Saturday, 21 November 2015

Standardised Management Conversation

The Book

I have written a mini-ebook called Standardised ManagementConversation (SMC) which I think is essential for healthcare directors, managers and senior clinicians. The SMC is a model which is to be used when various healthcare managers talk to those who report to them. It will also be useful for non-healthcare professionals and managers as the fundamental principles are more or less the same.

Since the conversation is standardised in the model, it makes conversation between people predictable and stable with no surprises. The model is based on sound principles, years of observations and practical experience. It draws on conventional management, clinical ‘lean’ management and some lateral thinking.

It is a small booklet. It is priced at £0.99 for UK and $0.99 for USA (equivalent prices for other countries) published in the ebook format via Amazon available at this link

The Cause

I will be donating all the money that I get from the first year (November 2015 to December 2016) sales of this mini-ebook to a charity called Udavum Karangal in India (  ) for the purpose of sponsoring an orphan child all the way through childhood till the child finishes education and leaves the orphanage. This scheme costs about $1000 or £600 which is actually a great value for money to see a child through childhood and education, thus providing a solid foundation for a stable adult life. I like long term thinking and long term benefits, that is why I have chosen this charity. I have personal experience of sponsoring children through this scheme. I have no other relationship with this charity, they do not know that I am doing this.

So here we go, if you are a director or manager in any field or have aspirations to become one in the future, especially if you are in healthcare, if you are a clinician with an interest in management, buy the mini-ebook SMC - Standardised Management Conversation. If you like it and use it and you are successful it is a win for you as a reader of SMC booklet, it is a success for me as an author and it is a success for a child till he/she becomes an adult. Well, if you do not like it, your £0.99 is pure charity.

It is a win-win-win whichever way you look at it. You may perhaps now want to make a guess on the gist of the content of the SMC mini-ebook.

Thank you for your support.


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PS: As a new author, new to e-publishing, if there are issues with it kindly provide me feedback so that I can improve on it.

Friday, 30 October 2015

Evolution of professionalism and ethical medical practice in UK and some lessons for India

Indian background: personal view of my experience in India

The issue of ethicality for me, as for many doctors in India, started before joining medical college. In my time and until today, the issue of admission to higher education by merit as judged purely by school final examinations and entrance tests versus the need for social justice to correct the vestigial effects of historical wrongs remains a highly volatile, emotionally-charged ethical dilemma. Once we joined medical college, we saw that the professionalism was often tainted by the general corruption and laissez-fare attitude of which it is often accused.

We overcame these issues due to four main factors:

a) We were really passionate about being doctors;

b) the subjects were really tough, so there was not much time to think about anything else;

c) some highly ethical, professional teachers had a disproportionately positive impact on our thoughts; and

d) most of us were only passive players in any unethical and unprofessional behaviour (at that time, that made it okay).

My own brief period of post-graduate training in India was a mixed experience - for me because of where I worked, my training was directly related to my effort, with the occasional heartache when some VIP’s son (it was usually the son) forcefully robbed me of my opportunity. Many of my colleagues completed their post-graduate training with limited skills; some of them could afford (the time, money and connections) to gain it in the real world after they finished their training and become better doctors; the normal reality of life engulfed the rest and they entered a self- perpetuating cycle of talent deficit. In the years as a young doctor in India, and then later as an experienced surgeon who practised in India for a brief period, I saw repeated examples of unsupported doctors driven to displaying unprofessional and unethical behaviour which were adversely affecting the patient’s clinical care amidst a few individual islands and beacons of high moral behaviour. To avoid being misunderstood or misquoted, let me make it very clear - my view is that the doctors in India want to deliver the highest quality of clinical care and they want to apply ethical methods. The social construct and systems often try to push them away from ethicality; some doctors manage admirably to resist this.

Broad UK contextual principles

The UK is indeed a very ethical and professional atmosphere for doctors. Generally, expressed behaviours are a function of societal standards and expectations. The UK has a high degree of expression of the whole spectrum of the domains of human action - a high level of personal free choice which is tempered with a high level of societal ethics; and a high level of legal control should the personal free action cross ethical boundaries. To phrase it differently, people can do what they want, they do that with consideration for the rest of the society and when they cross boundaries there are laws and rules in abundance which are generally enforced effectively. This was not achieved easily.

