at, at the beginning.

What one of my consultants, uh, said about one practice, um, the problem with her is

that doctors confuse their relationship with their patients, with that, with

their employees, and it doesn't work.

Uh, and of course, uh, my generation had from time to time

and that, that, that raised a few tensions is having your employees

registered with you as a patient.

You, you end up writing a sick note for stress at work for your own organization.

No conflicts of interest there are there.

Oh my goodness, a hundred percent.

So Richard, I, I a hundred percent agree with everything, but I've got a lot of

things in my head going, yes, but yes, but yes, but yes, but okay, because I

think it's, when we hear all this, we go, yes, of course, yes, of course.

You've gotta get to the motivation.

Yes, of course I need to exert what work out how I can exert this, this softer

power that's not due to hierarchy and all that, but either I'm too young,

I'm a registrar in the department.

You know, I had this at a conference.

I was talking back, I was talking about conflicts, and this registrar

stood up and said, yes, but I need to get a job next year in this

department with these consultants.

If I raise this issue, I'm just not gonna get this job.

Or, um, we, we just say, well, I, I don't, I genuinely don't have the

time, I don't even have five minutes.

'cause we need burnout.

Or, um, one thing, one pushback we get a lot is a lot of change involves

getting other people to do stuff.

People go delegation, they no one to delegate.

end of story, there is no one to do that.

So even if I wanted to, I couldn't do it.

And like that's a big conversation stopper.

So how would you address those things?

Because I think it's those things that just leave us feeling really helpless.

And that's what I'm, observing in, in doctors.

It's this feeling of being completely stuck.

'cause we think we've done what's in our zone of power.

We think we have tried to control the controllables and

it didn't get us very far.

Well, I, I wouldn't want you to think that, uh, everything I've said is

a, is a, a surefire path to success.

Uh, if, if success is leading beneficial change.

Um, but I think it puts you in a position of being more likely to

succeed than you were if you don't.

And I think there was something, uh, you were talking about there.

Um, uh, because I've never been purposeful, I've never been planful.

Uh, and, and how I've got to where I've got to is basically throwing

myself at every door, collecting a lot of bruises, and every now

and then I've knocked one down.

And I think what I never learned was that, uh, uh, and, and I've got some words I've

written down because I think the words are, precision of words is important,

that there is a difference purposeful perseverance and blind persistence.

And I think what I've done a lot is blind persistence.

And I would commonly say that, that I was just too stupid to know and I was beaten.

So I, I think I, I think we, we did talk about planning your battles and

I, and you know, if we've talked about money as a currency, if we can also

talk about power as a currency, we've got to think about how we spend it.

Uh, and if we keep on spending it fruitlessly, we don't get anywhere.

Um, but I think If that mid zone, we've talked about an individual

who's going change is difficult.

I don't have a track record of success, but I'm up for trying again, I might

have time, I might have energy.

I would counsel to go very slowly and very thoughtfully.

I think we've talked about wasted e um, in process, we talk about waste in energy.

We can think about that, that power is a very scarce resort.

Think very carefully about how you are going to apply it.

We talked about intuitive learning going, does this likely to be successful?

Does it, does it feel right?

And of course, the more you do, the better you get at it.

You, you have your own experience learning.

You, you get a smell for it.

And, and you can imagine people like me in my stage of career,

go, that's not gonna work.

And reasonably colleagues go.

Why not?

Uh, and we've had to work through the answer to that

question is because I say so.

No, it's not, that is not a good question.

I say so, and I've had to say frequently and I've got better at it with practice,

um, hang on, give me five minutes and I'll get back to you on that,

because at the time of speaking, it's that first order sort of reflection

as Calvin talks about bang, bang.

And, and then once we do the second order stuff, we can then test as a team.

Because I, it was really interesting, all the blocks to

change, you said, for example, were all failures of team dynamics.

They're all failures of teamwork.

And so if I, I would feed that back to a person who came to me and

said, I seem to be stuck on, uh, uh, and, and, and, and go there.

Yeah.

So that, that registrar, I can't change 'cause I'm bottoming the hierarchy and

I've, I've gotta raise this issue with the consultant, you would say, well,

okay, that's a failure of the teamwork.

