From the Archives: The NHS — From Vocational Calling to Common Purpose

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1:24Good afternoon to the UK Column viewers and listeners. I've come back in the studio for an interview this afternoon with a gentleman Duncan White. Duncan has sent me a lot of very interesting information in some emails plus an attached document and he's got a fascinating background, which I'm going to get him to tell us a little more about that. But what we're going to do today is at least start off with having a bit of a discussion about the NHS and some of the problems in the NHS. So without any more to do, Duncan, thank you very much for joining us today. Pleasure. You were kind enough to email in, so I'm just going to ask how did you discover the

2:25UK Column in the first place? Well, some years ago I signed up because I came across it from a colleague who advised me about it and then more recently I joined a conversation group who are very keen on UK Column and ExxX News service and put me in touch with one of your correspondence Debbie and we went from there. Yeah, excellent. Okay, thank you very much for that. It's always interesting to hear where people find this and they're often interesting stories around that little saga but I admit that at lunchtime I just walked up the road from the UK Column studio where there's a really excellent little food wagon and as I was waiting for my toasted sandwich one of the guys in the queue said, you're Brian and I said yes and he said, well,

3:27I'd just like to say that I watched the UK Column News with my work colleagues and all my family watch as well. So he was in one of the companies, the industrial units, just a few hundred yards up the road from the UK Column and as I said to him, it's always quite a boost when people do this because you think yes, we are actually getting out and achieving an audience. So thank you for doing the same there Duncan. Now let's let's hub a look. You sent me some interesting stuff about your background. You said you were a senior technical advisor to the UK Home Care sector for nearly five years and you've worked on several working groups with the Care Quality Commission, the National Institute of Healthcare Excellence and Skills with Care. You've worked on some task force projects at the Department of Health and Social Care. You've also got an involvement

4:29with a motoring organisation which I've lost that one at the moment. We'll come back onto that and I believe you're also involved in the charity. So tell us a little bit about yourself, set the scene for our viewers and listeners today. Okay, well I started off as a registered nurse in both mental health and acute services and inevitably the career paths takes you into management and I worked my way up to executive level in both acute and psychiatry before joining a private enterprise, rescuing bankrupt nursing homes and turning around failing nursing homes before I embarked on a career with a city of London consultancy working in healthcare systems across the ten countries, all four jurisdictions of the United Kingdom, plus a six overseas project

5:30and spent a couple of years in the Gulf and on returning from the Gulf I wasn't quite ready for retirement so worked as an advisor in home care services to a trade association and that took me into working groups with the Department of Health, Business Enterprise Innovation and Skills working on things like implementing the Care Act and the Model Slavery Act and I worked also with the Care Quality Commission Skills for Care and various other project groups that gave me a very great understanding, a very broad understanding of how the bureaucracy behind the healthcare system works and then since retirement I've been working with a couple of charities. Okay, thank you for that and I believe that you've also done some time with the Army, is that right? Yes, I was commissioned into the Royal Army Medical Corps as a nursing officer and spent 12 years in front line roles there.

6:35I never worked in Army hospitals, I was always working with the Infantry Tank Regiments and Front Line formations so had a very lively involvement in places like Germany, Holland, Cyprus. Okay, all right, thank you very much for that. Well that's quite a spread of experience in a range of different sectors and I can see that that puts you in a very good place for commenting on some of the things that you've seen happening in those particular areas. You sent me a very interesting text about the NHS which starts off with the Bulleted Headline Demand Failures and I read through this with great interest and I'd like really to talk through that these subjects with you for the

7:37interview today but before I do I'd just like to tell a little anecdotal story which you'll understand as I get into it but many years ago what would it be now? Well I'm going to say probably about 15 years ago I was up in London with a lady who'd had a professional career in the NHS. She'd worked her way up from nursing on the wards to ward sister and then in later years she'd moved across into NHS management and a little while before I went up to London to see her she said to me that she'd taken on a new job at one of the London teaching hospitals. So it was a sunny Saturday morning if I remember correctly and we were in the back garden of her house up in London having breakfast and I said to her how is the new job going and there was quite a long pause and then she said well

8:42it's sort of frying pan and fire and I said well that's a little bit sounds a little bit unfortunate you know what's happening and she said to me well the problem is I live in a world of meetings we have planning meetings we have strategy meetings we have preparation meetings we have this meeting and that meeting and she said they're very time consuming and not a lot seems to come out of them but she said sometimes it's worse than not much happening things do come out of them but they're the wrong things and I said what do you mean by that and she said well there's quite a lot of experienced people sit around the table and they've been at the medical profession for some years and an idea will be put forward and the experienced people automatically know this is not a good idea and so diplomatically they tell the more senior people the reasons why the proposed

9:49idea is not a good idea but she said what always happens is we're told to get on with it so the idea is implemented and then sure enough in a matter of days or maybe weeks the problems start and then we've got the job of sorting out problems and convincing the managers that their idea was the cause of all the problems in the first place she said it's madness and I said to her what if it's not madness what if it's good management and there was a long pause and the lady looked at me as if I was slightly mad which is probably understandable and I said just answer the question I said you you are making the assumption that the managers of that hospital want to run in them efficient an effective hospital but what if they're not and she went very quiet for several minutes and then

10:51she said oh my goodness that explains that and it explains that and what I've done is just challenged and pushed her slightly away from the belief that the ideas were being put forward in order to help the hospital and I just got her thinking on the idea that maybe the proposals were deliberate ideas in order to create problems in the hospital and I can tell you that sometime later things got so bad in that particular hospital that the lady had to leave and she left on the basis that she said I just couldn't accept some of the working practices that were being enforced on people but worst of all was when I tried to use my professional knowledge and experience to put things right I was eventually invited to take some time off to look after my mental health and so that's a little anecdotal story and I wonder what your