Broad context for doctors

There are broader factors that act as the foundation for professionalism and ethicality. As soon as we begin working in the UK, we realise that the bulk of healthcare is delivered by the government through the NHS (though there is increasing privatisation at this time).We learn that the rich and poor can get the same access and treatment, which is more or less of the same standard, across the country. Healthcare has no relationship with the ability to pay – it is free at the point of care. An overwhelming majority of doctors are employed by the NHS on national contracts and there is no difference in pay, and thus earnings, for doctors from various specialties working in any part of the country. Private care exists for people with money or private health insurance; but it is usually to jump any queues and get some frills but the care quality is in substance the same. The system generally removes any financial or professional reasons that might trigger unprofessional or unethical behaviour.

Specific context for doctors

Doctors are held to higher standards of behaviour; these are regularly reviewed and set out in the UK regulator’s (General Medical Council’s) Good Medical Practice guide. Doctors’ annual appraisals are related closely to the domains defined in the GMC’s GMP guide. There is a specific area in annual appraisals titled ‘probity’ which is taken very seriously. Further, a doctor’s personal health problems have to be declared and their impact on effective functioning assessed. The GMC’s GMP is applicable not just within a doctors’ professional and clinical domains it is applicable to behaviour standards in a doctor’s personal life as well. If a UK doctor’s drunken behaviour during private holidays affected any member of the public the GMC wants to know about it and will investigate it to see if there were any patterns that might impinge on patient care. If a doctor attends a court of law on a completely private matter such as speeding on the road or a financial irregularity the GMC wants to know about it and is likely to sanction in parallel for any major convictions in court. A registered doctor is expected to have a higher standard of behaviour compared to the average member of the public and when it slips the regulator will not hesitate to act against that doctor. The GMC even has guidance on how doctors should interact in the social media even when doctors interact with social media on non-clinical matters. Voluntary compliance is the norm. Breaches are quite a few but these are resolved through either local or social pressure. A word from the senior, a call from the medical director or a well meaning assertive/aggressive warning from people in the social media is usually enough for doctors to pull back and fall in line. Doctors have to reflect on their developmental Continuing Medical Education/Continuing Professional Development (CME/CPD) activity, doctors have to reflect on the complaints they face. Currently, doctors are required to have regular 360 degree feedback administered by an independent party, funded usually by their employers - this feedback is obtained from randomly chosen colleagues including other doctors of various grades, nurses, managers and others. If this feedback shows a need for improvement that has to be undertaken. The UK regulator has recently introduced revalidation for doctors where annual appraisals form the core element of the decision to revalidate a doctor every five years and allow them to practise. All the above descriptions form a part of the appraisal revalidation process.

The evolution of current practices

This is an interesting exercise in conducting large scale change. It was a slow, incremental multi-channel process that took many years and many stages. CME/CPD requirements were defined by the Royal Colleges in the early 1990s. Clinical audits were introduced in a big way in the early 1990s, 360 degree appraisals were introduced as a part of progression for trainees in the early 2000s; reflective practice was introduced in medical schools in the early 2000s. Cross pollination of these practices between specialties and grades were encouraged. Formal annual appraisals were introduced with it being mandatory for trainees. Soon annual appraisals became an essential part of senior doctors’ career job planning and career progress with many elements already having been brought together. Now all these have been pulled together into a comprehensive appraisal-revalidation system which is mandatory.

In the late 1990s, the Bristol enquiry into paediatric cardiac surgery deaths on how a department’s poor performance went unrecognised over a period of time; in the early 2000s, the Shipman enquiry on how a doctor could escape any official scrutiny over many years of criminality; and currently the Francis report on how a whole local system focused on the wrong things causing patient harm without being challenged by clinicians were major national external stressors that have pushed the medical profession to re-focus on the patient and start taking responsibility.

