Care Home Quality Podcast - episode 9 with Dr John Rudd retired Doctor, RGN, RMN and Lawyer

Liam Palmer interviews Dr John Rudd. Having served in the NHS as a nurse and a lawyer Dr Rudd has clear views on tackling the waste and bureaucracy in the NHS.

Topics covered in this podcast

0.00 Introduction

Liam Palmer

Hello everyone, it's Liam here, just a quick preamble before introducing my next guest, Dr John Rudd. Dr Rudd describes himself as a retired lawyer and doctor of civil law and a former RMN RGN. He's a peer and friend of the esteemed former guest, Dr Umesh Prabhu. Did you catch Dr Prabhu's two episodes? He gave us an inspirational interview and he also gave us an interview for World Patient Safety Day. He made some good points actually, so if you didn't catch it, do try and have a listen.

Dr Rudd is a hugely experienced individual having seen the NHS develop. Served in the army as a nurse. The NHS and then as a lawyer specializing in healthcare. He has a really interesting perspective. Without fail, I always learn from my guests and Dr John Rudd is no exception here, although what I learned from him was different to what I expected. Isn't that the fun of meeting interesting people? I'll share my thoughts if you're interested on meeting this enigmatic and genuinely interesting character at the end, as always. Without any further ado and I do hope you enjoy it.

Dr John Rudd

Very nice to be with you Liam. It's my pleasure to do this interview with you.

Liam

Thank you so much. Just a little bit about Dr Rudd. Dr Rudd has a unique perspective on the development of the NHS. He was nine years old at its inception. He's had a really interesting and broad career as a nurse and then moving into law and specializing in healthcare cases. Lots of interaction at a senior level with health authorities. And I think you'll find he's got a really interesting take on the management and leadership challenges in healthcare right now, primarily in the NHS. But I think there's some broader application to his perspective, which is built over 50 or 60 years I imagine. So a really interesting character. Delighted to have got him to come and allow me to interview him.

So without any further ado, Dr John Rudd. So thanks again John. Absolute pleasure to have you here. So would you like to start at the beginning? Your start in the military?

3.58 State Registered Nurse and State Registered Mental Nurse

Dr John Rudd

Yes, indeed Liam. I joined the military at the age of 15 and I went to the Royal Army Medical Corps Apprentice School, which was based in Crookham in Hampshire, about two miles from Aldershot. You continued with your education but also you started basic nursing duty qualification which was called an NO3, which is Nursing Orderly class 3. At the age of 17 and a half, they decided they'd done all they could with me at apprentice school, so I was then transferred into what was then relatedly called Man Service. And I went to the Cambridge Military Hospital in Aldershot. Anyway, then I started my nurse training, Royal State Registration. And also I was one of two people who were selected to do something called dual training, which was for State Registered Nurse and State Registered Mental Nurse, as it was then.

Yeah, I left the military after 10 years service. So I went to a small hospital in Poplar, East London. And I worked there as the Theatre and Accident and Emergency Superintendent Nursing. So I made good experiences there.

One thing I missed out, was during my training in the Cambridge Military Hospital, in Aldershot. A lot of my colleagues from the apprentice school, obviously went into disciplines like radiology, laboratory technicians and the like. And of course sometimes in the evenings there wasn't a lot to do. So I used to wander over to the lab to to the theater or wherever and have a chat with these guys. And whilst I was having the chat I watched what they were doing and if saw something I wasn't sure about I used to say, "Oh, why do you do that?" Or, "What does that mean?" And I learned from their experience, which enabled me to know, instead of a holistic view of how the hospital worked. And very few people have ever done that.

Liam

Okay. And what age were you there John?

Dr John Rudd

What age was I? I was at the Cambridge Military from 17 and a half to 22 I suppose.

6.59 Advancing career in the new NHS

Liam

Okay. So very early in your career, sort of laying the foundation for your knowledge. Okay. Very good, thank you. Yeah. Okay.

