THE MOST IMPORTANT THING A LEADER DECIDES IS WHAT NOT TO PAY ATTENTION TO

Why organisations can have dozens of priorities and still miss the one thing that matters.

Aspirin has been around for more than a century. So why can’t some British hospitals get hold of it? Imagine a nurse opening the medicines cupboard. She’s looking for aspirin. There isn’t any. She checks another cupboard. Then asks a colleague.

Nothing.

It’s a small scene. But behind it lies a much bigger problem. Aspirin is one of the world’s most familiar medicines. For generations, people have taken it for headaches, toothaches and other everyday pains.

But aspirin does something rather more important. At appropriate doses, it helps prevent blood clots. It plays a role in treating certain heart attacks and preventing further cardiovascular events. In some circumstances, timely access matters enormously.

So a shortage isn’t necessarily a minor inconvenience. And this isn’t an isolated problem. In September 2026, an investigation based on freedom of information requests to NHS trusts revealed that 26 of the 42 trusts providing information about aspirin supplies had experienced disruptions between December 2025 and March 2026. That’s 62% of those responding to the question.

Other medicines were affected too, including co-codamol and ramipril. But here’s the strange part. This wasn’t the first warning. In June 2025, the Department of Health and Social Care had already acknowledged a shortage involving aspirin suppositories used in stroke care. In August, the government published plans to strengthen medicine supply resilience. By February 2026, further disruption involving dispersible aspirin tablets had been acknowledged.

These weren’t necessarily identical shortages. Different formulations have different suppliers and vulnerabilities. But the wider problem was already recognised. And action was already being taken. So why were hospitals still experiencing shortages? There are several possible explanations. Manufacturing difficulties. Shortages of ingredients. Changes in demand. Distribution problems. A hospital pharmacy depends on a supply chain extending far beyond the hospital itself.

Perhaps the answer lies somewhere in that chain. And that’s where our investigation takes an unexpected turn.

A MAN STANDING IN THE RAIN

On a cold, wet morning, Neil Alexander is standing in the rain outside a builders’ merchant. He’s watching council tradespeople arrive in their vans. One after another, they join the queue for materials before heading off to their first jobs. Alexander has come to find out why. He approaches one of the men. “Why are you here?”

It’s an odd question to ask somebody standing outside a builders’ merchant. The man needs parts. That’s why he’s there. But Alexander has another question. “Why aren’t they already in your van?” Now the conversation becomes interesting. Alexander continues asking questions. How often do you come here? How much of your working day do you spend collecting materials?

How many times will you return today? They’re uncomfortable questions. These are experienced tradespeople trying to get on with their jobs. They haven’t come to the merchant to be interrogated.

But Alexander isn’t interested in blaming them. He’s interested in understanding why they have to be there at all. And as the men explain what happens during an ordinary working day, a peculiar picture emerges. Their vans are full of materials. Thousands of pounds’ worth, in some cases. Yet the one part they need to complete a repair often isn’t there.

An operative arrives at a tenant’s home. He discovers he needs something he doesn’t have. So he leaves. He drives to a builders’ merchant. Finds the part. Queues. Drives back. Sometimes he has to make another journey. Neil’s investigation found skilled tradespeople spending two or three hours of their working day travelling to merchants and collecting materials.

The organisation sees perfectly normal materials collections. The tenant sees their plumber leave. And while that plumber is driving around, something rather important isn’t happening.

Plumbing.

But the vans aren’t empty. Quite the opposite. Some contain thousands of pounds’ worth of materials. One plumber has seventeen rolls of PTFE tape. Another has a ship’s wheel.

A ship’s wheel.

And yet neither has everything needed to complete the repairs on today’s list. The council has plenty of stock. It simply isn’t the stock its tradespeople need.

THE TROUBLE WITH BUYING THINGS

And this isn’t confined to housing repairs or hospital supply chains. It turns up in retail too. Some years ago, we were helping one of Britain’s largest retailers understand its stock problems. At one store, we discovered thousands of expensive, rather fancy towels sitting in stock. There was nothing wrong with them.

The problem was that customers shopping in that particular store weren’t buying them. So why were they there? Head office had negotiated an excellent purchasing deal. From the buying department’s perspective, it made perfect sense. The retailer had secured an attractive price. Except the purchasing decision hadn’t sufficiently accounted for whether that store’s customers wanted the towels.

