Fifty Shades of Command and Control

In these challenging times it’s always good when you come across a story that makes you smile. Better still, if it makes you laugh out loud! Here’s one I found amusing and whilst it’s not quite Seven Years in Tibet, the story of Prickles, who spent seven years in Tasmania, isolated and alone, is still a heart-warming story. Her picture is just fantastic, and the story has a happy ending too! I was also compelled to smile on reading the story of the un-named cleaner at Newmarket Library in Suffolk who after deep-cleaning the books and shelves, replaced all the books in size order rather than alphabetically and regardless of genre. Rather generously and perhaps in recognition of the times we are living in, James Powell, of Suffolk Libraries saw the funny side too. Describing it as an honest mistake, he noted that while it might take some time to sort out, time was one of the things they had in abundance.

And last week I heard a different kind of story, and it wasn’t the story as such that made me smile, but the way the story was told. The wonderfully candid and passionate Dr Dame Barbara Hakin, resplendent in her trademark pearls, was a guest speaker on a webinar I was part of last week. Chatham House rules applied, so I’m not going to share the detail of what was discussed. However, she had been invited to speak about how the NHS might be operationalised during a pandemic. She was well qualified to do so, having once been the Deputy Chief Executive of NHS England and responsible for commissioning and the operational planning for emergency situations. Her focus was an exploration of the concept of ‘command and control’ management approaches during an emergency situation. She had plenty of experience of dealing with such instances.

However, unlike other national emergencies, we don’t know how long the current Covid 19 ‘emergency’ situation will last. Learning from other previous pandemics, for example the Spanish Flu and SARs, we can predict it’s unlikely for there to be just one pandemic peak, after which life will return to normal. Almost certainly there will be a further wave (or two) of Covid 19 infections. And sadly, there are likely to be additional deaths to come as a consequence of folk not seeking help at the moment for other conditions for fear of becoming infected. Most commentators suggest that the development of a vaccine is probably the only way to guard against the longer term health impact of the pandemic. Without a vaccine, managing Covid 19 in the future will be difficult, but at least it shoudn't involve drinking a glass of Dettol every night as prescribed by Dr Trump.

Dame Barbara provided a fascinating insight into the largely hidden political machinations and the sometimes challenging relationships between politicians and experts. She made the point that essentially, command and control management should only be used in emergency situations, as there are better and more effective ways of managing complex organisations such as NHS hospitals and community services. Indeed, command and control management has long been rejected by many successful organisations. Its origins can be traced back to the work of Frederick Winslow Taylor. He was the son of a Quaker family, whose parents believed that children should be seen and not heard.

Right from being a young man, Taylor was constantly (some have said compulsively) measuring, counting and studying in the belief that he could come up with ways to make things more effective. It was something he very successfully took into his adulthood, first as a mechanical engineer, where he made a great deal of money, and then most famously through publishing his book, The Principles of Scientific Management. This was published in 1911, and is still regarded as one of the most influential management books of the twentieth century. However, his mantra of ‘follow the science’ eventually fell out of favour, as the work of other management writers (Mayo, McGregor, Herzberg, Peters, Mintzberg) began to challenge the intellectual underpinnings to Taylor’s work. As a group, they could loosely be described as belonging to the social science school of thinking. They were primarily interested in a more humanistic approach to motivation and the psychology of work. This is a different type of science to that which Taylor advocated. And apart from a brief renaissance in the middle 1970s, organisational management has largely seen flatter hierarchical structures, with greater emphasis being placed on developing healthy organisational cultures and an empowered workforce. That is, until a pandemic comes along. Then command and control methodologies once again come to the fore.

Has this approach delivered? Well I don’t do politics on this blog, and I’m sure in the fullness of time a Royal Commission will determine how successful the centralised command and control approach has been. But there are some clear wins: the NHS 111 service, which I’m sure Dame Barbara might recall, was intensely disliked when she launched it, has throughout this pandemic been almost universally welcomed as an effective service; compelling primary care to use video consultations; maintaining the lockdown and social distancing measures are other examples of centralised approaches that have resulted in a positive impact.