11:57reaction is to that story before we get discussing your points. Yes fascinating insight you have there into the machinations of the NHS and I think there's two elements to this I think firstly there are targets which have been set which bear scant resemblance to clinical need or health care promotion so you have perverse incentives to undertake courses of action that intuitively for a clinician you know are way off target and from the learned management perspective don't actually address the problems that they as managers are trying to remedy so you get this conflict this constant conflict going on pretty much every level of decision making within the NHS the second

13:03factor though is perhaps a little more risqué in as far as several years ago we were asked at very very senior level to undertake a course of action and I paraphrase to an extent when I say that the politicians and the bureaucrats wanted this by Tuesday and the answer that I gave was that if if you work from a Sadie's Benz or Bentley or someone and you decide you want to do a new car you first of all you identify the niche market you do product viability studies you do marketing tests you do engineering viability studies and you go through the design um paradigm of working out the best design the cheapest options the most cost effective options and so on and so forth and then you do customer relations exercises and that takes quite a long time and if you're working from a

14:06Sadie's or Bentley or whoever that takes a long time and it's part and parcel of developing a new car in the NHS a bureaucrat decides something is a good idea and once it by Tuesday forget anything about whether this is matched to needs whether it addresses a particular health problem or whether it is the latest management weaves and a very good example of that is the four-hour accident emergency weights which have absolutely nothing to do with clinical priority medical needs or whether that actually addresses patient needs I mean it's just nonsensical so I absolutely buy into your colleagues uh frustrations with the system and readily accept that after a certain amount of time she had to move on for the health and well-being and I very much reflect that because in my own experience I got to a point where I could see the future rolling out as a chief executive of a

15:09trust or whatever and when you look at these people they've got gravestones in their eyes because the pressure on them from the political system and the politicized system is such that the scope of flexibility the scope of creativity and entrepreneurial and entrepreneurial to identify and address those problems is taken out of your hands completely you're in the hands of a bureaucratic machine that dictates and uh very difficult very difficult I got out as well okay now it's interesting they're done because very quickly you you you've mentioned the politicization of organizations and I spotted that in the second sentence the the first topic that you had on this sheet was demand failure uh yes I'm conversely designed into the NHS by fault and then you say the demand failure leads to the politicization of organizations I think on what you're talking about

16:17there how do you come to that conclusion that when when the when the demand failure is in flow the politicization follows yes um it's it's a very interesting anthropological position to find yourself in when you're working as a consultant in hospitals who have really quite desperate problems that need unraveling that need and uh some formula to get them out of this uncontrollable mess what happens is that organizations that that are large and dispersed and are very diverse in their their service offering and in their in their presence in the community um they become very susceptible to turf wars and what happens is that if you phone the organization up and the first person you come into contact with has no idea what to do or no idea how to respond

17:22to this request you know you're in a bureaucracy and what happens is within the NHS is that no one person has the answer to anything particularly so you you find yourself in a situation where you are confronted by this monolithic organization and every turn you take you are deferred onto someone else or another department or another referral pathway and and what then happens is that 80% of the time the staff in in the organization gets spent trying to unravel this problem and and when when you go in as a consultant you try to design what they call a service line or a clinical pathway that sort of draws a straight line between the patient enters the system here and the patient exits the system there and you try and draw a straight line between the two the reality is that instead of having a straight line you have a very convoluted line referring backwards and forwards

18:25and the staff spend in certainly many of the cases situations I was involved in as a consultant clinician staff can spend 80% of their time trying to unravel these these convolutions and distortions in service provision and and and the left with only 20% of their time actually dealing with the patient which means that the lowest possible grade of staff the cheapest grade of staff get to do the vast majority of the word the young qualified care assistant the freshly qualified house officer and so on and so forth so you you land up with this politicization of turf wars and silos where it's not their problem it's someone else's problem and the quicker they can refer you on to someone else and discharge the problem to somewhere else is how the system works and as a patient going in you find yourself confronted with this monolithic organizational opaque functionality that just doesn't explain itself doesn't

19:32doesn't become apparent in terms of what's happening now when you're a nurse and you come in as a patient or when you've been working as a consultant overseas and you come back to England as a foreigner and you see what's happening through foreign as eyes you are awakened to this extraordinary silo thinking and this extraordinary amount of almost sort of confrontational combat between different organizations and certainly my own experience was such that you thought tooth and nail for resources and you you didn't give thought or or passage to any other considerations you were forced into this silo of of thinking where you defended your own patch against all on-comers and so you land up with medical staff fighting their little turf wars you land up with nurses fighting for more resources and of course the patient at the bottom of the pile well conveniently gets forgotten yeah and if we put the size of the beast to the public and you

20:43correct me if I've got this wrong but I think the NHS total budget is somewhere over 120 billion a year and I believe they employ over 55,000 so that's the figure that comes into my head 55,000 I think you'll find his nearer one and a half million okay well give us more on that where are those people oh I suppose those are across all not just hospital sector those across the hall of the care sector as well well I mean that the home care sector care in your own home is entirely different and is run separately by local authorities and there's about 1.7 million people working in home care in the NHS we have a situation where we have last time I looked it was about 1.4 million people working in the NHS now that's not just hospital doctors hospital nurses its community staff

21:48its outreach staff district midwives all that sort of on to a large of people one of the most disturbing elements I think that has come over the last decade or so is that NHS England was invented as a sort of parent body to control and govern the functionality of the NHS to smooth it out to make it more lean to make it more responsive and here we are 10 or 11 years later and we find that NHS England far from being that entrepreneurial in innovative developmental organisation is actually a staggering bureaucracy of 14,000 people working in NHS England headquarters and its regional offices so these 1.4 million people are dispersed across the entire spectrum of the NHS and the bureaucracy like all empires goes on breeding at will and it's now very interesting to hear