That's a failure of psychological safety, isn't it, within the team.

So then what would you say, so what, so would you say, what's the, what's

a really small thing you could try?

What, what would, what Would you be counseling them then?

Well, we've discussed, hasn't it?

We, we are looking at changing the behavior of individual A, and, and

we need to understand what good looks like from the position of individual A,

Go and have a conversation.

I mean, that's, that's one thing.

So many people haven't actually gone up to people and said, how are ya?

Uh, and, and, and in my team, we talk about, um, going off the

record, uh, that that's our signal.

Can we go off the record for a moment.

That that means.

You want to say some things you don't want necessarily want people to be,

to agree or it's not your position, or you might want to deny ever saying it

'cause you might hear yourself speak and go, nah, no, I don't like that.

Nah, nah.

But haven't you just identified that the research evidence shows

that shows organizations with a high level of psychological

safety are good at making changes.

A and it may well be that if there is no psychological safety in that

hypothetical situation, it is beyond that organization to make changes.

And then we come back to a, a macro situation with a national health service,

the market can't prune out the rubbish.

Uh, I, I dunno if it's ever happened to you.

Um, but I know of GPs who practice in areas where service A is very bad.

Now in a private sector, that that service would not be allowed to thrive.

But it's the National Health Service.

You have to put up with what you're given and be grateful.

Um, and, and again, we talked about that young doctor, it, it's more

difficult to look around and go, um, actually, organization B looks to be

really well led and, and suits my style.

I I, it's certainly happened to me.

I dunno if it's happened to you.

I've been an employee in many years back and been, uh, viewed

as, as not very good at all.

I've gone to a different place and been considered more than acceptable.

I don't believe I changed overnight.

Uh, and, and we haven't really had a chance to talk much

about the concept to fit.

We've talked really about right and wrong.

Um, I am here.

I don't fit, that's clearly wrong.

And, and we haven't really had a chance to talk about, although we talk about how you

might achieve changing the organization so that you are a better fit, but we haven't

said that we might want to do that for our own selfish purposes so it's more like an

organization that we, we want it to be.

And, um, I know you do it and we try and do it.

And part of that is modeling our own behavior in organizations and individuals

that we're trying to influence because they want us to influence them to

towards a new and better future.

if we go back to psychological safety and fit and actually all that

sort of stuff, I think we have this slightly learned helplessness that

it's somebody else that's got to provide psychological safety for us.

And I, I'm thinking about that registrar, I, I, I've given

this example loads more times.

I used to work with this brilliant bloke called Al, who, um, was a,

a co-presenter on the Lead Manage Thrive course for me at Red Whale.

And he came to medicine as a graduate, I think he'd run marketing

for a large bank beforehand.

And I remember just chatting with him and he said, oh yeah, we had that

issue when I was a a house officer.

I just went to the consultant and went, oh, Mike, let's

just sort it out, shall we?

And I was like, Ooh, I could never have done that because I felt the hierarchy.

But he was just like, oh, let's just have a conversation person to person

and just, you know, sort it out.

Whereas I know that when I was at the GP registrar and I wasn't happy

about something, I would go to the practice manager, go, this is my issue.

How are you gonna sort it out?

And of course, immediately she was on the back foot and you know, immediately.

Right.

I'm being criticized.

The practice being criticized is, is there gonna be a problem or whatever.

If I'd have gone to her and gone Can I just have a chat about this?

How, how are you doing?

How are things?

How does this like look like for you?

What, what are the issues there for you?

This is how I'm experiencing it, what can we do about it?

Well, immediately I've created a much more psychological safety.

And the, the idea is that this is sort of help helplessness, which I think

is unhelpful when we are in the victim mentality, is that the person we're

speaking to, they're responsible for creating the psychological safety for us.

I, uh, and because I'm not very knowledgeable in this area, uh, and I

like to use old simple models, I would go straight to transactional analysis in

those day, in those days, I, I would start talking about parent, adults and child,

uh, at very aware that as a middle aged, middle class bloke, given a fair wind, I

will revert into parents, uh, co o, okay.

Now we know that.

What are we going to do about that?

