Exploring potential

Lessons from the vaccination quest

I was fascinated by Sir John Bell’s claim that ‘the NHS* could vaccinate everybody in five days if it were better motivated’ as reported in The Times earlier this month. Ignoring the equally important constraint of the rate of supply, it is worth considering Sir John’s claim.

*apologies to readers from countries other than the UK, but this is a reference to the United Kingdom’s National Health Service (NHS).

It seems at first sight to be ridiculous, after all we are looking at a planned vaccination programme lasting through to September (latest estimate) to reach an adult population of (I estimate) 52 million. Sir John suggests that children should also be on the list so let’s use the full population of an estimated 67 million.

That will suggest a daily ‘in the arm’ programme of 13.4 million for each of Sir John’s five days. With an estimated 1.5 million (and getting an accurate figure is quite tricky) employed by the NHS (and ignoring those employed in social care) we would be looking at a jab ratio of around nine per day. Not impossible.

Ah! I hear you say. Not all NHS staff are qualified to give vaccinations and in any case they all have other jobs to do. And you would be right. And on the positive side, we have not included pharmacists and others who could be drafted into the supply side.

But isn’t it worth asking the question ‘why is our jab capacity so low?’. There is also a second question arising from Sir John’s remark: ‘is it about motivation?’.

Let’s deal with the second question first. Motivation. Our evening ration of heart-rending stories about front line doctors, nurses and other front line workers, exhausted and going way beyond what can be reasonably demanded does not suggest a lack of motivation. In fact, to suggest so might be considered offensive. But applied to the organisation as a whole (as I believe Sir John intended) there may be a point. Is the NHS as an organisation motivated to explore its own potential? What does ‘good’ look like to an organisation of 1.5 million people with an annual budget of over £250 billion?

This is not an article designed to denigrate the NHS but it provides a useful introduction to questions that should be bothering all of us who are engaged by organisations that are trying to optimise performance:

• Is my organisation realising its full potential?
• Does the way we are organised enhance or destroy value?

Realising potential?

Do we know what our actual potential is? Or do we judge our performance by what we did last year ‘plus a bit’? I appreciate that I am not giving credit to the elaborate budgeting processes that dominate our lives just before the start of a trading year, but looking at my own business I will probably say that if I am ahead of the previous year, I am doing well. But am I falling short of the potential of the business?

Some years ago we worked with a paper mill where the management was struggling to ‘hit budget’ for their production lines. They were producing around 400,000 tonnes of paper per year, but the machine capacity suggested they should have been producing 410,000 tonnes. Discussions with the production team revealed a theoretical maximum capacity of 584,000 tonnes calculated (at some personal risk) by taking the best they had ever achieved on a single shift and multiplying it by the number of shifts in a year. ‘That’s the trouble with you consultants, you don’t understand the business; you have not taken account of shuts and breaks.’ At further personal risk, I asked for a definition of ‘a shut’ and ‘a break’ but before I could get a response the production folk had moved on. ‘That can’t be right. Shuts and breaks can’t possibly ‘cost’ us 184,000 tonnes.’ And this was the point at which they asked the right questions. Instead of ‘how can we produce more than last year?’ it became, ‘how can we optimise the routine ‘shuts’ and minimise the number of ‘breaks’ we are experiencing?’ They calculated their own (more credible) theoretical potential and went on to produce 420,000 tonnes that year: 10,000 tonnes above ‘design’.

So I wonder, what is the right question for each of our businesses?

• What if every day was the equivalent of our best day? Would that set us the task of identifying what goes right on the best day and how that performance can be replicated?
• What if every sales person operated at the level of our best sales person? Would that make us more curious about how the best achieve their targets?
• What if every business unit grew at the rate of our best business unit? Or achieved the margins of the best? Would that lead us to enquire after the practices in our better performing units?

Each of these questions can lead us to discover the unrealised potential (or latency) in the organisation and has the advantage of exploration of future potential performance, rather than dwell on what may have been going wrong in the past. There was a difficult moment with our paper producing team when they thought that the exploration of potential was going to reflect badly on them for past failure. But once they could see that this was going to help them to achieve the difference they sought to make (producing recycled paper as effectively as possible), the levels of energy and consequently problem solving creativity that were released amazed me (and probably them).

Applying this to the NHS? Slightly more complex than a paper mill! But the process could be similar:

• What counts as a good day in my part of the NHS?
• How can I access the best comparable unit that performs as best in class?
• And applied to the current crisis. Where is the most effective deployment of the vaccine being experienced and how can we replicate that performance?