22:50that there are rooms ugly rumors within Whitehall that they may have to take NHS England and the NHS itself back under direct control of the Secretary of State and to to appoint that person as the the top manager the ultimate responsibility for the NHS which would be quite revolutionary really the bureaucracy has become a self serving beast that just goes on multiplying at nauseam and do you think that this bureaucracy has developed of its own accord or is this something that has resulted from planned and imposed policy? Interesting point what has happened on many many occasions is that an political initiative or a change in the law is implemented and the response from the NHS has

23:55been well to implement that we need X number of additional staff so with every legislative manoeuvre every ministerial dictat stroke of a minister's pen the bureaucracy that that then creates starts to burst into action starts to breed itself and you find that whole departments start to evolve and develop and and increase in in their man manpower headcount and you find that whereas something in say one country was was operating quite effectively quite smoothly um you come back to the NHS come back to England to the NHS and you find that it's been gold plated that the bureaucrats have added additional features to that ministerial dictat or

24:58that legislative measure and you land up with five gold stars bolted onto the side of this what the minister thinks was a very simple and very straightforward exercise in smoothing out the care process the the hospital management process and it just goes on replicating itself um and it's quite frightening to to see it in action okay thank you for that what what you were talking the other the other point that came into my mind was the issue of privatisation because we've over the years we've come into contact the number of medical professionals in indeed several years ago we we set up an NHS conference where we had a number of very good speakers talking about their experience of what was happening in the NHS and they varied from um clinical specialist doctors essentially we're talking about what was happening inside the NHS in relation to

26:05care we also had one lady who had um had got considerable experience inside the financial systems of the NHS um and she talked about everything from fraud and corruption but the theme that i'm going to say most of the speakers came out with is um damage being done by privatisation that although the government was constantly selling the NHS as a national treasure which was safe um behind the scenes what was happening was was that um elements of the NHS were being sold off bit by bit step by step and this i can remember some of these speakers were saying that they believed was a key problem because it wasn't as if the bureaucracy was allowed to get on with itself it had also got nibbling away at it a sort of cancerous privatisation do you recognise any of

27:11that sort of description or do you think those people didn't didn't quite see it correctly um firstly i absolutely do see that situation and secondly i think they've got it whole sale wrong i think firstly the NHS has not been privatised what has happened in several instances and i've been involved intimately with several uh contracts is that certain services have been contracted out but that contract is exactly the same contract as an NHS provider would have now in competitive tendering and particularly in the days of primary care trusts maybe 10 10 12 years ago and and there was a Gordon Brown came up with the idea of a a walk in clinic a Darzy clinic and i was responsible with five primary care trusts across the country for implementing that scheme and those contract tenders went out to anybody who was

28:17interested in tendering so there were NHS hospitals NHS trusts who were tendering and they were private health provider organisations that tended and the most economically advantageous tenders were always from the private sector always 100 percent they be and this is important fact it's not about the cheapest bid it's about the most economically advantageous tender and where people are very concerned about the privatisation of the NHS I think they are mistaken the NHS you you i mean you have to go back to founding principle you cannot create an entrepreneurial innovative creative organisation from a 36 layered bureaucracy that is stodgy unmoving entrenched and incapable of moving outside of its own parameters of thinking out of its own little

29:19box of thinking so when you come across tenders for creative new services and that's worked in psychiatry as well as acute services as well as primary care frontline services what you're looking for is innovative creative solutions to an established recognised problem now what I would suggest is that we don't need to privatise the NHS what we do need to do is denationalise it and that's a very subtle difference because privatising it is selling it off to the high spitter denationalising it is taking it out of the hands of the politicians and the bureaucrats and letting local organisations flourish and develop and respond to local priorities in a way that otherwise can't do because of national targets and medical protocols and whatever else so if you remove that blockage that massive blocking and unchain and you unchain the energy that is inherent

30:24within the professional people at work within the NHS and we've seen that happen where doctors who complain about the NHS being privatised tobbled off down the road in their jaguars and their bentles and work in the private hospital five miles down the road and get enormous salaries for that privilege and our stakeholders their shareholders in those private hospitals even gerry tritians and psychiatrists do the same so it's very much a false narrative and I think that unless we can face up to the fact that the NHS as it stands today as it functions today it can't carry on like this we cannot go on like this we have to create something better and different and I think the primary answer to that falls into two categories one we need quality assurance driven by contracts and secondly we need to be nationalised and create

31:25out of what our currently NHS trusts we need to create private enterprise that is owned by the public governed by public authorities but has the entrepreneurial capacity and permission to function like a private company in that locality and until we get to that level with sunk yes Duncan absolutely fascinating to hear you say that and as you were talking through nationalisation what came two things came into my mind one was it's a shame that David Scott is not sat with me because this is one of the areas that he is he's talked about numerous to me not on record but he's spoken to me about how he sees healthcare provision and he's talked about the fact that going back in time you would have the doctors serving their local community

32:32and people might be paying the doctors in those days direct you go and see the doctor and the doctor does something and he's paid direct by the patient but that was also a time when if necessary the doctor would travel to the home of the patient to see them so there was quite a simple element of commercial transaction together with the provision of the healthcare at the doctor level but of course the other thing was that the centre probably of healthcare would be based on the local hospital and that might have a couple of elements to it because we could have the local hospital which could be relatively big and in bigger cities it would be supported by even more local cottage style hospitals which I can just about remember in my lifetime would have provided either simple medical treatment somebody got a bad cart or they broken a leg they could go

