Rhetoric to Reality

I was reading another article about the NHS recently and found myself thinking about the way we've changed the language we use to describe problems. The issues themselves haven't really changed. We still hear about long waiting lists, pressure on emergency departments, patients being cared for in corridors, difficulties recruiting and retaining staff, financial pressures and the constant challenge of trying to provide more care with limited resources.

These aren't abstract problems that only exist in reports or board papers. They affect real people. They affect the patient waiting months for treatment while their condition affects their everyday life. They affect families trying to support someone who is unwell. They affect the staff who arrive for another shift knowing they'll probably be working under pressure and that many of the frustrations they experience are not because people don't care, but because the demands placed on the system often exceed what is available.

Nobody working in the NHS needs another document explaining that there are challenges. They don't need another presentation showing graphs and charts demonstrating increasing demand. They already know. They're experiencing it.

What has changed is the distance between rhetoric and reality. The reality is often familiar to anyone working within the NHS, but the rhetoric used to describe that reality has become increasingly sophisticated.

Over recent years, organisations have become extremely good at finding more positive ways of describing difficult situations. A problem becomes a challenge. A challenge becomes an opportunity. An opportunity becomes a strategic priority. By the time the language has gone through enough meetings, reviews and approval processes, it can sometimes become difficult to recognise the original issue that started the conversation. This is often where rhetoric begins to take on a life of its own. The language evolves, while the reality remains stubbornly unchanged.

Over recent years, organisations have become extremely good at finding more positive ways of describing difficult situations.

The NHS isn't unique in this. It happens across almost every sector.

Staff aren't exhausted; they're demonstrating resilience. Services aren't struggling; they're adapting to unprecedented demand. Budgets aren't being reduced; resources are being prioritised. Waiting lists aren't simply growing; they're part of a recovery programme.

None of these descriptions are necessarily untrue, but they illustrate how rhetoric can shape perception. The challenge arises when the rhetoric becomes more visible than the reality it was originally intended to describe.

Now, I'm not suggesting that everyone who uses this language is trying to hide reality. There are often good intentions behind it. Leaders have a responsibility to maintain confidence, encourage their teams and avoid creating a culture where every discussion becomes a list of everything that is wrong.

And there is, of course, a danger in constant negativity. An organisation where every suggestion is immediately dismissed will never improve. If every person who raises a new idea is met with reasons why it cannot happen, people will eventually stop suggesting ideas altogether.

The problem is that we've become less skilled at recognising the difference between negativity and realism. I know this because I've often been the realist in the room. and too often, describing conditions as they are is interpreted as negativity rather than honesty.

The problem is that we've become less skilled at recognising the difference between negativity and realism.

So being realistic hasn't been an easy position to hold, because realism can easily be mistaken for pessimism. The person asking difficult questions is often seen as blocking progress. The person who highlights legitimate risks becomes the person who lacks ambition, or energy. The person who asks whether something is achievable is seen as someone who doesn't share the same enthusiasm as everyone else. Yet, in my experience, most realists aren't against change. They're usually the people who want change to succeed because they understand what happens when poorly planned ideas fail.

Throughout my career, I've spent a great deal of time helping organisations improve. I've worked with people trying to solve problems, introduce new approaches and make services better. I've never believed that things should simply stay the same because that feels comfortable. However, I have always believed that enthusiasm needs to be balanced with judgement. A good idea is not automatically a good decision. A new technology is not automatically an improvement. A process that can be introduced does not necessarily mean it should be introduced.

This is where I think the role of the realist is often misunderstood.

The realist is often the person attempting to reconnect rhetoric with reality. They are not asking difficult questions because they oppose progress. They are asking them because progress only has meaning when it produces genuine improvements rather than impressive descriptions.

The first question for a realist to cope with is usually, "Can we do this?"

And that's often the easiest question to answer because modern organisations can achieve remarkable things when they have enough resources, enough determination and enough people willing to push something forward. A realist just wants to make sure that these things are considered appropriately.

Often the more important, and more difficult, question is, "Should we do this?"

That question requires a different type of thinking because it moves beyond possibility and into responsibility. Should we introduce a new system simply because the technology exists, or does it genuinely improve outcomes for patients and staff? This is critical to consider now we are talking about rolling out AI systems. Should we collect more information because we can, or have we properly considered whether we have a legitimate purpose for collecting it? Should we share data more widely because it creates potential benefits, or have we considered whether people would reasonably expect their information to be used in that way?

In healthcare, these questions are not minor details. They are central to trust.

A new artificial intelligence tool might produce impressive results in a demonstration, but who is accountable when it gets something wrong? Have we considered whether the data used to develop it reflects existing inequalities? Could it unintentionally reinforce historical decisions rather than improve them? Are we creating a system that supports professional judgement, or one where people begin to trust a computer simply because it appears objective?