Dr John Rudd

Yeah, whilst I was working at Poplar Hospital, obviously I was looking to advance my career shall I say. And there was an advert, they wanted a Central Sterile Supply Department Superintendent. And it was for commissioning this department to supply sterile equipment and instruments, et cetera, to 3000 beds, which comprised the Enfield Group Hospital Management Committee as it was then. And I thought, oh this is a wonderful opportunity. If you remember, I told you that when I went on to Man Service, six months of that time was spent in a Central Sterile Supply Department. Yes, that's right. Yeah, I remember.

Yeah. And here we are some nine years later, because I say, the National Health Service was starting to catch up with the military. Anyway, I applied for the job and lo and behold, I got it. We got the unit up and running, I think within about nine to 10 months. So that was pretty good from start to finish. That was getting all of the necessary equipment instruments et cetera.

Liam

So is it a good time to touch on the Insurance Broker thing? Did that inform any of your-

8.40 From the NHS to law

Dr John Rudd

Very briefly on the Insurance Broking. Yeah, I left the NHS. I thought the bureaucracy was overwhelming. So my family had an Insurance Broking company and its Managing Director had left and they said, "Would you like that position?" And I said, "Oh why not." So I went and worked in that capacity. And again, it taught me things. Interaction with people for instance. Whilst I was doing the Insurance Broking, I met with a very good lawyer who was a partner in a local firm, who, how can I put it? Was trying to poach me into working for him. And of course I've always had an interest in law. I said, "Well if you offer me enough money, I might consider it." Anyway, he did offer me enough money, so I did consider it and I moved into law. And it was only a small practice in London, quite near to Paddington Station as a matter of fact. The first day I got there, my boss who had recruited me, decided that he was going to... he'd gone on holiday for a week, and there was I, a newling to the law.

Not quite knowing what to do. You learn pretty fast I believe. Believe me you learn fast. That was my introduction to law. Anyway, my boss decided that he was going give up practicing law and he just remarried and decided he was going to move to Spain. So unfortunately our practice was going to be disbanded. He managed to sell it on to a much larger law firm, who were based in Bedford Road. Bedford Road London is pretty superior lawyers. Anyway, I didn't particularly like working in a large firm. So I then went to work for a local authority in Kent, in Gravesend in Kent, Gravesend Council.

11.30 ... and back to the NHS!

Dr John Rudd

I was doing litigation and conveyancing. There was then, I saw an advert for the National Health Service. They were looking for lawyers to work in the Regional Health Authority as it was then, in Sheffield. It was the Trent Regional Health Authority, very large area. We also had at that time, we had three teaching hospitals in various places. Sheffield, Nottingham and Leicester. So I applied for the job and got it. And then my next move was I wanted to get back to London basically.

Liam

Fair enough!

Dr John Rudd

So I looked for a job around there and I became a Principal Legal Officer, at the London Borough of Islington. Most of my tasks were advocacy in the local County Court. And I enjoyed that immensely. However, let me say this, throughout my term of doing law, I was also doing a little bit of nursing on the side, as it were, to keep my hand in. I did some agency nursing work throughout the whole of this term. And then in 2000, I decided I was about ready to retire. In fact, I had some ill health, which I won't go into but anyway, that was another reason why I decided I was going to retire. But I didn't want my brain to retire, so I decided to go back to academia and renew my doctorate. So I did a Doctor of Laws. But basically was on research and a thesis as well. But that's what I did.

Liam

So thanks John. I really appreciate you sharing your career story. So John, we're going to move on to draw upon your broad experience of working in the NHS and with, in terms of litigation, working for significant health authority and what that's taught you about how the NHS has evolved. But in a way, turning that to a message for now, turning that to a message for Executive Directors in the NHS for those running NHS trust, but also potentially some indirect advice for Care CEOs in the private sector who might be large organizations and might suffer some of the fate of the things you've talked about already in terms of the sort of creeping bureaucracy and lack of accountability that seems to creep into large organizations.