To ask these questions will require time, and we may be too late to change deployment plans to deal with the current crisis. But it would be a shame not to capture ‘best practice’ for future crises (and we are told there will be more pandemics that will need to be managed). It will also require a confident NHS that is willing to explore areas of poor performance without facing the threat of criticism that is likely as the politicians seek to apportion blame through an inevitable post-pandemic inquiry.

Enhancing or destroying value?

We would like to think that our carefully designed organogram is the way to get the best out of our people. But does it? How much of the time we could be spending on delivering the goods and services of our organisation is spent managing upwards? Meeting the needs of our supervisor, manager, investor or owner? And how much time is spent by supervisors, managers, investors and owners in requiring a flow of information to give the comfort they desire?

What would be the optimal way of organising 1.5 million people in delivering world-class health care?

We end up with the interminable debate around centralisation versus decentralisation, or empowerment versus control and see periodic switches from one way of operating to another. Quite often the switch will hinge on a newly appointed leader, rather than necessarily a change required by business conditions.

And in the case of the NHS there is also the distraction of public versus private, holding that private organisations have the high ground when it comes to delivering value for money. But is there any truth in this? The more contact I have with larger organisations, government or privately run, the more I see inefficiencies arising in service delivery:

• The retail assistant ‘there’s no demand for that around here’ accompanied by a shrug and no follow through
• The insurance company that cannot tie in the way the claims department operates with policy renewal process
• The bank where you need to overcome a technologically led series of barriers before talking to a problem solver.

No, this is not a question of public or private. This is a question of managing scale and creating an organisation that can evolve to enable front line operators to get on and do their jobs: meeting the reasonable needs of their customers (or patients).

What if decisions could be taken locally, at the point of contact with the user of the organisation’s services? And what if everyone at ‘head office’ evaluated their role in terms of serving the end user rather than the reporting regime applied because of the need of investors/government to stay informed of progress?

Of course, organisations need robust control systems and equally obvious is the need for some sort of reporting. But do these needs have to get in the way of creating value for the end user?

There is some good, if challenging, news. Data can now be distributed widely in an organisation and technology can enable decisions to be taken locally with the impact aggregated into a collective view of performance. It is now possible to combine the data that is needed at the front line with the data that is needed to maintain control centrally. But these advances in systems and processes are not always matched with an evolved view of responsibility and accountability. And there remains in many organisations a belief that the further away you are from the customer, the more authority can be bestowed. I can hear screams of anguish: ‘you don’t understand our front line, they can’t be trusted to serve customers without strict procedural guides. Your thinking is a recipe for disaster as we would be open to wide-ranging fraud and deception.’

Customer-centricity is now in vogue and rightly so because it will be the customer that will become the final barrier to entry, the final piece that will help our ‘stickiness’ with our markets. But too often customer-centricity leads to additional reporting (enter Net Promoter Score and others) grafted onto an existing supply dominated reporting system and more reports that need aggregation and more folk at head office. If we truly want to be customer-centric, then we may need to look at the value-adding potential of our organisation. In turn that will require more decisions at the coal face and a move from command and control to guidance and support by our management structures. So, if we cannot trust our front line, we have a fundamental problem in delivering a promised service to our customers.

How often does our management structure inadvertently get in the way of optimising business?

• How much data do we make available to our front line operators that will help them to do their best for customers (or patients)?
• How much of our activity is led by our belief that people in the front line need to be controlled, or that we have to check up on what they are doing?
• How often do we think about the impact of a new system or procedure on the customer (or patient)?

So what would be the optimal way of organising 1.5 million people to deliver world-class health care? Separate localised Trusts is probably part of the answer so that health care is available from suppliers close to their communities. But with decentralisation comes the tendency to aggregate some Trusts and it is at this point that the balance between local decision-making and the need for control and reporting may need review.

My challenge to the NHS organisation would be for every person in the system to respond to the question ‘how have I added value to my patients (individually, or collectively) today, and how could I add more value tomorrow?’ For the doctors, nurses and other front line workers this may be an unnecessary question, or at least it is easily answered. For those not in the front line, not so easy perhaps.

And I would have a similar challenge for any organisation: ‘how have I added value to my customers (individually, or collectively) today, and how could I add more value tomorrow?’.

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If we are to fully realise our potential within each of our organisations, first we need to free ourselves from a view that our performance tomorrow is somehow based on our past performance and therefore a reasonable view of ‘good’ is whether we are ahead of last year or not. Second, we need to examine the way we are organised. And that may mean a reconsideration of the need for the traditional ‘command and control’ head office.

Will we ever get to a programme that can get vaccines ‘into the arm’ in five days? I doubt it, but wouldn’t it be fabulous to develop the capability to do so in a month. Truly world-class and energising for all those involved.