However, whilst command and control management shouldn’t negate local decision making, it is at a local level where some of the negative impact of the effectiveness of this approach on services can be seen. The supply of PPE has been challenging and an added burden to clinical staff. Whilst I can accept there may be a global shortage of PPE, why it has taken so long to mobilise manufacturing industries to step in and help remains a mystery. It is the kind of initiative that demands a centralised approach, yet it’s been down to local health economies to develop their own contingency solutions.

‘Follow the evidence’ has been the political mantra throughout this pandemic. The scientific evidence base is difficult to evaluate, and at the very least, seems to be a rather politically-managed and moveable feast. The evidence base developed through the pandemic ‘dry run’ ExerciseCygnus, undertaken in 2016 (way after Dame Barbara had left NHS England), has never been published and doesn’t appear to have been acted upon in this particular crisis. Perhaps as I have noted above, the relationship between politicians and experts really does have fifty shades of understanding when it comes to both the science and how it might be used – buts that’s probably too political for me to say – stay safe everyone.

Miss Otis regrets she’s unable to wed today…

The title of this week’s blog was originally chosen months back. Today should have been the first day of our marriage, and J, perhaps with shades of things to come, had laid down the law about my posting a Sunday morning blog at 05.00 of the morning after we got wed. I don’t like those pre-planned tweets, but agreed I would schedule one with a simple blog posting explaining why there was to be no proper blog today. 'Miss Otis regrets she is unable to lunch today', is one of my favourite songs to play on the guitar, and although the words tell a sad story, it felt like the perfect explanation for my blog readers.

But then the world changed.

We are in lockdown and having to learn new ways of doing most things, some of which are a challenge. Learning to effectively don PPE and then wearing the full kit for many hours for example. Other things are less arduous, and can actually be quite fun. Thanks to the help of my sister Ruth, my elderly father has become a convert to online grocery shopping, and declared the other day that he might give up going shopping to Waitrose ever again (there are, of course, other supermarkets). I have been able to get out and physically do my shopping once a week. I love Tesco, and the directional arrows on the floor - it’s given a whole new fun dimension to shopping, which I hope we don’t lose.  

I have started a new job as a Non-Executive Director at Blackpool Teaching Hospitals NHS Trust. It’s of course not a great time to be joining a new organisation, but the welcome has been brilliant, and they have managed the ‘on-boarding’ processes completely using online and virtual communication. As part of this process, I have been having introductory conversations with the other NEDs. Whilst in the main these have helped me understand the approaches to quality, finance, people and so on, there has been a common thread in these conversations around enabling change in challenging times. All were able to cite examples of where things were now being done that previously were thought to be difficult or even not possible.

Teleconference consultations, Zoom meetings, working from home, integrated approaches to care provision, and developing new quality assurance and governance arrangements to name but a few of the things mentioned.

I can remember a time not so long ago where working from home was something very few people did or organisations allowed their staff to do. Now, I think it will be difficult to see organisations reverting back to a world where turning up to your office or flying across the world for a meeting is still the norm. If home working continues, many organisations will be able to divest themselves of expensive buildings and even relocate to less costly areas in the UK. Individuals will also be able to make savings too. Our cars have sat idle on our drives for the best part of a month, we have not had to fill up with petrol and have saved considerable sums of money and more importantly a great deal of time, by not commuting. I think in many people’s minds, there will be very little incentive to start all that again.   

I took part in a virtual PhD viva last week. It was for the last of my PhD students. It was successful in all senses of the word. My student was in Saudi Arabia, I was in Blackpool, one examiner was in Manchester, the other in Cumbria. Although at times the audio was a little temperamental, the whole event mirrored what an actual ‘viva in person’ should feel like. I was impressed with all the participants (mine was a silent part!). We have been using virtual supervision for a while, as our student was unable to leave Saudi. But again, I thought why couldn’t such an approach continue in the future? It would reduce fees, travel, pollution and so on. It might be the same for many undergraduate courses. Already some students are demanding a rebate on their fees, as face2face classroom teaching has stopped, and replaced by online learning. Of course, the consequence for universities might not be so wonderful, but I’m confident they will change and adapt to a brave, new world of higher education.