The purchasing department had achieved a saving. The stockroom told a different story. And just like the vans in the repairs organisation, the organisation had plenty of stock. It simply wasn’t the stock its customers needed.

THE £49 PROBLEM

Back in the repairs organisation, Alexander’s investigation is revealing something about the way organisations manage their resources. They generally know what they’ve bought. They know how much they’ve spent. They can report the value of their stock. What they often understand much less well is what people actually use.

And how predictable that usage is. How often is a particular part needed? In what quantities? How much does demand vary? Does one operative use the same materials as another? These questions may seem mundane.

But the answers determine whether an operative can finish a repair or has to drive around looking for a part. And when managers don’t understand what is being used, something else tends to happen. They introduce controls. The Stock Right Now team described organisations imposing rules requiring authorisation for purchases above £50. It sounds sensible.

Except something strange happens. People start placing orders for £49. And when an operative genuinely needs something costing more than £50, the work stops. He completes a requisition. Sends it to his manager. The manager reviews it and authorises the merchant to release the part. Meanwhile, the operative waits. The manager does paperwork.

And the tenant is still waiting for the repair. But the team discovered something even more extraordinary. In the authorisations they examined, they couldn’t find a single instance of a manager refusing a request.

Not one.

The organisation had created a process for saying no in which nobody ever said no. A control intended to save money was consuming the time of skilled tradespeople and managers simply to administer it. Meanwhile, the real problem remained. The materials people needed weren’t available when they needed them.

And this is where Alexander’s approach becomes interesting. Instead of prescribing the same stock for every van, he argues that organisations should study actual consumption. Some materials are needed frequently. Others hardly ever. One operative may work on plumbing repairs. Another may specialise in different kinds of work. Their stock requirements won’t necessarily match.

And those requirements change. Once you understand consumption, you can adjust stock to match it. You can reduce unnecessary inventory. You can replenish materials according to predictable demand.

And you can give people closest to the work the authority to obtain what they need without forcing every decision through another layer of bureaucracy. Alexander’s approach rests on three principles. Understand what people actually need. Give them appropriate control over obtaining it, and relentlessly improve your stock levels against predictable usage.

And continually remove what they don’t need. In the repairs organisation, the result was less stock and more completed work. The strange thing wasn’t that the solution required sophisticated technology. It was that the organisation had spent so long managing the stock it owned without sufficiently understanding the work the stock was supposed to make possible.

And the underlying principle extends beyond physical inventory. Call centres handle recurring types of enquiries. Claims organisations process recurring types of claims. Pension administrators deal with predictable retirement events. Much of this demand can be studied. Yet organisations often continue to design their work around inherited structures, established procedures and assumptions about how things ought to operate.

Rather than what the work is actually telling them.

BUT THERE’S A BIGGER PROBLEM

Alexander’s approach gives us a way to investigate supply-chain performance. But it leaves us with another question. A much bigger one. Imagine you’re running a hospital. You’re responsible for patient safety, staffing, waiting lists, diagnostic equipment, budgets, medicines, buildings and countless other things demanding attention. Aspirin matters.

But so does a broken scanner. So does an overflowing emergency department. So does a shortage of nurses. Each problem has consequences. Each makes a reasonable claim on your time.

So how do you decide? Because medicine supply problems have been recognised for years. Housing repairs organisations have struggled with materials availability for years. Policies have been introduced. Improvement programmes launched. New systems purchased. Yet important problems persist.

Perhaps the question isn’t whether leaders have noticed them. Perhaps it’s whether they’ve ever decided how much attention those problems deserve compared with everything else. And that takes us somewhere rather interesting.

FIFTY LINKS IN A CHAIN

Eliyahu Goldratt, the physicist who developed the Theory of Constraints, argued that the performance of a system is limited by its constraints. Imagine a chain containing fifty links. Every link has a weakness. Every link could be strengthened. Somebody could probably produce an excellent business case for improving each one.

But one link is weaker than all the others. You could spend your entire budget strengthening the other forty-nine. The chain would still break at the same place. The rational decision is to strengthen the weakest link first. Then find the next one. Alan Barnard, who has spent years developing and applying Goldratt’s thinking, brings this principle into management decisions.

The difficulty isn’t identifying things that could be improved. Most leaders can produce an impressive list. The difficulty is deciding which improvement matters most, and protecting the organisation’s attention long enough to achieve it.