So, adult behavior for me is a pretty learnt behavior.

Um, and, and, and I can be quite paranoid about asking my team if I

start to slip into controlling parent.

'cause I'll live there quite, I also live in nurturing parent quite happily as well.

And, and, and, and it's not good.

We know from the research that that's not, uh, not how teams do well.

Why do I put the effort into behave in a slightly cultural kind of manner?

Because it means my team will be better.

Not necessarily more profitable, but, but, but happier and more

effective, and more forgiving.

That's a nice thing about an adult, adult team.

It's more forgiving.

Uh, whereas if you've got parent child going on, children can be,

the child role can very unforgiving.

Yeah, and that is the basis of psychological safety.

It's not that I'm just trusting you're gonna be nice, but it's the trusting that

if I muck up and say something really bad to you, you're gonna forgive me.

You're not gonna hold, you, are not gonna hold it against me.

And the transactional analysis, I think that was Eric Berne,

wasn't it, The Games People Play.

Well, he was the, uh, mentor for, uh, Stephen Karpman

who did the drama triangle.

So what I'm talking about is when we get into victim, which then puts other

people into persecutor or rescue, they feel they're gonna rescue us or they

more often they feel blamed themselves and they go into victim, 'cause the

minute we start blaming other people in victim, we become the persecutor.

And so, doctors, I think what's happening is we are feeling so victimized, we

start blaming everyone else, and of course they then feel victimized.

And what you end up having is an argument about who's the Vic biggest victim.

And it's, it's an argument all the way to the bottom.

It's not an argument going, look, hey, I can see how difficult this is for you.

Let me just share the impact.

You know's the whole nonviolent communication thing.

This is what I think I need.

How can we find a win-win solution?

How can we do it together?

The problem is we have never, ever, ever, ever been taught

the skills of how to do that.

Bizarre, isn't it?

For a profession that sows.

We, we are really good communicators.

Really?

I've not met a good one yet.

Just

we're with patients, but like, let's apply to the patient.

So, so if you had a patient that comes in yelling at you, you automatically

go into, okay, let's unpack this hope.

Hopefully, unless you're thinking I'll just get lost.

Uh, I, I, I, well, I let, let's go.

'Cause we talked earlier about how doctors are used to deploying expert

power in the consulting room, and sometimes they carry on doing, uh, uh,

expert power, uh, outside the consulting room even if they don't have it.

But I think that deployment of expert power is very close to

behaving like a nurturing parent.

Uh, it, it, it's, I I think this therefore, um, off you go next.

I, I, why are you still sitting there?

Nine minutes.

Off you go.

And we know from Burne's work that our own behaviors will tend to

force others into the alternative.

So if we are behaving in parent, we will drive other people to child.

But haven't you just described a scenario where a grumpy registrar will

behave childlike and that will flow the partners into parent, 'cause they

spend eight hours a day in parent mode.

I mean, it's, it, it is a mutually satisfying relationship, 'cause the,

it's the cross ones aren't, but doesn't that mean then that to drive to adult,

we know that adult to child and adult to parent creates friction and requires

effort and planful not just chatting, but now I need to think about my next words.

We have a, a communication truism at Zytal,, which is that, um, in times

of stress, all ambiguous communication will be interpreted adversely.

That's rule one.

Rule two is all human communication is ambiguous.

So, so if someone's determined, they, they, you know, you can have a, you can

have a formal complaint about saying good morning, if you're really determined

to get down there and manipulate them up into controlling parent and

then take pot shots, you can do it.

And, and, and we know people who are very good at it, and we know people

who've made whole careers out of it.

It's worked for them.

Well, it, you say it's worked for them.

I can't imagine they are happy or fulfilled in their jobs.

So you know, they've got what they wanted, but it's not actually worked for them.

It doesn't work for anybody.

When you're sucking this drama, does it?

Well, you've opened the door there to something I don't quite know how to say.

Because we talked about dependency, and clearly it goes back to

my own psychological profile.

The way I've got to as being a partner and as being a chief

executive of my own organization, I have high levels of autonomy.

And that's the most important thing.