Some counter points

Is the NHS system perfect? Certainly not. Will it catch the bad doctors? Probably not. The scientific evidence for many of these methods is arguable. Many doctors opposed it actively all along and resist it passively even now. Some use it as a purely tick box exercise so that they will have a licence to practise their jobs. No one can be sure if these improve clinical quality for the patient.

What it does seem to have done is to increase the professionalism and ethicality of doctors. When anyone suspects a breach of professionalism and ethicality by doctors anyone is entitled to report the doctor to the GMC. The GMC does a full investigation only for a small number of the cases reported to them. During the investigations the GMC looks for reflection, maintenance of clinical skills, and development of insight. If the GMC is satisfied with these then it decides on minimum sanctions or on no sanctions at all. If it is not satisfied, the sanctions can be very severe, including erasure. The GMC, backed by the law, is a powerful force for doctors to seek a higher degree of professionalism and ethicality.

In practice, a large number of doctors who are international medical graduates (IMG) and who are from black and minority ethnic (BME) origins believe the system may be broadly very fair for the UK local graduates, but for IMGs and BME doctors there is evidence of a higher rate of reporting to the GMC and a perception of a higher chance of sanctions and a higher severity of sanctions. This is seen by many IMG and BME doctors as somewhat defeating the otherwise worthy ideals that in general work well. It is not as though there are no other sub-radar ethical problems: defensive practice, higher levels of service utilisation with its implications of unnecessary interventions, racial divisions (in jobs, exams, pay grades, bonuses) and others.

Transferable lessons

The principles underpinning UK medical practice are universal and hence transferable. The core principles are:

a) expecting a higher standard of behaviour from doctors in the practice of their profession and in their personal lives;

b) having a strong, progressive regulator backed by law; and

c) encouraging and supporting doctors at every opportunity to be ethical and professional, but with the clear

d) understanding that any breaches will involve facing the full impact of regulatory and legal enforcement without fear or favour.

The practice of these principles is not easily transferable since the context and environment is very different in India.

As very junior surgical trainees in India we used to ask patients to buy a variety of drugs, sutures and allied implements for their care - we would also make a judgement on the economic capacity of the patient, and on that basis ask them to buy a certain amount more than what would actually be needed for their care, sometimes upto double their actual requirement. We then used to store this in our individual cupboards and use the surplus for the care for other patients. Sometimes, we told the patients that this is what we were doing, sometimes we did not – either deliberately or simply due to lack of time. Essentially all of us were running our own individual small scale charity process. We saw this as completely ethical, moral and professional. We were saving lives, we were curing patients.

In the UK, this will be misrepresentation, lying, theft, financial misdemeanour, etc, all of which obviously are offences with the potential to end careers.

In India unnecessary investigations could have a financial motive (essentially fraud), in the UK it is mostly simply a matter of high utilisation (hence an issue of lack of operational standards). In India, talking to the next of kin of ill patients is normal accepted practice; in the UK, speaking to the next of kin without specific consent is sanctionable under the Data Protection Act and is a clear breach of right of privacy.

Creating an Indian system

A two-channelled approach may be needed in India. The first channel is to enable a higher standard of positive behaviours from doctors.

My personal suggestion is for doctors to create and maintain their own personal-professional portfolios. These portfolios could be reviewed by either employers or peers (individuals or professional bodies) every two years; and voluntarily submitted to the state medical councils every four years. In return these doctors could get the status of updated/enhanced registrations. Over a period of time, the medical councils and professional bodies can work together to make the portfolio very robust (perhaps in 20 years’ time the whole process can include a 5 yearly voluntary written knowledge test). A higher degree of respect, recognition and remuneration for doctors who have updated/enhanced registration could be an incentive to encourage the uptake.

The second channel would be to reduce the incidence and severity of negative behaviours in doctors. Pro-active, transparent, supportive intervention by the relevant professional society and the state medical council will be crucial. However, when those interventions fail a strict regulatory and legal approach will be needed.

A time defined, long term, incremental protocol, with specific measures that must be achieved, should be mandated with implementation commencing urgently.