33:43to the local cottage hospital for that but the other thing that the local cottage hospital might do is provide care for a very elderly patient who was perhaps recovering after an operation in the slightly bigger hospital what I'm really describing is that the the healthcare was centred around these hospital units which were automatically at a local level is it the case that we should be thinking about perhaps going back to this this idea instead of a vast hospital out one in deriford sorry I want to implement the deriford hospital I think on a full capacity day has about six and a half thousand people in there patients and staff that we should be sort of decentralising and heading back towards this local hospital provision does that make sense yeah that makes absolute

34:45sense and it would be good to have a conversation with your your colleague about that and I think there are again a couple of problems associated with this with the current format the current disposition of the NHS I think your colleague and yourself have come across one of the great answers to one of the great problems of step down facilities now we have hospitals full of people who are medically fit the medical system can't make any further contribution to they're medically fit the discharge but home care social care can't get them out so we have bed blocking which is very unpopular phrase but nevertheless it describes exactly what is happening and then if we had step down facilities that hospital could say okay someone is medically fit but not socially fit for discharge they can go to a step down facility in days of your that would have been the community hospital and one of the most unfortunate jobs I ever had was the decommission of community

35:49hospital and and everybody locally was up in arms because it was seen as an absolutely pristine facility supported by a league of friends money poured in but nevertheless the local health authority would determine to bulldoze it and did so if we had step down facilities where patients could move out of acute hospital settings into a caring environment that would be laid by not just nurses occupational therapists physiotherapists so that the therapeutic element was still there was very much present very much there on demand but you'd moved out of the medical sphere of influence into the therapeutic sphere of influence that I think would be an absolutely essential step forward for the NHS to embark on the second element to this is the role of the general practitioner the general practitioner is divorced from the wider NHS they live in little silos in little private businesses

36:50dotted all over the place now if you and you know my experience of working with NHS GPs is that after about year seven in post they're bored out of their tree so if we could get GPs integrated into the wider clinical sphere so you could have a GPs who was an orthopedic specialist recognised as part of the hospital orthopedic team the gastroenterology specialist part of the gastroenterology team in the general hospital you could start integrating properly the hospital and primary care into a seamless service where specialists and expertise move between the two but at the moment you're stuck in a son of a you can't get out of it and it it it it wrecks the clinical pathway it wrecks the service line management it costs us a fortune in terms of NHS budgets and it delays patient care so I think your colleague and yourself in that conversation

37:51have hit the proverbial nail on the head okay thank you for that so I lost over the number of people employed I got that one badly wrong but I've clawed some points back on this one um what did I want to say on that yes okay well if this is if this has got the seeds of a good idea about it have you ever seen this sort of thing proposed to the people at high level who are supposedly worrying about the demise of the NHS and what to do to save the beast yes I have made that suggestion and when I was on the care act implementation task and finish group and glorified title if ever I heard I and the two or three others were very keen to promote the the idea that you should have stepped down facilities and that it would be entirely the

38:52legitimate for the NHS to open nursing homes for want to be better titled so that people could move out into a care environment and I think the the bigger picture in terms of trying to get that idea across comes up against immediately comes up against the NHS hospital trust, turf, territory and hospitals get their money in different ways from various methods but the the problem for them would be how would they get the money to pay for those step down facilities for those community hospitals would it be a separate organisation should it be a separate organisation or should they should the main major hospital hang on to it control it and run it and there's a case to be made for either but in terms of taking that idea up to the

39:55department of health and I just say particularly when I was working on an implementation task force up there they wouldn't hear of it it was absolutely unheard of that they would not entertain the idea that the major thrust is consolidation you get all the major services into one big hospital you look at gypsum, james is in leads massive monumentally huge hospital and and one of the arguments that was very much currency at the time was that small hospitals can't provide the level of expertise to keep consultant medical staff and senior nurses clinical nurses up to speed with the latest developments you need a big university teaching hospital to do that so small hospitals of about 350 beds or less their future is very much under threat so you have this huge industry around

40:55big hospitals and we haven't learned the lessons that France and Germany and other countries have where you have smaller community facilities that can accommodate a lot of the subacute step down patients and that is a serious error in planning a serious mistake in thinking about how to organize and corral the resources and the energy you've got in the health system right that's extremely interesting because I'm still coming to terms with the fact that you took away the privatization bit which I'm very happy to accept but this in my own mind was one of the one of the key problems and now you've you've got me thinking that in the first instance we've got the power of the bureaucratic monster

41:57which is going to defend itself for every opportunity because people have got jobs and they're very highly paid I was always very interesting when I started to realize that we we'd suddenly gone to degree chief executives a management degree chief executives of hospitals so these I don't know how many years ago this started but but it was the professional training of of hospital CEOs and those individuals were then were walking into extremely highly paid jobs I mean I think some of the bigger teaching hospital chief executives were on about 260,000 pounds or were a few years ago and that always says to me that people who are in a job on that level of payment are not going to give up their job easily and they're also going to defend their patch against anything which they

42:58think is a threat you know to their livelihood so I can see through money itself how people can quickly be controlled but the other thing these chief executives demonstrated was a was a break between people going into the medical system out of a desire to help people to look after them to care for the sick and injured and you had these professionals who were coming in from a business management and a fiscal management point of view and I always felt that was the start of something not very good in the NHS that you no longer had a hospital where probably the key decisions on all matters were made by consultants. Yes it was and remains a significant problem and I there were two occasions where I ran into that