However, I think one casualty of the pandemic is that future ‘academic tourism’ is likely to have been completely quashed. Which is a shame, but totally understandable. Fortunately for me, my academic career spanned a period where travelling the world, to present at conferences, building international networks, links and student recruitment opportunities was fully supported. I was able to travel to over 35 different countries during my time as an academic, and some of which, I went to many times. Favourite countries will always be those in Eastern Europe, including, Slovakia, the Czech Republic, Estonia, Slovenia, Croatia, Poland, Hungary, and the Ukraine. I have such wonderful memories of these places and the people I met and worked with.

And yesterday I was able to add to these memories. On Friday we made up brown paper ‘wedding bags’- in each were wine, gin, beer, a copy of our wedding order of service, a packet of seeds (of hope and love), packets of confetti, chocolate hearts, and paper butterflies – things that we had prepared for our wedding day. We enclosed a handwritten note saying we wanted to folk to have a drink with us to acknowledge the kindness they had shown us over the past few weeks. Saturday morning dawned, and the doorbell started ringing. One by one our wonderful neighbours left gifts for us. There were flowers, a cake, a beautiful flower arrangement in the shape of a chicken, champagne, cards, plants and a multitude of goodies.

One card asked us to stand on our drive at 13.00 to share a socially-distancing drink of celebration. When we got outside, all our neighbours were standing there along the verges, with their glasses, all dressed in their finest #Wedstock attire. They had each brought the Order of Service and sang the first hymn, raised their glasses and threw rose petal confetti. In a world that has changed, it was wonderful to see that random acts of kindness are still to be found. In the words of our First Dance, Hallelujah!

Will You Reach Out And Touch (Somebody’s Hand); the ‘doing’ and ‘being’ of nursing in a pandemic

The title of this week’s blog takes as its inspiration, Diana Ross’s first single recording, way back in 1970. It became one of her most popular songs at concerts, where she would ask the audience to ‘reach out and touch the hands of the person next to them’.  Not quite so far back, it was some 39 years ago that I had a vasectomy. It was performed under local anaesthetic with the surgeon giving a running commentary throughout. Part way through the operation, I began to feel a numbness creeping up from my feet and hands. Sheer panic set in and I thought I was about to die. I couldn’t breathe and started hyperventilating, which obviously made things even worse. I couldn’t speak even. But my distress was noticed by the surgeon, who very tersely told the nurse to ‘hold his bloody hand’.

Which she did. I immediately began to feel calmer and have never been so grateful for that nurse being there and reaching out in that way. I have heard many stories this week of nurses doing the same thing for those patients in ICU at the end of their lives. Some of the stories were of the sadness that loved ones were on their own, with relatives not being able to be with them at the end of their life. Understandably, a very distressing situation, almost unbearably so. Some of the stories were of a more positive nature. Nurses seen to be holding a person’s hand while they slowly passed away.

Apart from my vasectomy episode, I have never been even close to that experience, but I would imagine there would be great comfort to be taken by someone being there, even someone not known to the patient beforehand. Human touch is very precious. There have been many famous studies that have shown the power of a hug, and the release of oxytocin (the so- called Love Drug). Touch can also lower the hormone cortisol, a key trigger in moderating our stress response. It would be almost impossible to be a nurse and practise without touching those you are working with.