Being in a, being in a position where I didn't have high levels of autonomy would

drive me mad, Full stop, new paragraph.

I see the new setup of NHS as my younger medical colleagues having

very low levels of autonomy.

And it's traditional at this stage for people like me to say,

well, youngsters of today, they have it easy, it shouldn't be me.

Yes, I did the one and twos, yes, I do the one in ones.

But enormous levels of autonomy.

Absolutely.

It's so fascinating.

The other thing I think happens with autonomy and control is people will say,

you know, when I talk about the zone of power, what's outside your control?

What's inside your control?

I'll, uh, I'll, you know, they'll say, well, what's inside my control

is what I eat for lunch, or, you know, and I, and I'll push it.

I'll go, what time you leave work?

No, I'm not in control of what time you leave work.

Definitely not.

I said, oh, well, who is in control of what?

Well, the patient, the thing, the road.

I said, well, okay, who is in control of when you stand up and you leave?

Like literally stand up off your desk and, and leave?

Oh, well, I mean, that's me, but that's not really.

I said, no.

So we get to the point where I'm saying literally you are in control of you.

If, if, when you stand up and leave that building, nobody

else is in control of that.

Oh, yeah.

But, but no, but I can't, I cannot leave If there's a sick

patient, like a sick child.

And I say, well, you could leave.

No, I, I can't.

I'm a good doctor.

Well, actually what you are saying is you are in control of when you

leave, but you don't like what the consequences are gonna be if you do leave.

And this is not a moral compass.

I'm not saying it's the right thing to do, to leave when you should

be seeing an, an extra child.

You know, you might be struck off, you might lose your job.

But that doesn't mean you're not in control of it.

And so when doctors feel helpless and feel that they don't have any

control or autonomy, they do, they have much more control and autonomy

than, than other health, even other healthcare professionals.

But what they don't like is the consequences of doing stuff.

Because either it's really significant consequences when like someone might die

or something, or someone's gonna think badly of them or they may upset someone or

it's going to be difficult conversation.

it's because it's too difficult.

It's because it feels too hard.

Because it, and it affects our sense of self.

At at what the cost is too much.

But then they don't look at the cost of staying the same,

a, a Agreed.

But we are all products of our social conditioning.

I, I agree with everything you're say.

Um, and you know, I, I, you know, again, there's a middle aged bloke, sometimes

I'm walking around and I'll ask staff going, you just have to forgive me.

I'm a product of my social conditioning.

And, and, and I think if you, if, if, if you, I, I see I seem to

be forgiven fairly frequently.

Perhaps someone's following behind smoothing the waters.

But can I just say, Richard, the difference is that you are, yeah, you're

productive of your social conditioning, but you've got the self-awareness

to know that and then to give people permission to tell you that and to say it.

And that's what psychological safety is.

It's, it's psychological Safety is not always being perfect.

Cause we, we can't be, and we make mistakes and we

accidentally offend people.

And if, if people are wondering about, you know, talk Chris Turner podcast, you

know, the guy civility saves lives on, you know, how to challenge unhelpful behavior.

Half of us don't even know the behavior's unhelpful at the time.

Unless somebody tells us, we, we, we are not gonna know.

And that is the point is that when someone says to you, that wasn't very

helpful, you go, oh, that's interesting.

Thank you for feeding back.

Tell me what wasn't helpful about it and what could I do differently?

What could I do differently next time?

But while we're stuck in this helplessness and this victim mentality,

we want to blame other people.

That feels actually, it's more comfortable, it's more comfortable to be

blaming other people and to be helpless.

Now, this is where I have to be really careful because I do not want

to resilience victim blame, and that resilience, victim blaming is gaslighting.

It's saying Here, see a hundred patients, and why haven't you

taken up that lunchtime offer of some mindfulness that we gave you?

You know, like that is resilience, victim blaming.

This is not that.

It's saying this is about when you find yourself in the victim mentality, go, have

I really looked at what I'm in control of?

And what am I avoiding doing just because it's too hard?

Or because it's going to, it's gonna, my amygdala won't let me do

it because it, I might be disliked the courage to be disliked, or the

potential of upsetting somebody, or even it going into my own identity.