14.56 Outpatients misuse overburdens the system

Liam

So we've got four points that we talked about that you wanted to expand upon. So if we can, we'll dip into that. So we were talking about changes to the running of the Health Service. And the first point you wanted to talk about John was outpatients misuse. Do you want to explain that a bit more?

Dr John Rudd

Yeah. Outpatient misuse. Look, if you go and see your General Practitioner and he thinks, or she thinks, Oh I think this patient may need to see a consultant at the hospital. It's a little bit above my pay grade, I think they've got X, Y, Z condition. So they send them to see the appropriate consultant. Now when they go and see the appropriate consultant, one of the things that he's going to look at, or he or she is going to look at is what were their blood tests done by the GP? I always remember going to see a Gastroenterologist, and she said to me, "Have you had any recent blood tests?" And I said, "Oh yeah, I've had X, Y, Z. done and this, that and the other." And she said, "Oh, nothing I would be interested in then." In other words, unless you do specific tests for specific conditions or conditions that you think the patient may have, it's pointless.

So in other words, that patient who's referred by the GP to the consultant, doesn't go with the appropriate information, that could have been gathered, whilst they were waiting to see the consultant. So what happens? Oh well I want to do X, Y, Z tests on you and I'll see you in three weeks time or four weeks time as the case might be. So in other words, instead of having one appointment you have two and two will turn into three and so it goes on.

And the other misuse is that people nowadays go in for something, called Day Surgery, which years ago, would probably have been, they'd probably been in hospital for a week. But now they can have it done in a day and they go home. And what happens? They say, "Oh, we see you in Outpatients in four weeks time." Why? If they're perfectly fit and there's nothing to complain about and they have no problems, why do you need to see them?

I'll tell you why, it's called defensive medicine. What's defensive medicine? Well, if something did go wrong and we hadn't seen them, we could be sued. And that's what they practice. Because they have to pay these consultants, or doctors in fact, have to pay for insurance to cover themselves for mistakes. I use that advisedly. Malpractice would probably be a better term to use. Do you see where I'm coming from?

Liam

I do. I think your points clear, so that's well made. Do you want to go on to complaints procedure then John?

18.08 NHS Complaints Procedure not run by people who are 'nursing aware'

Dr John Rudd

Well, let me put it this way, if you want to make a complaint to the NHS about treatment or anything really you have to go through the hospital complaints department and the complaints procedure. Now this will vary from hospital to hospital. There's an organization called PALS, P. A. L. S, which stands for Patient Advice and Liaison Service. Now this isn't a national scheme, although it's rolled out nationally. Each hospital employs its own PALS Department shall I call it. And the reason this was introduced... And I think it was introduced by the Secretary of State who's name was Andrew Lansley. Anyway, you go to PALS and most PALS Departments are very understaffed. They're not clinically, legally or nursing aware shall I say. They have no expertise in the department or most of them don't anyway. And they really don't know what to do. At my own local hospital, they turn everything that remotely resembles a complaint into a complaint. So it goes to the Complaints Department.

Now I think under the procedure, they normally have eight weeks in which to, invert commas, investigate, close inverted commas, the complaint. But again, there's no laid down procedure on to how you investigate a complaint. Let me give you a personal example. It wasn't a complaint in the first place as far as I was concerned, when I wrote to PALS. Apart from getting an automated response to my email, I never heard a word from PALS Department at the hospital. But lo and behold the next thing I know, they've turned it into complaint and passed it on to the Complaints Department, who again, have nobody in that department who's clinically qualified in medicine, nursing or anything else relating to our hospital.

They then tell me, "Oh well, you will get a letter from the Chief Executive within the eight week period saying, what's happened." But me being me, look at it and say, "Oh, well how are you investigating this?" And then they tell me, "Oh, we've passed it on to the Radiology Department." Oh, where the invert commas Department complained of, close inverted commas. So they get the perpetrator of the alleged complaint to investigate their own mistake.

Anyway, when it gets to the CEO who I've been asking the Complaints Department to ensure sees all the emails that pass between me and the Complaints Department and make sure that the CEO sees these emails. I then get a letter, which gives dates of things that have never happened. No emails of those dates from me. So where these emails have come from heaven only knows but they certainly weren't from me. And this is the letter saying, "Oh, we've investigated this."