I am hoping that these words make meaning and help thought in creating workable recommendations to enhance the ethics and professionalism of doctors in India. This will be essential for the future of the doctor-patient relationship and to enhance the reputation of doctors in/from India.


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This was originally written at the request of Prof Rajan Madhok as a part of background documentation for a conference in Kolkata in January 2014
The Global Indian Doctor: Workshop on promoting professionalism and ethics

The article was republished in Sushrutha (Volume 7 Issue 3), BAPIO's magazine published on the occasion of their annual conference 2015.

Sunday, 25 October 2015

Mentors or 'Godfathers'

The power of Mentors
Sir John Savill, CEO of MRC delivered the Bland-Sutton lecture at the ASGBI annual conference, Liverpool, 2012.

In his acknowledgements he said that at age 34, with 2 scientific published papers he was appointed professor of medicine by Peter Rubin (later Sir Peter, former President of the GMC) who was one of Sir John's mentors.

He said this from the main hall stage with hundreds of people in the audience.

On an internet check it looks like this happened in 1993 at Nottingham.

I wonder in 1993 how many people with more than 2 published papers did not get appointed.

I narrowly missed out on the generosity of such kind mentors; I was only just 50 miles away ;-) Okay, I did not have a single published paper at that time - surely I would have qualified for Assistant Professor!

Who are your mentors?

Of course you could also see this as jobs for the boys or godfathering (as in the cinema godfather and not the socio-religious custom of godfather).

Have things changed? Have things really changed?

These kinds of support is probably okay in a sector where one has invested own's own personal money, time, knowledge and effort. Is it okay where public money is involved? 

The past and the shadow of the past takes a very long time to leave us; we must ensure that it does not negatively affect us in this day and age.

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Saturday, 24 October 2015

Yvonne, BME, Women & King's Fund

On 22 October 2015 the Kings Fund announced that it has appointed Marcus Powell as its new Director of Leadership Development ( ) King’s Fund CEO Chris Ham put out a tweet about it. That provoked a set of tweets from Yvonne Coghill who seemed to be disappointed on why Vijaya Nath who was the acting director of leadership development did not get the substantive post.

This reminded me of my interaction with Kings Fund in October 2012. It could give a background on why Chris Ham did what he did now. It could help us understand the difficulty involved in obtaining justice and equality to various sections of the society.

I have experienced the TMP at the King’s Fund in 2009, it is possibly the best programme in leadership and personal development for healthcare professionals in UK. So I have an interest in King’s Fund and its activity. I have always wondered on why the various brilliant activities have not delivered the outcomes to the UK that King’s Fund would have liked to see.

That is when I discovered that the King’s Fund General Advisory Council which is appointed by HRH Prince Charles did not have a single member who was from the Black or Minority Ethnic segment of our population. Here is a highly respected think tank which is well aware that BMEs make up a significant section of the population and are a major part of the engines that run the healthcare system in UK yet did not have the maturity or the insight to realise that the General Advisory Council was exclusively white.

I then found that the General Advisory Council that I refer to was appointed in December 2010. Chris Ham took over as Chief Executive of the King’s Fund in April 2010. The General Advisory Council is appointed by the President on the recommendation of the Chief Executive.

I wrote to the President of the King’s Fund HRH Prince Charles, raising my concerns about the lack of inclusivity at a high profile place which he heads as President.

The private secretary to Prince Charles responded stating that the appointments are a matter for the Chief Executive and passed it on to Prof Chris Ham; the letter also said that Chris had ‘will wish to be in touch with you about the points that you raise’. When I saw the letter I knew that things would change.

Of course Prof Chris Ham then wrote to me to say that he aimed to strengthen representation from BME groups and ‘will achieve this’ ‘from January 2013’

When I saw this letter, I knew that the King’s Fund General Advisory Council would have BME members from January 2013 and it did. If I remember right, Lord Adebowale and two (or three) others were promptly appointed. The current General Advisory Council seems to have numerous BME members. 

When I saw that letter from Prof Ham, I also was a little bit uncomfortable, the letter is office speak and officialdom in its content. There was no regret for the lack of insight and BMEs were seen as representatives or representation.