A new data sharing initiative might allow information to flow more easily between organisations, but have we considered governance arrangements properly? Are responsibilities clear? Do people understand who can access information and why? Have we thought about the consequences if information is misused or misunderstood?

These questions are not barriers to innovation. They are part of responsible innovation. The difficulty is that these questions rarely create the same excitement as announcing a major new initiative. The person who says, "We can transform this," often receives more attention than the person who says, "Before we decide on transformation, can we be sure we understand the risks and whether this is actually the right thing to do?"

These questions are not barriers to innovation. They are part of responsible innovation. The difficulty is that these questions rarely create the same excitement as announcing a major new initiative.

The first creates enthusiasm.

The second creates accountability.

One appeals to rhetoric. The other demands engagement with reality. Both are necessary, but organisations often find the first more comfortable than the second.

And accountability can sometimes feel uncomfortable because it requires people to think beyond the launch event, the press release and the presentation that celebrates the beginning of something. It requires people to consider not only how an initiative will begin, but how it will operate months or years later when the excitement has faded and the practical realities emerge.

There is also another reason that realism is often an unpopular, and difficult, position to occupy.

In many organisations, the people who are remembered most fondly are not necessarily those who asked the most important questions. They are often the people who supported the idea from the beginning, championed the initiative and spoke confidently about what could be achieved. They become associated with optimism, ambition and progress. They are remembered as the people who said "yes" when others hesitated.

The realist is often remembered differently.

The person who asks difficult questions can easily acquire a reputation for being negative, even when their concerns are entirely reasonable. The individual who asks whether the timescales are realistic, whether the risks have been properly assessed or whether sufficient resources exist can become labelled as someone who lacks enthusiasm rather than someone who is exercising judgement.

The person who asks difficult questions can easily acquire a reputation for being negative, even when their concerns are entirely reasonable.

But the strange thing is what happens when things don't go according to plan. When the project gets into difficulties, or fails to deliver, usually for the reasons the realist asked to be considered at the start. The enthusiastic supporter of a project is often able to move on. They move to the next transformation programme, the next strategic priority or the next exciting opportunity. Their association remains with the launch, the vision and the promise. They are remembered for their positivity, their confidence and their 'can do' willingness to support change.

The realist, however, is frequently still there. They are often the ones dealing with implementation difficulties, managing unforeseen consequences and trying to resolve problems that may have been highlighted from the very beginning. They are left clearing up the mess created when ambition outpaced planning, when enthusiasm substituted for evidence or when uncomfortable questions were dismissed because they disrupted the momentum surrounding a new initiative.

This creates a strange imbalance in organisational memory.

The person who said "yes" is remembered as positive. The person who asked difficult questions is remembered as negative. Yet when projects fail, experience suggests it is often the realist who remains to deal with the consequences. They inherit the problems, manage the risks that were underestimated and try to rebuild confidence when expectations have not been met.

when projects fail, experience suggests it is often the realist who remains to deal with the consequences. They inherit the problems, manage the risks that were underestimated and try to rebuild confidence when expectations have not been met.

Organisational rhetoric tends to celebrate confidence and certainty. Reality, however, is usually managed by the people who asked the uncomfortable questions before anyone else recognised they needed asking. As a result, the realist can sometimes become associated with failure despite having warned about many of the issues in advance. Not because they caused the failure, but because they are still present when others have moved on. They become linked with the recovery effort, while those who championed the original idea have often turned their attention elsewhere.

The irony is that the realist wasn't trying to prevent success. Quite often, they were trying to prevent the exact failure they find themselves remembered for. Their questions were not designed to stop progress. They were designed to ensure that progress was sustainable, ethical, achievable and genuinely beneficial. The challenge is that caution rarely attracts the same attention as confidence, and scrutiny rarely generates the same excitement as ambition.

Yet organisations need both.

They need people who can imagine what is possible, but they also need people who are willing to ask what happens if things don't work as imagined. They need visionaries who can see the future, but they also need realists who understand the practical realities of getting there.

The reality is that many problems do not occur because people lacked ambition. They occur because the ambition wasn't matched with enough questioning. They occur when rhetoric about transformation, innovation and change is allowed to run ahead of reality. The warning signs were there. The concerns were raised. The risks were identified. But nobody wanted to be the person who interrupted the optimism surrounding a new project. Then, later, when things do not work as expected, everyone asks why nobody predicted it. Quite often, someone did. They just weren't the person everyone wanted to listen to at the time.

nobody wanted to be the person who interrupted the optimism surrounding a new project. Then, later, when things do not work as expected, everyone asks why nobody predicted it. Quite often, someone did. They just weren't the person everyone wanted to listen to at the time.