I, the more I work with you know, people, the more I realize

that this self-sacrificial identity is really important.

So if I, if I'm not telling everyone I'm busy on the edge of burnout,

what does it mean about my identity?

I, I, think you, you, that is a variety of the social conditioning that starts,

uh, I, I, with, uh, forgive me, the lies that we teach, potential medical

students, that teach the same medicine's a really wonderful vocation to join.

Well, it can be.

On the other hand, it can be a, uh, it can be a tough and rewarding job

and it can be a completely shit job.

And just because it's tough doesn't mean to say it's shit.

And, but because it's shit does mean to say it's tough.

It doesn't map, map, map well map one way.

And that's all into rewards.

I was lucky in my career to be dragged outta bed fairly frequently,

antisocial times to do stuff, which I thought was worth doing in my opinion.

And that worked nicely for me, among a team that would go, oh, that was cool

you know, with the external validation.

And I don't think that's what they get at the moment.

They get the shift work or whatever.

Yeah.

Um, I've slightly gone off piste, haven't we?

But I think this does boil down to the question that the original reason

why I got you on the podcast was I'm really obsessed with this idea of

people thinking nothing can change for me until the system changes.

And my line is actually you need to change what you are doing, 'cause the system's

way above your pay grade and my pay grade.

And I think you are thinking actually you can change the system.

So how, how would you advise someone who is feeling really, really helpless?

Really?

Like, I've tried stuff.

It's really difficult.

There's all these different reasons why, why we can't change.

I've got, I've got no time, I've got no energy.

But I hear what you're saying and in theory that makes sense.

But on the ground, where do I even start?

So the, the first thing is to really understand what good

looks like and why it looks good.

Um, and, and get, that doesn't have to be written down, but you know

what I mean, really boiled out.

So the phrase better service for patients doesn't work for me.

What does that, what, what does that mean?

Quicker, faster be.

What does that mean?

And then we cut into the how you would do that first cut.

And then we go back to our conversation earlier about is this worth the candle?

Because we're into risk.

We're talking about return on investment or what a nasty

management consultant phrase.

Um, as you know, it looks like that investment.

But hang on.

Now we've had to think about the what and we think about the how you are now talking

to myself who ha has a team around them that know every shortcut in the business.

If we redefine the how, utilizing our shortcut, what does the business

case, oh, another nasty management consultant phrase look like?

Ah.

I didn't like the first one 'cause it looked really

difficult with days of labor.

Quite like the second one 'cause it's got a day labor and I'd be really

interested in getting home earlier, making more money, dropping the complication

rate, dropping the mortality, being invited to speak to a conference.

I mean, how, how we can go on for half an hour on that without even thinking.

But I've gotta know which one it is, ' cause we got to prioritize and

focus our change to get what you want.

And I really, really, really, really need to know what you want.

And we've worn out the old Einstein phrase that says, if I had an hour to

change the world, I'd spend 55 minutes thinking what to do in 5 minutes doing it.

We use it so often we've worn it out, but the docs are all going.

Yeah, yeah.

Well if, if you could just sort this out, I've gotta go and see Mrs. Mackins now.

Bye.

I don't even know what we're trying to achieve now.

You just said you wanted something different and flew out the door being

very important and playing the um, the, the stroud waving trump card.

Sorry, I don't accept the stroud waving trump card, 'cause I

was doing it before you were

What's this?

What's a stroud waving trump card?

Shroud wave.

Oh yeah.

What is, okay, what is, just explain that?

It's an unjustified, unaccurate, untrue, maliciously delivered if we

don't do it my way, someone will die.

Yeah.

So it, it's like the, the, higher calling is serving these

patients and that is gonna trump

Everything

everything.

Including the risk of burnout.

and, and, and it leads to very distorted risk management.

because you can always, always argue that any risk will end

up with severe patient harm.

So in, in a training session, we were debating this, when can I leave work?

You know, I can't get up and leave.

And someone said, I can't leave when I'm on call on a Friday night, because

what if patients need to see me?

Uh, well, what?

Okay, well what, what?

She said, what if there is a sick child in that queue?