22.12 Learning from medical negligence

Liam

So do you want to talk about medical negligence and learning from.

Dr John Rudd

Yeah, unfortunately accidents happen and we can all learn from accidents. Whatever they be, be they motor accidents, accidents at work, accidents at home or if they be medical accidents.

Nobody has a monopoly on how they do things. But you can learn from your mistakes. We should all learn from our mistakes, but unfortunately that doesn't seem to be the case with the medical profession. They don't seem to learn. And I'm sure you've been told this before by other people you've interviewed, probably a good colleague of mine, Dr Umesh Prabhu has probably told you about this.

People don't seem to learn from their mistakes and that is a problem. This really goes back to the last subject we were talking about, complaints. Hospitals should learn if a complaint is upheld, they should learn from that complaint. But they don't. They don't do anything.

I think when we were talking off the record as it were, I mentioned that I happen to know from an email I received from a local resident. The day he had made a complaint to the hospital and the hospital had denied it. And they had gone on to take that complaint further to the Parliamentary and Health Service Ombudsmen Department, who investigate these matters. And her complained was upheld, but she says, "Oh but the hospital haven't learned from that, they haven't done anything to rectify the mistakes that they were making." And that is the problem. People are not learning from their mistakes. I don't think I can put it any firmer than that.

Liam

No, I think that's perfectly clear John. I think and well... You made a really strong point there and it goes into an area of my interest about learning organizations because if you have a learning organization they do learn from mistakes and that's what's needed in healthcare obviously. Yeah, that's really interesting.

Dr John Rudd

It's needed in every area. In industrial accidents, whatever. These things need to be learned and then unfortunately, in a lot of cases they're not.

Liam

It's very rare isn't it. Yes.

25.11 The Meeting culture - meetings about meetings but nothing gets done

Dr John Rudd

Brings me I think to our next subject, is the meeting culture.

Liam

Yeah, go ahead. What do you mean by that?

Dr John Rudd

Well people seem to have a penchant for meetings. They have meetings about meetings, about meetings. But they never actually do anything. Nothing ever seems to come out of these meetings. They sit around the table and they'll talk about doing this and doing that, but nothing ever gets done.

I used to sit on the Patients Participation Groups. Every GP Surgery now has to have one of these groups.

And it's sort of like a patients of that particular surgery who decide, "Oh well yeah we'd like to do that because we think we might be able to influence how the surgery works." Or doesn't work for that matter.

Fortunately I have a very good surgery. I've never had any problems or complaints about the surgery there. They're providing me with excellent service. What they do for the rest of the population in my area I don't know, but no seriously, it's a good surgery.

But I used to go to these meetings, we used to sit there and we used to have a cup of tea and a biscuit and chat and whatever. But we were really superfluous, we didn't need to be there because the surgery were doing what it should be doing. And frankly it was an unnecessary exercise.

It was okay. But lo and behold, they then introduced Patients Commissioning Group, which was a sort of patients side of the Clinical Commissioning Group.

About every two months they used to have a meeting of all the surgeries in the Clinical Commissioning Group. And we all used to sit around a table for two or two and a half hours in the evenings talking about this, that, and the other.

But again, nothing ever transpired from these meetings. They were a complete and utter waste of time. I used to call them talking shops, which is all they were.

27.41 Advice to CEOs of care organisations - get off your backside and walk around

Liam

John, what advice would you give to an NHS CEO or a Care CEO about becoming more effective or serving the customers better? You've talked about what you don't like, what's wrong, bureaucracy, inefficiencies. So what would your message be to run a large health organization better? What advice would you give them?

Dr John Rudd

Yeah, well my advice to these people would be to stop sitting in your executive office, in your ivory tower. Ignoring everything that's going on around you and saying, "Well, I am the CEO. I am the chief."