You know what, I'm going to take the advice that is often given to people who work in organisations. Rather than focusing on what's wrong, I'm going to look for the positive opportunity hidden within each challenge. After all, we're regularly told that language shapes perception, that negativity is unhelpful and that successful organisations need people who look for possibilities rather than barriers.

Perhaps the NHS doesn't actually have problems. Perhaps it has a reputation management challenge because we haven't yet found the right way to describe what is happening. Maybe the issue isn't what people are experiencing, but the fact that we're using language that encourages them to focus on the wrong things.

After all, we're constantly told that language matters. Negative language creates negative perceptions, while positive language helps people see opportunities. Every challenge is apparently an opportunity waiting to be uncovered, every setback is a learning experience, and every difficult situation can be reframed if we're creative enough with our choice of words.

So perhaps the answer isn't to fix the problem. Perhaps the answer is to rename it. After all, rhetoric is often far easier to change than reality.

Take waiting lists. The phrase itself is clearly a communications disaster because it encourages people to think about the patient rather than the system. It makes them picture someone who has been told they need treatment but is now left wondering when that treatment will actually happen. It makes them think about pain, uncertainty, disruption to daily life and the frustration of having little control over when their situation might improve. From a reputation perspective, "waiting list" is far too honest. It's realism. We don't want that.

Reality has a habit of sounding less impressive than rhetoric. I mean, patients will experience reality rather than the communications strategy, but we don't need their negativity. so perhaps patients aren't waiting at all. Perhaps they're taking part in a "Dynamic Care Prioritisation Pathway", where treatment is carefully managed according to clinical need, available expertise, workforce capacity and the wider demands placed on the health service.

Reality has a habit of sounding less impressive than rhetoric.

Yes, that sounds much better.

The patient who has spent twelve months waiting for a hip replacement isn't someone who has been stuck in a queue. They're someone participating in a carefully designed healthcare journey. The NHS isn't failing to provide timely treatment. Instead, it's demonstrating its ability to balance complex demands across millions of patients with different needs.

The fact that the journey has taken much longer than expected can then be reframed as evidence that the system is making responsible decisions. After all, we wouldn't want the NHS rushing people into treatment without considering priorities, available resources and clinical safety. There might even be benefits to the extended journey. Patients have more time to prepare themselves. They have more opportunity to consider their choices. They may have more time to make lifestyle changes or explore ways to support their recovery while they wait.

I feel better already - quite optimistic. I mean, all of those things might be true.

There is, of course, a slight problem is that the person who can't walk properly because of a painful joint, who is struggling to work, who has stopped doing activities they enjoy or who is relying increasingly on medication might still describe the experience as waiting.

No, that's realism. Better snap out of it! It's probably because they haven't yet adopted the new terminology.

Optimistically the same approach could easily be applied to patients being treated in corridors. Again, the phrase itself creates an unfortunate impression. It's far too negative. It makes people think about overcrowding, lack of privacy and a healthcare environment that doesn't quite match what they would expect when receiving medical treatment.

Clearly, this is another failure of communication. Negativity at its worst.

Hang on a minute. For years, organisations have explained the benefits of flexible working environments. Open plan offices have been described as modern spaces that encourage collaboration, improve communication and help people work together more effectively. Nobody describes an open plan office by saying the company has run out of individual rooms. They describe it as a flexible environment designed to encourage interaction.

Perhaps hospitals are simply ahead of the business world.

That makes sense. Patients aren't being treated in corridors. They're benefiting from "Flexible Clinical Care Environments", where healthcare professionals can remain close to patients while making better use of available space during periods of exceptionally high demand.

Yes, this phrase creates a completely different impression. It suggests planning, adaptability and innovation rather than pressure and shortage. It sounds like a carefully designed approach rather than a response to circumstances where demand has exceeded capacity.

Hang on. The difficulty is that the patient lying on the trolley probably won't experience it quite that way. They'll still know they're in a corridor. They'll still hear conversations happening around them. They'll still be aware that the environment isn't what they would have chosen if they'd been asked.

The description has changed, but the patient experience hasn't necessarily changed with it.

That is the essential difference between rhetoric and reality. One exists in documents, presentations and press releases. The other exists in the lived experiences of patients and staff.

Never mind, let's move on. After all we can't stop patients from being negative. But NHS staff are different. They're expected to be positive. Staff shortages provide an excellent opportunity for positive reframing. Rather than saying the NHS doesn't have enough staff, perhaps we should focus on the opportunities created when people gain experience quickly, develop skills earlier and take on responsibilities sooner than previous generations.