44:04head first as it were on one occasion in a hospital in the very southern end of the Midlands they had employed a 29 year old director at manager, director at general manager who was not a clinician he had come out of the university with B.A. or something and gone straight into doing B.A. and at the age of 29 got an executive director's role of a large medical unit in a district general hospital and it took about four months for the senior hierarchy to realise that they had a catastrophe on their hands and on the second occasion I met a 35 year old who had come from car manufacturing done his M.B.A. and had decided the health service was rich pickings and moved in and lasted 15 months and it then took the clinicians nurses two years to sort the mess out. Now that's not to say that people coming in from outside are bad I've got

45:11an M.B.A. myself because I recognised early on in the early 90s that you were going to get nowhere unless you had a D.M.S. and an M.B.A. but it soon became apparent that people who have no hospital experience, no clinical background taken inordinate amount of time to assimilate themselves into the hospital culture it is vastly different and there was that apocryphal case of the brigadier who took over notting in general hospitals and assumed that the medical consultants would be his officers mess and that they would have power hours in the officers mess until the clinical consultants ganged up on him and threw him out and he didn't last very long at all. That brigadier was severely traumatised by that situation. So I think we need to get a real sense of balance about about how we're led and about how NHS trust led undoubtedly you need business acumen

46:14but I think it's probably more important to know your product. I mean would you employ a medical doctor to run the production line at Ford cars or the nuclear submarine yard in Barrow, Inferness? Well probably not. So you need to get a sense of balance around it and you need to work hard on getting those people up to speed in terms of the culture and the operationalisation of health care and there was a fast track course a few years ago where doctors, dentists who decided they want to get into management could go on a fast track system and work their way around a hospital for a couple of years and then take over as assistant assistant chief exec or something and that didn't last very long either. It's a very fine line you have to walk in terms of getting the right skills, the right business acumen and the right industry knowledge to take over and run a trust. It's been done, it's been done well but they have been some serious accidents on route.

47:21As for earning quarter of a million quid, how many nurses could you employ for quarter of a million quid? I mean just bonkers in it. Okay, number of points coming to my mind is the other one that I was interested in was when we started to see nurses put on degree courses and so originally a nurse would go to a hospital to begin training and she would inevitably, those days be a sheet now of course it could be a man or woman but they go on the the ward and they start at the bottom. They would be changing beds, they would be emptying bed pans, they would be doing all of the menial jobs and then they would slowly work their way up through responsibilities to whatever it is, staff, nurse

48:22nursing system, matron and I recognised that system because essentially that was the system in the military as well but then we had the decision that nurses were going to go to university to learn how to nurse and then we had the nurse with a degree but no experience coming on the ward almost being shocked that they were going to be asked to do jobs which in experience nurses have been asked to do over a great many years for a reason. It took them from the bottom to moving up through and I could identify with some of the criticism that came around this new system because at one stage in the Navy at least they decided they were going to take more people in the officer corps from degree courses and in one particular year you had people who had come from university that they had two stripes on their arms. They were left tenets and in quite a short space of time

49:30there was some problems occurred because these left tenets had no experience whatsoever but as far as some of the more junior sailors were concerned if they had two stripes on their arm they knew what they were doing and there was on two occasions they were very nearly fatal accidents because the inexperience left hand had too much faith in their own ability and they made decisions which were completely crass but I'm just in for some easing a point here somebody made the decision that we wouldn't sort of have an apprenticeship system for nursing and the same applies for doctors really we would bring in these people who've been trained at university and they are unleashed on the wards without any experience and what I've always wanted to know is who was the person who were the people who made the decision for this sort of change in the organisation? Yes there's a bit of a

50:38history here going back into the late 70s and 80s the vocational calling that was nursing gave way to a very strong drive to academic enterprise so what had been a vocational hands-on minds on course over three years with quite a lot of science and a lot of disease and pharmacy and all the rest of it thrown in yes of course but it was then under under a scheme called project 2000 in the late 80s mid 90s took nursing students out of hospitals and put them into universities as you rightly said and it became an academic pursuit and the the time that those academic students spent in the clinical environment on wards in departments was very limited

51:40and certainly the experience of senior managers like myself in by the mid 90s was that as a project 2000 university graduate came out onto the wards as a fully qualified nurse they had to be taken off those wards and put back into school because they had never given out a drug round of 34 patients they had never given last offices to a deceased patient they had never gone into theatres they had never gone into mortgories let alone post mortgames and we landed up taking those nurses off the wards put in and back into school to teach them how to be nurses and that was quite a cultural shop for them because they had been taught throughout that period that university period that they would be the cream of the cream they were the qualified they were academic achievers and so on and so forth and when they actually got on to the wards they suddenly found that actually not only

52:43were they the bottom of the pile but actually they were the ignorant bottom of the pile and there were unqualified care assistants teaching them how to give drugs to patients how to perform last offices on a dead body and so on and so forth terrible terrible shift in emphasis for them and quite a cultural shock for lots of them quite a few of them didn't survive and moved on quite quickly but you mentioned also about doctors and one of the big issues that the medical profession has gone through over the last several years is that let's say 20 years ago you would you would go and see a consultant or the PD gastroenterologist thoracic surgeon whatever that surgeon would be a consultant and to get to be a registrar the rank below a consultant they would have taken about 30

53:43thousand hours of academic and practical education to get them to be good enough clinically to be a consultant or a general practitioner now those doctors coming through the system now only get eight to ten thousand hours of education in that context so we have fully qualified medical practitioners at consultant and GP level who have about a third of the amount of post registration training that the account of parts 20 years ago would have had so the expertise of medical staff particularly general practitioners has gone down and for example it has been calculated that general practitioners miss eight out of nine new cancers so nine people turn up with the suspected cancer eight of them will get missed one of them will get diagnosed as probable cancer