BMEs in such councils if they are representatives, they are representatives of what or whom? Of other BME people in the country? Do white people in the council appointed to represent other white people in the country? I do not think so.

I did not pursue this further. I am not sure if I should take any part of the credit for putting BME in the GAC of the King’s Fund or blame myself for becoming part of what could be seen as a tick box exercise and not challenging it at that time?

I do not want any BME ‘representatives’, I want people who are there and happen to be BME. We have to challenge this narrative which implies that the majority is there by a certain credential and BME are there to represent.

Yvonne, Vijaya and BME members of the General Advisory Council – I hope I have given you some background to the story of how organisations function; not that you did not already know it, in which case I have provided some specifics about King’s Fund. I am absolutely certain that the BME members of the GAC are very worthy to be there but for a minute put aside your uniform, put aside your membership and clarify if you are representing BMEs in healthcare or you are people interested in healthcare who happen to be of BME origin. The easy answer is for the BME to think that they are the later category and the King’s Fund to say so; that will be comfortable for everyone. The reality is such questions need no answers, they need serious mature deep thoughtful reflection followed by explicit tangible action.

I am confident that the new Director of Leadership will do a great job for the King’s Fund but if he wants that to translate into a great job for British healthcare, his agenda, span, scope of action just became much greater.


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PS: I have already spoken about lack of BME presence in Berwick report and predicted that it may not have a desired impact on UK healthcare

Thursday, 22 October 2015

Micro Culture within Organisations: What is it? Why does it matter?

Culture is the ideas, customs and social behaviour of a particular people or society (Oxford English Dictionary). Organisational culture is the behaviour of humans within an organisation and the meaning that people attach to those behaviours (Wikipedia). The operative part of the ‘definition’ of organisational culture is the ‘meaning that people attach to behaviours’. It immediately becomes apparent that it is not about how we behave; it is all about what others who work with us think what our behaviour means. That is why getting organisational culture right is very tricky if not impossible. Understanding the concept of microcultures could help us in this difficult area.

Culture in Society

The society we live in has macro and micro-cultures. Macro-cultures are thought to be the majority groups whose norms are very visible and these become dominant, overarching and can be seen across historical timelines which means they are often long lasting. Interestingly within the macro-cultures there may be dominant small groups whose influence on the macro-culture is significant and overwhelming. For instance, parliamentarians are a small group who have disproportionate influence on society, they are representative which means we choose them to influence us. An example of a dominant small group within the macroculture who are non-representative are Oxbridge. There are many other examples of dominant small groups.

Society also has micro-cultures. The microcultures are generally thought of as being numerically small, voluntary, short-lived, situation specific, weak, non-dominant and not so visible.  However there are very numerically large groups within the population who form microcultures, for instance ‘women’ and unions amongst others. We can also see micro-cultures that have been around for a very long time such as the Amish and yoga. There are also microcultures that are very powerful such as think-tanks, activists, extremists, etc; some microcultures have been so powerful in their times as to change the society in permanent terms for instance the antislavery movement in the west. Microculture has always been viewed by the macroculture of any specific period in time with suspicion, as a threat, as very different and generally poorly understood.

There is another cultural entity called subculture which is distinctly different from yet often misunderstood as being a dominant small group within macrocultures or being a microculture.

It seems that macro-culture is similarity based who do not mind, often understand and even tolerant of reduced values. Microcultures are value based meaning that there are strong traits of equality, morality, ethicality and other traits held precious with microcultures feeling that they are forced to tolerate similarity. Subcultures are based on difference and variance ‘I am better than you. You are worse than us’ etc and exploit those differences without exploring the contexts adequately, often to personal benefit or detriment of the members of the subculture.

Organisations and MicroCultures

Organisations mirror society and within organisations there are micro-cultures. In organizations, especially in healthcare organizations, ‘micro-cultures’ have not been subject to proper study. There is a general assumption that it is best for everyone in an organisation to have a similar culture i.e. an overarching organisational culture. In reality, there are numerous cultures within an organizational culture, which is only normal. However, there may be some good micro-cultures which may want to observe and learn.