But that’s harder than it sounds. Because organisations are full of good ideas. A customer problem deserves attention. So somebody launches an initiative. Costs are rising. Another initiative. Staff are leaving. Another. Technology needs updating. Another. Each proposal may be perfectly reasonable when considered individually.

But nobody asks what all these reasonable decisions are doing to the organisation’s ability to finish the work that matters most. And the consequences can be extraordinary.

WHEN EVERYTHING BECOMES IMPORTANT

At one company, consultants at Bain & Company discovered that senior managers were spending more than 80% of their time on issues accounting for less than 20% of the company’s value.

Eighty per cent.

The people responsible for deciding what mattered most were spending most of their time on things that contributed comparatively little to the company’s value. At an Indian consumer goods company, Bain found that 20 of its 25 most senior executives were each involved in more than eight initiatives.

Eight.

And in many cases, nobody had clearly established what those executives were expected to contribute. Were they there to make decisions? Review progress? Provide advice? Or simply attend meetings? Each initiative had become another claim on their attention. Bain called the problem initiative overload. The result is a leadership team with an impressive list of priorities.

And increasingly little attention left for any one of them. The problem with these initiatives isn’t necessarily that they’re bad ideas. Quite the opposite. Most of them are probably good ideas.

And that’s what makes them dangerous. Because every good idea consumes something the organisation cannot manufacture, purchase or borrow indefinitely.

Leadership attention.

Which raises an awkward question. If everything deserves attention, what deserves more? The answer lies in a discipline that sounds almost too simple to be important.

THE ART OF ATTENTION

Disproportionate attention.

Not every problem deserves an equal share of leadership time. Not every worthwhile initiative deserves to begin today. If one constraint is limiting the organisation’s ability to deliver useful outcomes, improving everything else may achieve remarkably little. Remember Goldratt’s chain. Strengthening the forty-nine links that aren’t limiting its strength might look like progress. It might generate impressive reports.

But the chain is no stronger. The same applies to organisations. The most important question isn’t what leaders could improve. It’s what they should improve now. What is the one problem whose resolution would make the greatest difference to the organisation’s ability to deliver useful outcomes relative to its total resource effort? What deserves a disproportionate share of leadership attention until it is resolved?

You don’t necessarily need Neil Alexander’s particular knowledge to lead the resolution of a materials problem. You need to establish its importance, bring together people who understand it, give them the authority to investigate and protect their ability to work on it until the problem is resolved.

And when the constraint moves, leadership attention must move with it. That’s the uncomfortable part. Disproportionate attention doesn’t simply mean deciding what matters. It means deciding what matters less. It means saying no to worthwhile initiatives. It means disappointing people with perfectly sensible proposals.

And it means resisting the temptation to confuse having many priorities with making progress.

BACK TO THE MEDICINES CUPBOARD

Now, NHS leaders might reasonably argue that aspirin shortages aren’t their biggest problem. Perhaps they’re right. Perhaps diagnostic capacity, emergency admissions or staffing represent greater constraints on their ability to care for patients. In which case, they should concentrate their attention there.

That’s rather the point.

But consider social housing. In social housing, our research identified approximately 2.5 million repairs recorded as closed without the work being completed, alongside another 1.2 million still outstanding at year-end. These aren’t simply numbers on a performance report. They’re people waiting for their homes to be repaired.

And if that scale of unresolved work doesn’t warrant disproportionate leadership attention, what does? Housing leaders have plenty of worthwhile initiatives to choose from. But the question isn’t whether those initiatives are worthwhile. It’s whether they’re more important than fixing the problem that is currently preventing the organisation from delivering what tenants need.

And if they aren’t, why are they still competing for attention? And that brings us back to the nurse searching for two aspirin tablets. Perhaps the answer lies in better forecasting. Perhaps it’s manufacturing, procurement or distribution. We shouldn’t pretend to know without investigating.

But important problems rarely disappear simply because somebody has acknowledged them, written a policy or launched another initiative. Somebody must decide that resolving the problem deserves sustained attention.

And decide what else can wait.

Because sometimes the best way to stop the headaches isn’t to order more aspirin.

It’s to fix what’s causing them.

P.S. If you’re interested in getting more repairs fixed the first time with the same resource, my new book is here: https://www.loweffort.com/book1