54:44and referred on to oncology so there's another rate well they develop higher higher level cancers go to sage two three four and die so we have that real problem within the health service about expertise and successor planning right now what Duncan sorry to come back in here what my question then is that if if you've got a lot of experience in the NHS I have a nightmare experience of the NHS is from family connections and friends who've been involved in the NHS but I'll say that's on a spectrum from people involved in nursing to a couple of hospital consultants but you and I are having this discussion this conversation now and we've identified that a particular change in emphasis from learning on the job to being trained in the university has not as not delivered a good result

55:47we can see this again who made the decision to bring it in this is what I always want to know who were the people who said we're going to change the structure we don't want to do it as it's always been done we're going to bring in this new thing who are they and how do they get away with introducing something which I think has been there's been very detrimental on the NHS I mean it's not one person or one group it's a it's a cohort of people who come together and let's just say a theoretical model a discussion model would be a group of people at the British Medical Association decide there's an issue that they think means addressing they go to the department of health with a paper that describes the nature of the problem and the department of health mull it over for several months they form a working party to drill down on it recommendations and

56:52ideas are percolate to the surface costumes are applied to that and if you say well okay we can save two years on a medical post-registered medical course and that's going to save thousands of pounds and we can get people up to speed in terms of being a senior clinical practitioner that much quicker then it gets stabbed rubber stabbed after the working party and the costumes and all the rest of it so it's not one person it is a massive bureaucratic exercise where conflicting demands are put together and the balance is made in terms of cost benefit analysis in terms of environmental impact assessments and it was decided that particularly for nursing the project 2000 taking students off the wards putting them into university and creating

57:54academic nurse was a far better cost benefit analysis benefit to the NHS because you could then reduce the number of nurses because they were more technically competent they were more advanced practitioners you need slightly less nurses per ward and you could fill the gap with unqualified care assistance so there was that very defined approach in terms of costs and what was thought to be improved services improved care it didn't work out like that yeah okay I've been interested in an organization called Common Purpose for many years Common Purpose is a cause itself a leadership charity it trains future leaders and certainly when I was really looking into its activities 10 years ago I was fascinated by the fact that it had clearly

59:00latched on to the NHS in a very very big way and so the NHS was paying out some pretty substantial sums of money in order to get people put on this course which created future leaders but if I now follow through the NHS I can actually see that the NHS leadership academy is itself virtually a wing of Common Purpose so the Common Purpose agenda is now now permeates the whole of the NHS and I don't know whether you've come across Common Purpose if you have I'd be very interesting interested but it seems to me that many of the poor sometimes disastrous sometimes very strange decisions that are being made within the NHS are actually coming from their own what they call their leadership centre of excellence and this to me now seems to have become a

1:00:06specialist area of the NHS which is doing a lot of damage because it's completely lost touch with with the real aim of the NHS to help make people sick people better and to care for people it's gone into its own management guru speak are you familiar with Common Purpose at all or the NHS leadership academy and what it does yes indeed and I have to openly admit here that my own view of Common Purpose is such that where I to be magically appointed as Prime Minister tomorrow morning the first thing I would do is that anybody anywhere in any organisation that had been indoctrinated by Common Purpose would be made redundant on the spot let's make no bones about it Common Purpose is nothing more than an ideological fifth column because the whole ideological position of Common Purpose

1:01:15in the title it is Common Purpose and it's infiltrated the police and various other agencies and organisations so I think in terms of the setting up running of an NHS leadership programme that reflects those common purpose agenda it's hardly surprising that what you get is clones you don't get people coming out of that who are grounded in developing services they come out ideologically indoctrinated and it is catastrophic in its implications now there may be good people coming out there may be not some good people coming out but I let me think now 22 23 years ago the King's ran a course called top managers courses and senior managers courses and they were very focused

1:02:17on how to marshal your resources how to direct and create fellowship how to create leadership which Common Purpose doesn't it's about ideology and I think that the consequences of setting up a common purpose mirror image within the NHS creating clones will only reinforce the silo thinking will only reinforce the stodgy bureaucracy and will prevent the NHS from ever being anything other than what it is today and the idea that we have ceded the management classes with change agents is a complete myth I'm sorry but you've got me on a you've got me on a soapbox with this one well don't can I I've got to say I'm I'm utterly delighted because

1:03:23you and I have not spoken to each other before today and so I threw that at you I had no idea what you were going to say but I was utterly delighted to hear somebody else speak with sort of vehement about what this organisation is about and what it does while you were talking I just went on to my laptop here because I couldn't remember the date and actually where are we it's the 24th of May 2013 UK column posted a really excellent article about the penetration of common purpose into the NHS and it was called the NHS Common Purpose towards a million change agents and it was written by a man called Martin Edwards who I've known for many years and he's he's done quite a lot he's done a lot of research on his own but in the early days helped me

1:04:25research common purpose but in his particularly detailed article he's got a lot of quotes which have come from the common purpose elements inside the NHS themselves and a million change agents was a suggestion by one lady that this is what the NHS needed in order to rectify all of its problems a million change agents when I looked at it with complete horror because of course or what I have seen over the years is that wherever common purpose initiated its transformational change the organisation began to fall apart from the inside don't know how you'd react to that yeah I can see where you're coming from on that I can see where your your colleague who authored that piece that's coming from I think the sort of I mean for a start the idea that you've got a

1:05:28million change agents he's just well it's pipe dream isn't it I mean it's Disney-esque fantasy land and and the further it permeates down through the grade through the rank structure within the NHS you land up with this step for one sort of situation where you you have people who are in completely indoctrinated and completely beholden to this quasi-marchsist approach you know and you start to wonder just what is happening to because the mentality of this approach you know if if the the inspiration behind common purpose wasn't to append Western society and the organs of Western society why do they why are they doing it why why on earth go down this road and the more