Much of the time, such touching will be instrumental, that is performing everyday tasks such as washing, changing dressings, taking a patient’s pulse, or undertaking a physical examination for example. Some use will be protective in nature. For example, helping someone to the toilet to prevent a fall, or restraining someone from harming themselves or others. Touch can also convey feelings, demonstrate emotions such as compassion and empathy. Such expressive touching is the kind of thing that holding a dying patient’s hand personifies. Even where the person might appear to be unconscious, such touching will let the person know there is someone there for them and that they care. That is a powerful and personal thing to do for anyone, but particularly at the lonely point of being near to death. Expressive touch can also be used to communicate, for example signing words and phrases directly onto the hand of someone who is profoundly deaf. 

Arguably, well I will argue here, touch in many ways captures both the ‘doing’ and ‘being’ of nursing. The instrumental touch (the ‘doing’ of nursing) requires skill, knowledge and experience to carry out nursing tasks effectively, safely and appropriately. We only have to look at the numbers of nurses currently being seconded to work in critical care – everything they know as a nurse will be a firm foundation to build upon, but how to correctly put on and use personal protective equipment (PPE) and how to work in an intense environment will require additional training and preparation. Likewise, those caring for patients in the community or a nursing home who are Covid19 positive and who require palliative care, might need additional preparation and refresher training. Palliative care is something almost impossible to do without close proximity to the person and of course, touch.

Likewise, the ‘being’ of a nurse is where expressive touching is best seen. It’s the way that nurses can best demonstrate empathy, kindness, dignity and compassion in the care they provide to others. For me, and I’m sure for many, many others, the ‘being’ of nursing is about taking time to listen, finding the appropriate words to say, being truthful, having the patience to listen to what’s said and to pay attention to what has not been said, to ensure the care provided is truly centred around the individual person’s needs, and taking their wishes into account when those sometimes difficult decisions need to be made.

An understanding of these two elements of nursing were the skills, values and attitudes I hoped every one of my former School’s student nurses took away with them, as they registered and started their careers. The stories I have heard during these past three weeks reassure me that across the UK, nurses are very effectively demonstrating both the ‘doing’ and ‘being’ of nursing. Where words can sometimes be hard to come by, a reassuring touch can take the place of a thousand words.

While much of this blog has been about nurses using touch in their care of their patients, importantly I think that touch will increasingly become an important part of supporting each other, as the Covid19 surge arrives and with it the reality of not being able to save everyone. As Dean of School, I would often have colleagues coming to me with distressing news that they were having to deal with; relationship breakdowns, a life-shortening diagnosis, the death of a child, or simply the associated mental health problems of feeling stressed about some work-related situation. Whereas I always had a box of tissues to hand, I often found that a hug at some point in such conversations worked almost as well as anything I might have to say. It was an approach that seemed to work equally well with both male and female colleagues.

And finally, to end on a completely different note, I saw this brilliant illustration of social distancing, the antithesis of touching – it both made me chuckle and reinforced the message of staying at home. For all those where staying at home is not a choice, including those that care for us, ensure we are fed and kept safe, who keep the electricity flowing, and the dustbins emptied, I say thank you, your dedication touches my heart in a way I have not felt before.

We can be heroes, for more than one day*

You know you are getting old, when you can no longer catch a bale of hay. On Friday, our feed supplier brought some hay and straw, pygmy goat food and mixed corn for the hens. He was the personification of ‘physical distancing’ and for me and our goats, he was a hero. The van pulled onto the drive, and the driver climbed into the back and said he would throw them at me. Back in the day (when I was in my 20s), I could throw hay bales all day long. On Friday, I realised I was no longer 20! Those bales certainly felt heavy as I caught and stacked them.

However, it was a welcome distraction as we got to the end of the second week of the lockdown. As always there was a lot to learn. For example, I learnt that Rory Southworth climbed Mount Everest in his own home – read the story here just to look at the pictures of his long suffering partner’s face. Also, I learnt that Germany is fortunate to have Roche. The company is the second largest pharmaceutical company in the world (Pfizer is No. 1), but actually it’s a Swiss multinational company. And boy, do they make a lot of money! Most of it is from selling life-changing drugs to folk across the world – but they also have a fabulous diagnostic arm to their work; which I guess gave Germany an advantage in testing their population in a way that the UK simply couldn’t.

