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Editor's blog 29 May 2009: It's a CDE thing

Good morning and happy Friday to you. The sun is shining. Hurrah.

Fingers crossed, from the middle of next week a more normal service will be resumed here, as I will have finished a book on the NHS (touch wood), and finished being the acting press officer for NHS Alliance. Both are interesting challenges.

The art of management books - for such we must call it, as there's certainly no science - is to suggest that success and wealth are as easy as ABC, if you'll just do it the way Jack Welsh / Jim Collins /Tom Friedman / insert guru of choice here, tell you to.

But it's really never as easy as ABC. I was having a think recently about how much organisational dysfunction is related to CDE.

CDE is not some new NHS regulator (Council for Defensive Excellence, anyone?). Rather, it is an acronym for communication, demarcation and expectation. My contention is that many problems can be usefully considered in those three categories to uncover common mis-thinking. Once the mis-thinking is outed, it may be possible to start changing things for the better.

Communication comes first (I am a journalist and editor, so I would say that, wouldn't I?). Yet it is staggering how frequently bad, inadequate or totally absent communication is at the centre of problems.

Bad or unclear communication is often a proxy for bad or unclear thinking and strategy. It also often leads to defensiveness. Many NHS organisations, and the Department of Health in shining particular, tend to be defensive. Public debating of ideas and policies is not commonplace.

Why so defensive? Firstly, defensive approaches to policy and strategy  lead to defensive communication. Both the public and the media spot this with ease. It reassures neither group that the defensive tone suggests closed thinking and aversion to new ideas or to questions. This is not a good look for any organisation.

The NHS and the DH both have an unfortunate tendency to see debate as dissent. There is also the comically false concern about debate or discussion being 'political'. What the fuck is that about? The NHS is one of the most 'political' things that civil society does with taxpayers' money - lots of it, too. 10-% of GDP. Probably enough to rescue a few banks.

So one of the first audits an organisation wanting to be self-aware should do is around communication. The left hand needs to know what the further-left hand is doing.

Demarcation is one of my favourite words. It probably reached the apotheosis of its use in popular currency in the 1970s, when the trades union movement was at its peak of political influence. It is simply marking out of territory, and knowing and agreeing what should go where and who is responsible for what.

Confusions over demarcation issues can obviously arise from bad communication, but the business of borders and boundaries is more than a consequence. In the NHS, it has long been acknowledged that the problem points in the system for patients and indeed clinicians and even managers are the handover points - the boundaries between the hospital and the GP (hello, discharge summaries), between health and social care.

Demarcation is not only about being aware where the boundary lies: it is also about every person, team or organisation adjacent to a boundary keeping that boundary under view and review to make sure that people who use the system are not getting stuck or lost there.

Expectation comes last for alphabetical reasons only. Highly effective teams and systems align the expectations of the individuals and teams working in them with an overall approach, philosophy or strategy, and keep everybody's noses pointing in the right direction (though bearing in mind the need to tolerate debate, not always the same direction).

This internal coherence and focus should help the team to address its customers, stakeholders and partners with clarity about what is to be provided.

Clarity and candour are always good. Life can be a proper rock and roll circus, but ideally there's only one way that we want to see no expectations.