1:06:31I see of common purpose the more I appreciate that you know situation the organisation is sort of like the world economic forum and the Paula Alensia Citroe organisation in the United States Hillary Clinton and Obama were both the Fissionados and followers of there's this sort of slow bird indoctrinating quasi-marchsist sort of approach and if you project that that sort of cultural methodology forward over the next sort of five or ten years you can see that the organisations are not going to survive simply because they're the boundaries the processes the structures are all going to be undermined and you really have got me on a ideological so far today I'm afraid but it's it reeks of desperation that an organisation as large and as

1:07:39purposeful as the NHS should be can be subverted by an ideological drive that's got absolutely nothing to do with healthcare it's got nothing to do with healthcare at all it is nothing more than an ideological institution and it bodes very unwell this this this this is absolutely fascinating to hear you say this let's throw in the next bits that when we investigated common purpose what what we saw it doing was it's almost like a virus it gains a foothold in an organisation and then grows inside it and common purpose from the outset was always very interested in people who were controlling budgets in organisations particularly if they had control over a

1:08:40training budget because if common purpose could get in and do a little course and then they've recruited somebody in that organisation if they could recruit somebody who had control over the training budget they could get several steps up the ladder to get a bigger event going inside the organisation and they did this inside the police they did it inside the NHS inside education they were everywhere in the public sector but the other bit that we became aware of is that it wasn't as if they were simply putting people in a room and talking to them what qualified people explained to us and I'm going to say one of the gentlemen who who taught me most in the early days had was well trained in psychology as a result of his work in the NHS and social services and he said to me very quietly one day but you realise of course Brian they're using NLP

1:09:44neuronal linguistic programming and I had no idea what that was and so he started to explain to me it was the use of applied psychology in order to change the way people change their views and their values and he said it's a very powerful tool because you can use it on a group of people and they will have no idea what you're doing with them and and this was the point at which we started realised that the common purpose courses themselves were taking control of people by using applied psychology and this made common purpose an extremely dangerous organisation I felt because it buried its way into an organisation largely by I'm going to say deceit and stealth it was certainly deceitfully what it was going to do but it was also using applied psychology in order

1:10:47to capture its own audience and future leaders inside that organisation and for the NHS we not only saw the common purpose elements taking control of the NHS now via the NHS leadership structure we had also unleashed the power of NLP inside hospitals and before I hand back to you if I just add to this that of course once we discovered that the cabinet office in 2010 was boasting that it was able to use applied psychology to change the public's mind this was all the work of the behavioural insights team which was run alongside the cabinet office but we now started to see policy and future policy of organisations being framed on the basis that they were going to use

1:11:53applied psychology to drive the government's agenda and this to me was an immensely dangerous combination particularly where you put it alongside healthcare yes absolutely and there are several strands to this I mean perhaps first and foremost because the NHS is such a monolithic enterprise and because it has such a higher regard within the public appreciation and it has almost become a religion therefore the amount of influence over policy makers both at local city, county level as well as national government the capacity to influence policy because of what it is is immense and that is dangerous in itself now you would expect a large organisation the biggest

1:12:53after the KGB I think someone once told me you would expect it to want to have some influence at policy level but when that becomes an ideological unified ideological proposition rather than local interest than you are automatically and immediately in a minefield the second element is that the ideology behind it is so seductive that people who are politically less versed in the machinations of government and decision-making processes are easily seduced by this very luxurious, smooth talking approach to how we are all relate to each other how we engage with each other how we feel about each other so that you get what are that saying if you get them young enough

1:13:55you can keep them forever and I think the people who are at the beginning of their careers who are indoctrinated in this stuff come out the other end utterly convinced utterly convinced that this is the way forward it's the only way forward there are no alternatives and that is even more dangerous because it brought no opposition or challenge or competitive ideas or improving ideas and it entrenches this inbuilt silo thinking it is protestically dangerous and then I think the other item is that NLP is one of the most abhorrent faux sciences imaginable I mean it's absolute disney-esque witchcraft it is you know we hear in terms you know in covid lockdown and all that and Susan Michi the well-known communist was in charge of the nudge or involved in the nudge units in terms of nudge psychology nudging the

1:15:01population until believing that lockdowns and masks were the be all in the end all it would save humanity from itself sort of thing and you realize that people like Susan Michi are involved to a common purpose and people of her ilk are involved with common purpose they use language they use NLP to change the meaning of words they change the impact of words so that your vocabulary means something different once you've changed the language once you've changed the meaning of the words that are being used then you start to change how people think you start to change how people appreciate and you remove from them the capacity for independent thought NLP is a scandalous absolutely scandalous faux science and you know it's witchcraft for the 21st century and you know I mean I'm not for censorship by any stretch of the imagination quite the opposite but

1:16:05really you know we have to look as a society as what we allow to be done unto us and if we allow NLP common purpose to do unto us what it is doing then we're just heading towards stepford wives I'm sorry but it's just nightmare scenario don't get on doubly fascinated now because when I threw common purpose at you I thought with your experience there's a good chance that you might at least come across it and therefore have something to say about it but clearly you've not only come across it you've really thought about what it is you're declaring you feel pretty uncomfortable with what it is can I ask when when did you first become aware of common purpose and was that in an NHS setting or was it somewhere else no no it wasn't in an NHS setting I for a period