And yes, the phones have gone over, but I can't leave them to c NHS 111

because what if they don't assess them properly and they don't send them, and

are, they're not that good in our area?

And I'm like, and then luckily someone else on the, in the, in the training

said, yeah, but what you do on a Sunday afternoon when there might be

a sick child in the queue, you know?

It's just this nonsensical thing of we can always say, well, if that result

isn't filed, if that normal result isn't filed, well, what happens if, if, if you

can always extrapolate the worst case scenario of something dreadful happen in.

The problem is you do see these.

Isolated incidents where something absolutely almost happened, you could

not have predicted or whatever, but we use it as the shroud waiting.

It's, it's like this Trump card of get out of jail free of,

I can't come to that meeting.

I can't put it in that time because patient need and that trumps everything.

And I do see that with senior clinical leaders.

I'm like, why?

If you had a choice of doing the extra clinic or spending that time on leadership

and management, you should be spending that on leadership management, 'cause

you've got the experience to do that.

And you let the people, know, you know, who, who aren't there to, to do the

thinking for your department to, to do the service delivery essentially.

And, and I think that's an unhelpful, coercive power.

Uh, and, and, and it leads to a negative term.

We then into boundary setting, uh, into our own, uh, our own boundaries.

And, uh, I'm grateful for a friend of mine with the phrase, um, the graveyard

is full of indispensable doctors.

Um, and, and, and we talked about autonomy.

We talked about self-realization that if you are into, um, being very

important, in fact indispensable, being told that it will carry on after

your dead can be a very uncomfortable.

We talked about raising cognitive dissonance, but sometimes we have

to raise cognitive dissonance so the individual can resolve themselves.

And then we're talk, we're into process change, but we're into process change

in people so blimey, we seem to have gone into psychodynamics without

actually, well, that, that's okay.

'cause there are no boundaries there.

And we're dealing with people.

Well, it's, it's a behavior change model, isn't it?

I mean, is and, and that, you know, coaching, I'm a big fan of coaching

obviously, and I'm sure, sure you are as well, but that's what

helps you, you know, the coaching can actually get you your why.

And what's the important thing here and what you're trying to change, and give

you your why, then, then you're gonna go

do it.

And what we've done in our own organization is done the whys and

laughed at ourselves when we've gone.

It's obvious, isn't it?

Okay.

Why haven't we been able to explain it to me?

Um, and gone right down to values.

And then once we've done a five whys or have 'em and it takes to get

down to why is that important and capture the value we then build up.

So at last week's, uh, board meeting, we are then looking at our work program and

cross-referencing against our values.

And values.

I think that can be a bit of a misunderstood term.

It's just basically what's the really, really important thing to you, right?

Um, so, uh, for example, we have a colleague who hasn't been doing

their paperwork correct, correctly.

It's very easy.

I find I don't, because I don't do it.

Uh, Craig going, look, our value of integrity means doing

what we say we're going to do.

You said you were going to do this, you haven't done this,

so can we talk about integrity?

And that's, I find that very helpful in staying a long way away

from you haven't done what I told you, no change in language, and

therefore you are a bad person.

Which is exactly the medical, I hate to use the word leadership model

that I see disturbingly frequent.

Yeah.

And then we use shame, don't we?

And, and doctors are already feeling shame that they can't see their

patients in the way they want to and all, all that sort of stuff.

So it's difficult.

I think I've already asked you for your top three tips.

Keep going.

What?

So yeah, what would you, what would you say?

Someone's just feeling really helpless and stuck, but they are in a position

where they could influence and change, they're not sure where to

I think my opening line to uh, if they needed something would be don't

just do something, stand there.

Pause, analyze, think, don't move yet.

Just work out what you, what the next steps are.

As I'm grateful to, one of my trainer colleagues stood up in, uh, the Bristol

area, must be three or four years ago.

And you know what, Rich, when I first heard you talk about this, I thought

it was all management bollocks, but it really works, doesn't it?

And I go, yeah, it's a recent Toyota, the biggest car company in the world.

it's interesting.

I've got a friend who's a, a, a coach and she does a specific form of coaching

where they literally spend two hours working out what the main issue is.

And I think, yeah, if you can actually just work out what the main issue

is, that is part of the problem.