On Thursday, we learnt that the Secretary of State for Health and Social Care, whilst being sadly concerned about the numbers of doctors who had died in their work to help others, didn’t seem to know that the number of nurses who had also died were not counted, apparently. Ruth May, England’s Chief Nurse attempted to redress this on the Friday update. In a slightly emotionally-charged address, she acknowledged the sad death of two nurses, Areema Nasreen and Aimee O’Rourke to Covid19. They, like all the health care professionals who have lost their lives caring for others, were real heroes too, and my thoughts and prayers go out to their families and friends.

I don’t know who in PR/Communications thought it was a good thing for the Chief Nurse to be televised wearing what looked like scrubs, but for someone who does such a lot positive things for the nursing profession, this was disappointing. I’ve yet to see one of the scientists turn up to the briefing in a white lab coat, or the Chief Medical Officer turn up wearing a stethoscope around his neck, or am I just being stereotypical and sensitive?

I had to pick up my repeat prescription and I wondered how the chemist would manage this. I needn’t have worried. They were all suited up, masked and wearing gloves. We, the customers, had to stand in one of six boxes marked out on the floor in bright yellow hazard warning tape. The staff came to us and dealt with us at a distance. My prescription hadn’t been filed correctly and I had to stand there in this box for what seemed like ages. It reminded me of attending one of the ghastly organisational development events at the University, where some over eager 20-somethings would enthusiastically ask us to step in and out of similar box taped to the floor in an attempt to stimulate new thinking. I’m glad to be retired and get to find other ways to stimulate my thinking.

For example, I have been intrigued by the use of the term modelling, in the daily Covid19 briefings. When I was a child, I used to build Airfix models of racing cars, aeroplanes and so on, but that was a long time ago, and a very different type of model. What gets used in the briefings is epidemic curve modelling. I think it’s based on the research by Lekone and Finkenstadt (2006) looking at the Ebola virus. Their approach takes into account that the infection rate over a given period of time will inevitably vary from person to person and country to country, and that different countries will increasingly take restrictive measures as the number of cases rise. Which makes it a highly useful planning tool. Of course, statistical inference can only take us so far in providing the absolute definitive answer to when the peak might come for the UK or the lockdown should end. 

  

However, what it has allowed the NHS to do, is calculate the number of probable critical care beds, staff and equipment that might be needed when it does come. Hence, the new Nightingale Hospitals being built across the UK. I have been fascinated by the process and the sheer logistics behind trying to get the first ready in just 10 days. The person who led the project is Colonel Ashleigh Boreham. He was almost at the end of his military career, with just a few weeks to work before he left the army, when he was asked to take on this role. And being a real life hero (he served in both Iraq and Afghanistan), he said yes and has done a fantastic job. There was a core team of about 65 army personnel working on the project, but often as many as 200. I’m hoping that someone has being keeping a visual record of the project, as I’m sure it would make compelling viewing. Of course, it’s awful that it is needed, but wonderful that we have a military with the necessary logistical, engineering and planning skills to deliver projects such as this when the country needs them.

Finally, although I have loved my career pathway, I did once think about joining the army, although it was the Israeli army. I was just 12 years old, and it was the Six-Day War. Understandably, my parents said no. It was a good call, as I think I am too much of a free bird and no hero, to have appreciated the benefits that being in the army might have given me. And for some reason, known only to the dark recesses of my mind, thinking about the army, made me think about the wonderful Arlo Guthrie’s ‘Alice’s Restaurant’. This brilliant musical monologue was first produced in 1969, and you can watch the film on Netflix. However, here is a link to a version Arlo recorded back in 2005. I find it amazing that 40 years on, he could still play the song’s memorable riff for 16 minutes and remember the words so well.

Stay at Home, Protect the NHS, and Save Lives - you are all heroes.

*Apologies to David Bowie