1:17:10of three years was national director of clinical practice and clinical supervision or relate which used to be the marriage guidance council but is now called relate and deals with all manner of relationship issues not just divorce which it started out with and my job I got regional managers all over the place and there are psychotherapists and sex therapists and all manner of psychological practitioners and some of the programs some of the schools of psychological thinking that practitioners from me we got 2,200 practitioners across the entire country and partner organisations in Germany Scotland, Mortagy, Brawl to whatever wherever and some of the schools of psychological thought that were being practiced struck me having as a psychiatric nurse with a DMS and an MBA

1:18:16as being not quite right and I started to drill down seriously into things like Kelly's personal construct psychology Milan school of family therapy NLP and there's a few other bizarre schools of psychological thought and practice and as soon I soon realised that the psychological apparatus that was being used to change people's thinking about relationships change people's thinking about not just relationship man or wife relationships between and within families within extended families in terms of communities neighbours streets all that sort of thing were being adversely impacted by these weird perverse schools of psychological practice and thinking epitomised by NLP so we're going back to turn of the central you know 2,000

1:19:24and since then I've one of my many hobbies is to research into such things as this which took me into you know world economic forum and all that sort of stuff as well so you know you get labelled as a bit of a conspiracy theorist at times but when you sit down and study NLP and you look at the motivation behind people that are trying to impart the principles of NLP to others you have a very defined command and control psychology going on and it's the same with common purpose it is a command and control psychology program it is nothing else other than we will instill in you the psychological framework where we can control your appreciation analysis construction of social environments social events into interpersonal relationships relationships

1:20:24with patients and so on and so forth in a way that we can then control and by importing into your awareness priorities that you otherwise wouldn't have come across and those priorities are ill disguised Marxist this column this stuff well I always challenge the you know the theory bit because a conspiracy is is a recognized event state activity the adding of the word theory was the attempt to take people's eye off the fact that they need to understand conspiracies of real but what a fascinating discussion because I never expected that the soft anew that I together with you're good self we'd end up back on the subject of common purpose and what it's doing you have taken it far enough to say that it's it's a fifth column

1:21:25organization and I completely agree is it unrealistic for me to think that if a fifth column organization with a particular political agenda you've likened it to Marxism we could debate that a bit but I understand where you're coming from if that organization has been unleashed within the NHS is it any wonder that the NHS is in a complete state of chaos and breakdown at the moment under NHS leadership as it calls itself is it any wonder no I don't think it's any wonder to anybody who has the now to drill down and see what's happening and I think that if you take into consideration the concept of the long march through the institutions we have an

1:22:26absolutely pristine example of a long march through the institution and the long march is ongoing it's perpetual it's nonstop and it it brings about a revolutionary frame of reference because of the slow burn approach and one of the key elements in this approach to infiltrating organizations and I use the word infiltration with great hesitancy but one of the the key components of that ideological move into institutions is that you break down the traditions the heritage the customs the practice and the volition towards what the purpose of the organization

1:23:31is and the purpose of the NHS is that you have a volitional commitment to helping ill people sick people curing people getting them better and if you break down those profound psychological components as to why you and the organization exist you absolutely create confusion and chaos that is a design intention it's not an accident it's not an unfortunate corollary of this important program it is a design intention it's designed to break down those pillars of accountability responsibility and authority that allow the organization to function as a cohesive coherent lined up all it's purposeful common purpose

1:24:34and I think that until you recognize that and until you take a deliberate intentional course of action to reestablish the moral values the morality and the ethics of a caregiving organization you will land up with a self-satisfying self-perpetuating bureaucratic entity who sees itself as a change agent for society as a whole through influencing policymakers influencing local decisions and influencing how people think that is nudge politics that is nudge psychology that is what they was deployed during covid and is being deployed in large-scale institutions and we've seen the woefulness of the police and we've seen a couple of chief constables chief constables saying that

1:25:34we must get back to solving crimes rather than policing the internet and Facebook and Twitter and all that crap because they have woken up to the fact that their police force has been subjugated to this this common ideology that is happening in the health service or they're happening in the civil service and other organizations so I think we have a monstrous ideological challenge ahead of us and I think we there's not enough people to understand this thank you very much for being so forthright on this and you're clearly showing that you've got a lot of knowledge and you consider a lot of aspects around this I'm going to suggest that because I've lost a little bit of track of the time but I think we're on about an hour and a quarter and hour and 20 minutes. Now 47. Okay we had a little bit of a technical break there so a little bit less. I think we should

1:26:40stop here but I'm going to say to the audience that in the little bit of text you gave me towards yes he was at the end you were talking about current grief so you were talking about social care the grief to end all grief waiting less maternity services mental health both COVID and lockdown and then you're talking about NHS care to sick people the NHS is a sick people service if you would do me the honour it would be great to have a part two with you and I would propose that we we we start looking at the the use of this psychology at the beginning of COVID well that brings us into the spy bee arena and sage teams of the government but we can have

1:27:43look at this psychological element and then we can work the other way we can follow through to see what happened to care provision in the NHS following the use of the COVID pandemic psychology and I think this would lead us back to your statement on what the current griefs are because of course so many of the problems today have been caused by the decimation of the NHS under lockdown rules yeah sure yeah fine look forward to that okay well Duncan we're into there thank you very much for joining me today and also thank you very much for getting in contact with the UK column in the first place it just shows what happens when somebody takes the initiative so I'm gonna say a big thank you to that and we will be in touch and hopefully

1:28:46we can fix up a date fairly soon for a part two but thank you pleasure you Dave Roberts here there you are surrounded by fans sharing wings sharing drinks high-fiving random strangers everybody remembers the game nobody remembers the guy coughing behind you until a few days later at 2 a.m. you wake up with the fever and your throats on fire now what urgent care clothes ER SLAM telehealth maybe but the pharmacies close you needed a medical emergency kit these aren't first aid kits they contain essential prescriptions used for over 30 common conditions sinus and ear

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