And I think, yes, a lot of, I'm just thinking back to this, this session we

did with consultants where they were so pissed off, so disenfranchised, and

we spent two hours talking about what you're in control of, what you're not,

and the fact that you, you have to just accept the stuff outside your control,

which they found incredibly difficult.

But actually when they worked out what, what is the main issue that the one

thing, then you know what to change, then you know what you can go after.

And everything else just that falls by the side said, well,

I'm, I can put up with that.

I can put up with that, but this is the thing that we really, really want.

And then you've got something to go after.

this, if you look at the original productive general practice books, which

we, uh, uh, I contributed to a decade ago, you'll find the start of each

module is first create your module team.

And I think I would advocate that vociferously and violently because I

think if you do that, you can get the average medic to do the bare minimum.

Okay, great.

So get your team around you.

Um, stop and pause and wait.

And there's one last thing I want to ask you because I think I'm gonna

be asking this a lot more to people.

This thing about delegation, what would you say to someone says, well, fine,

that's all very wanna good, but there's absolutely no one to delegate to?

Well, it does reflect back to, um, uh, team dynamics and, um, as you recall when

we first time I heard you saying that, and I don't, it is probably not fair.

I'll take, it's not fair, but I'm sure we can imagine a scenario where

someone has said this needs doing perhaps not in a very comprehensive way

and just said, it's now your problem.

I think that's what I'm trying to understand.

Um, in the delegation, there's a difference between coordinating the

tasks that need to be achieved for the team to achieve what it needs to achieve

and going, I'll do that, you do that.

And there's a difference between that delegation, uh, which

refers on hierarchical power.

I am chief executive, please, will you do this?

Answer yes, thank you very much, because it's gonna need to be done.

Um, as opposed to, uh, I'm off.

I've gotta go and see a patient.

It's now your problem.

Goodbye.

And I think there's delegating and dumping and I heard elements of dumping

in the first time we talked about this.

that's interesting.

And I think that's probably what people ask.

Who can I dump this thing on?

And then they say, well, if I don't know someone that's got

to, and I'm like, yeah, okay.

In aviation we have a phase that goes, um, plan the flight and flight the plan.

And what that means is you spend the time beforehand analyzing what is required to

happen for safe flight, uh, and actually always having a plan B, always having a

plan B and often sees D, but that's not what we're talking about at the moment.

And then you put the stress into the plan.

If I do all this in this order, I am going to be safe.

And what you don't then have is the cognitive bandwidth

of, should I be doing this?

Is this the right decision?

You don't make decisions on the hoof.

You do what decisions you've made.

And so I think going back to dumping and, uh, delegation, if there's a clear

action plan, we talk about a breadcrumb trail at work, is there a breadcrumb

trail that takes me from here to there?

And there are bits on the breadcrumb tray, please, will you do that bit?

Yes, please.

Will you do that bit?

That's delegation.

Not just here have it and I never wanna see it again.

Yeah.

Oh that's a much nicer way of thinking it.

Richard, thank you so much.

Now listen, if people wanna find out more about you and Zytal, where can they go?

Uh, we have a, uh, a website that's always being changed,

which is Zytal, uh, XYTAL.com.

And always, I mean, I suspect we have the, uh, uh, the same problem, Rachel.

We always love chatting to people and finding out stuff and go, oh, is that what

it looks like from where you are sitting?

'Cause where it looks like I'm sitting, so, so the email

is richard.more@zytal.com.

it's been really fascinating for me, Richard, and we'll, we'll get you back

on 'cause there's so many more things.

And if people have got questions, please email in.

hello@youarenotafrog because we can get Richard back to q and a perhaps.

And you know, I think there's a, there's a lot of yes buts and so

whats, but um, I think Richard, you've seen, you've seen it all haven't you?

And I think you've seen all the objections and stuff like that and, um, this stuff,

this stuff really works and it, it is not the case that everything is going

to shit and it will always be like

We find it, I find it phenomenal that we've been in 1300 practices.

Absolutely.

So get in touch.

Anyway, Thank you so much and have a good rest of the day.

And to you.

Cheery bye.

Thanks for listening.

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