They've got to get off their backsides. Start walking around, talk to staff, talk to patients, talk to visitors, look and see. Spend a day on a ward, not five minutes or probably even nothing in some cases. Go to departments, have a look, see what people are doing. Say to them, "Is there anything we could do to make your life easier? Is there anything we could do to make things better in your department?"

Liam

Brilliant.

Dr John Rudd

You've got to say this to patients, "Is there anything that we could do to help you enjoy your time in the hospital better?" You know. "Are you receiving good quality food?" If they're not, you go down to the Catering Department and you have a look and see what's going on and you ask the Catering Manager, saying, "Look, patients are not happy with X, Y, Z. Is there anything that..." Don't say "You have got to do X, Y, Z." Say to him, "Is there anything you feel we could do to make that better or simpler or easier or whatever, or more enjoyable for the patient?"

30.33 Conclusion - learning from the ground up and giving priority to common sense

Liam

Brilliant.

So there you have it. What did you think? It was good, wasn't it? I wonder what stood out for you? After I heard the interview, I had a sense of the meaning for me. I wanted to kind of fit it into my own frames of reference. I wanted to take something clear away from it and I think the core themes that sort of struck a chord with me, was listening to Dr Rudd's assertion about waste and about poorly thought through access to healthcare for the patients.

I think it was a sense of bureaucracy, a lack of common sense and a bit of frustration with all that.

And it made me remember when I was 18, 29 years ago, as I was just looking to leave college in the Thames Valley and at the time the rage were getting onto management trainee programs. They lasted two years. Two that came to mind were John Lewis, the retailer obviously, and Mars Confectionary.

There was a giant chocolate factory in Slough at the time, I believe it's been turned into a sort of Innovation and Research Center, but at the time it was a massive employer and people were very well paid there.

And these training programs allowed you to work for three to six month placements in different parts of the business. And at the end of it, you then chose what area to go into.

And I think there's some real wisdom in that because it allows you to build your understanding of the business by understanding how the pieces fit together. In my language that's understanding the constituent parts of service delivery.

But obviously in healthcare it's the same sort of thing. It's the constituent parts of service delivery around healthcare or care.

And so I think if that's how you start building your knowledge of a system, I think it gives you clarity about how things fit together and in having that clarity, I think it shows you waste, it shows you bureaucracy and it shows you closed thinking or a lack of common sense as I think Dr John Rudd would say.

So I think that's a unique perspective that Dr John Rudd got by starting in healthcare at 15 and working in different areas in liaising with different departments and also being a nurse, a clinician and so having... And also working in the army. So having an appreciation of what works and what doesn't. So I think that sort of struck a chord with me. And I think moving up to date I suppose, obviously you've got lean thinking as a sort of solution to that.

You've also got world-class thinking. It's kind of one and the same. These ideas came out from Toyota. There's a really well known book called The Toyota Way, all about lean methodology. And actually it's about prioritizing the customer.

I was fortunate enough to work for a company that implemented lean and it was really interesting.

It was revolutionary because the whole company was focused on the demand from the customer. Everything was focused around what the customer was doing, what the customer wanted, and then suddenly everything becomes a lot more clear.

And I think although those ideas are not new, they're not implemented in that many places. I know that the NHS is starting to implement some of these ideas.

In conclusion then I think as it's written somewhere, there's nothing new under the sun is there.

And I think this idea of working across different areas to gain a holistic understanding of something, is not a new idea, but it's something interesting. It's something that works really well.

And listening to Dr John Rudd, made me remember that. And then if you go a bit broader, any of you if who are into podcasts, Tim Ferriss, that genius from the States, from Austin, who's got the Tim Ferriss Show podcast with a couple hundred million downloads.

He talks about polymaths, people that have interests in several different subjects and how the synthesis of these different disciplines and interests causes them to be more effective.

And I can't help but think that in a time of specialization, in some ways, having a broader understanding of different disciplines or different departments actually helps us to understand the different pieces individually.

So that's my thoughts. I hope that was useful. And thanks for listening. Any comments or questions do let me know.

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