The micro-cultures have similar structure, activities, qualifications, finance, job descriptions, titles and staff specifications as the macro-culture but the expressions and the results of these vary significantly from the organisational macro-culture.

How To Do It

What or how are the specifics of a good microculture that enable a different expression and better results?

In the micro-culture that I experienced, we did whatever was statutorily required of our organization and mandatorily required by our organization. The micro-culture related methods and behaviour are over-and-above what was required of us; it was not a replacement behaviour neither did we think it was an add-on. It was just the essence of the way we worked.

My observation suggests that what we do more of some things and less of others. Here is a brief list:

We did more of
We did just the amount required of us
Direct specific communication
Emails/memos/ ‘cascade’
Generic incremental ‘planning’
Formal planning
Taking responsibility for others
Holding to account
Learn small & frequent
‘Formal’ learning
Routines for us
Variations for the patients
Talk often and short
Long speeches and big meetings
Internal recognition
External recognition

Due to these methods and techniques we were able to have a supportive and friendly environment.


We may attempt to measure the successes of micro-culture in many ways. Since culture is often defined as the ‘way we do things here’, I have chosen to measure it by some of the things we did differently. Many of these methods were exclusive to us, some have been done much ahead of time before other areas. I have chosen our record of innovation as a ‘measure’ to demonstrate the success of our micro-culture. I have already published about the innovations

The results in general principle, result in happier staff, lower costs, quicker times for patients, often better results, better retained learning and such other positive impacts.

Culture and its effects are difficult to measure. Surveys have been used with staff self-reported scores and users perceptions. These are useful up to a point. The tangible link between micro-culture methods, processes and behaviours to outcomes will always difficult to elucidate. However, we believe that while a happy working environment is vitally important, we also believe that such an environment should result in some relevant outcomes. We believe that while our structure, activities, specifications, qualifications and knowledge are more or less similar to any organization and its specific departments our expressions of these and our results are different and take the form of the innovations which have been described above.

What can we do with the concept of Organisational MicroCulture?

Microcultures are often appreciated but at the same time often criticized. Some microcultures seek attention, some often shun the limelight.

The point is to assess the micro-culture on the basis of contextual impact, what is good for one may not be good for another, what works at one time may not work another time, what is seen as bad may become acceptable at a later point of time. (Mandela, IRA, PLO)

In organizations firstly micro-cultures should be allowed. We know that often there is no single recognizable so called organizational culture especially within the healthcare context. Next, more importantly supported on the basis of results that matter for the patients (and not on some vague notions of what a pan-organisation culture ought to be).

If you were a senior person in an organization, as you support a micro-culture you will also have this burning desire to ‘spread out’ ‘roll out’ an identified brilliant culture and reap the benefits of results and happiness for the whole organization; unfortunately it does not work like that. We may love the way that the Amish live today but we will be unable to roll it across the world or even use it for us. Products can be rolled out, packaged popular cultures can also be rolled out (eg MTV) but work place behaviours seem to be too personal, too individual, too variable, hence too complex to roll out.

What we can do is to grow our own, micro-propagate. We can become aware and make others aware of effective micro-cultures, managers can encourage and enable interaction with micro-cultures. Managers should be aiming for an environment of varying positive microcultures (and not necessarily one large single positive culture which generally exists in management books). Managers should not be aiming for a coalescing of cultures, though that sometimes happens on its own. Processes and activities can be copied, a culture cannot be copied.

Though I have described our observed methods, there is no real ‘model’ and hence there is no proper way to ‘replicate’ it. However, there are principles which can be reflected upon which can then result in growing your own micro-culture. We are not issuing a self-assembly kit – we are sowing some ideas some of which you may want to use to create your own beneficial micro-culture. It is our view that micro-culture cannot be replicated but can be propagated.


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A) There is a particular academic reference to the first few paragraphs of this blog which I have misfiled and will post it here when I find it
B) This topic was presented at the Clinical Microsystems Festival, Jonkoping, Sweden in 2015