Yes, there's certainly some truth in that. Many healthcare professionals develop remarkable skills because they work in demanding environments. They learn to make decisions under pressure. They become adaptable. They develop confidence because they're regularly exposed to complex situations. This could easily be described as accelerated professional development.

Of course the cursed realist is likely to ask some additional questions before celebrating this as a success story. Are we deliberately creating opportunities for people to grow, or are people being asked to take on additional responsibilities because there simply aren't enough staff available? Are we building a stronger workforce, or are we relying on committed individuals to absorb pressure because they care about their patients and colleagues? Are we supporting resilience because it helps people thrive, or are we expecting people to become resilient because the system has left them with little alternative?

The answer, inconveniently, might be that both are right.

A challenging environment can produce highly skilled professionals while still being evidence that something needs to change. Someone can develop valuable experience while also being placed under unnecessary pressure. A team can demonstrate incredible commitment while still working in circumstances that shouldn't be considered normal.

Recognising the positive doesn't mean we've solved the negative. Nor does rhetoric eliminate reality. It merely changes the language used to discuss it.

But maybe that doesn't matter. Once this approach to language becomes accepted, almost anything can become an opportunity.

A hospital car park with no available spaces isn't evidence of poor planning. It's evidence that people value NHS services and an opportunity to encourage healthier travel choices. The person who arrives late because they've spent half an hour driving around looking for somewhere to park isn't experiencing an inconvenience. By having to park further away they're taking part in an unexpected exercise programme before their appointment.

A computer system that fails when staff need it most isn't necessarily a technology problem. It's an opportunity to maintain traditional skills and remind people that healthcare professionals can still adapt without relying entirely on digital systems. The fact that staff have to create workarounds, make extra phone calls and develop unofficial processes could be described as proof of human creativity.

An appointment letter arriving with the patient after the appointment date isn't an administrative failure and more. It's an opportunity to give patients more time to reflect on whether the appointment is still required. Someone missing an appointment because they received the information too late has simply misunderstood the innovative approach being taken.

Heck, with enough imagination, almost anything can be transformed into a positive message.

I'm being sarcastic of course. Rhetoric is remarkably flexible. Reality, unfortunately, tends to be considerably less cooperative. Because the real danger isn't the use of rhetoric itself. Every organisation uses rhetoric. The danger arrives when rhetoric becomes a substitute for reality rather than a way of communicating it.

the real danger isn't the use of rhetoric itself. Every organisation uses rhetoric. The danger arrives when rhetoric becomes a substitute for reality rather than a way of communicating it.

A waiting list with a different name is still a waiting list. A patient in a corridor with a more professional title is still a patient in a corridor. A staffing shortage described as an opportunity for growth is still a staffing shortage.

Positive language has its place. Organisations shouldn't spend all their time focusing on what is wrong. People need hope, ambition and confidence that improvement is possible. But there's a difference between explaining reality positively and pretending reality has changed because we've chosen better words.

The NHS doesn't need a collection of increasingly creative descriptions for difficult situations. It needs honest conversations about what's working, what isn't working and what needs to improve. Because sometimes the biggest opportunity isn't finding better words to describe a problem. Sometimes it's being realistic and accepting that the problem needs solving.

Language shapes perception, but as I've said in countless articles, perception is not the same as reality. That perhaps is the central challenge facing many modern organisations. They have become exceptionally skilled at managing rhetoric while finding it much harder to confront reality.

The NHS does not need people who only see problems, but it also does not need people who believe every problem can be solved by choosing more positive words. Sometimes the most constructive thing someone can say isn't "How can we make this sound better?" Sometimes it's "What do we need to change so that we no longer have to explain it?"

Sometimes the most constructive thing someone can say isn't "How can we make this sound better?" Sometimes it's "What do we need to change so that we no longer have to explain it?"

The NHS doesn't need better slogans. It doesn't need more creative ways of describing difficult situations. It needs honest, realistic conversations about what's working, what's failing and what needs to change. It needs people who can imagine what's possible, but it also needs people who are prepared to ask whether that possibility is desirable, ethical, properly governed and genuinely beneficial.

Because the person asking "should we do this?" isn't necessarily the person preventing progress. Sometimes they're the person making sure progress is actually progress.

Optimism matters. Ambition matters. Innovation matters. But realism matters too.

The strongest organisations are not those where everyone agrees that everything is possible. They are the ones where people can challenge assumptions, ask difficult questions and discuss uncomfortable realities without being labelled negative. Sometimes the person saying, "I'm not sure this is the right thing to do," is not the person standing in the way.

Because ultimately, success is not achieved when rhetoric sounds convincing. Success is achieved when reality improves.