Think ouside the box

Wrong problem

Let’s start the week with Henry…

… Henry Ernest Dudeny, a mathematician… early 20th century. He created a puzzle; connect nine dots on a three-by-three grid with only four straight lines… the pen mustn’t leave the paper.

People fail because they visualise the dots prescribing a box shape. The solution to the puzzle involves drawing lines ‘outside the box’…

… hence the phrase ‘thinking outside the box’.

If you are ever in a meeting and someone, usually the boss, declares ‘let’s think outside the box’… it’s time to look for a new job. You’re working for a David Brent.

TOtB is confusing, ambiguous and looking for solutions beyond the practical boundaries or constraints of the problem…

…invites people to say; ‘if only we didn’t need to worry about the real situation we could do this or that’. To which the answer is… you can’t, coz you do.

It’s easy to be distracted. End up trying to fix the wrong problem.

What’s needed is creativity inside the box… lateral thinking.

Barry Schwartz in his book The Paradox of Choice;

‘…with… [too many]… options, we can be overwhelmed…. the key takeaway… it’s really hard to choose between a lot of options.’

In its endless business case and business planning nonsense the NHS makes an art-form of options and ends up decreasing the chance of compromise and increasing the risk of choice deferral.

In English, you end up with a fudge… sounds familiar.

Out-of-the-box and beyond the boundaries loses the lateral opportunity to focus on creativity and innovation within.

Encouraging the positive deviants who, given identical circumstances will do better than others. It’s the key to the success of The Academy of Fabulous Stuff…

… people doing and sharing good stuff despite everything!

Looking inside ‘the box’ forces us to get to the root cause of the problem… ask ‘why’ five times and you’ll usually unearth the real problem you’re trying to solve.

Thinking within the box, reducing options, makes for better decisions and optimises time.

‘Doing things differently’ involves understanding exactly what it is you are doing now and exactly which bits need to be done differently.

The NHS gives us plenty to think about. Particularly now; there’s something weird going.

In May, the Nuffs told us the NHS has more funding and more staff than ever before;

• 1,4m directly employed
• a further 212,000 in general practice.
• Since 2014, 26% more in hospital and community
• over 29% more in general practice.
• Staff costs are two-thirds of NHS expenditure
• and doubled in cash terms to £67bn in 2020/21, relative to 2008/09.

The workforce expansion between 1998 and 2022 has exceeded the increase-to-population-need, over the same period. Growing 62% compared to a 28% increase in the needs-adjusted population.

Yes, there are issues with staff-sickness. Distribution of extra staff is not equal geographically and there is variation in the growth of the professions and services.


An IFS study in December last year says there are more beds since 2020 but many are still occupied with Covid patients, (Fig 6).

Page 15; the Service is actually treating fewer patients than it was pre pandemic;

• 13.8% fewer outpatients,
• 13.8% fewer emergency admissions (including COVID-19)
• 11.1% fewer elective and maternity admissions…
• Patients treated from the waiting list, down 10.5% compared with 2019 (strike implications)
• 9.5% fewer incidents recorded by ambulance services
• 19.1% fewer conveyances to A&E, despite 4.1% more 999 calls
• GP appointments are up by around 4%, but the number of GPs has fallen…

… apart from the GPs almost all of the other categories are delivering less care than before the pandemic.

What’s going on, in the NHS box?

Whichever way you look at it, with more staff, the NHS is less productive and we need to think about this.

Look carefully (Fig 9&10); beds occupied by patients for more than 7 and 21 days is up and the size of the adult social-care workforce, for the first time in 9 years… shrank.

It’s clear, putting more people and more money to work in a system that is sclerotic doesn’t make it more efficient and is not the solution.

Look inside the box…

… we are trying to fix the wrong problem.

News and Comment from Roy Lilley
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Reproduced at by kind permission of Roy Lilley.