“But what really interests me is how balancing the budget and reorganising the public sector might fit together – and could still be made to fit together by the coalition. Because to genuinely reduce the cost of public services, you really need a big idea about how they might work differently – you need a diagnosis and a prescription.
The coalition has a diagnosis – they understood the disastrous effect of targets – but no prescription that really fits it. New Labour had a prescription but a faulty diagnosis.
Without the diagnosis, public service reform just becomes public service cuts, and they often lock in costs elsewhere in the system. I have written before about how historians covering these years will regard our main story as the looming crisis in public services, and the race against time by empowered service professionals to come up with the ideas they need to re-configure them.
But it is worse than that. Without a big idea behind spending cuts, any government gets impaled on the horns of a dilemma described so powerfully by the systems thinker John Seddon:
“The truth is counterintuitive: focusing on costs drives costs up. It doesn’t take a rocket scientist to work out that we’d be better off if we could design a service that meets people’s needs, quickly, effectively and once.”
There is the great paradox which has eluded successive governments. If you focus on cutting costs, the costs will rise. If you try and provide a more effective service – which might well not be digital by default – then costs will fall.
Seddon is an important figure in all this. He is the presiding genius over a whole range of related ideas that, taken together, would completely transform the effectiveness of our services. Before the election, I took him to see Vince Cable, hoping they would hit it off (they didn’t really get the chance). After the election, I organised a debate at the Royal Society of Arts with him under the title ‘The New Efficiency‘.
He remains a kind of king-over-the-water for the kind of service manager who is most frustrated by the direction of public service reform over the past decade.
Seddon’s frustration with Whitehall is expressed in a wonderful monthly e-newsletter which has become required reading in local government circles because it is so enjoyably rude.
He isn’t right about absolutely everything – this isn’t a hagiographical blog – but I have come to believe that he represents the wave that is about to break over public services.
Perhaps Labour will run with this approach, and the related approaches I describe. Perhaps they won’t. Perhaps the coalition will realise, at this late stage, what needs to happen. I don’t know. But the wave will eventually break, sweeping the whole caboodle of lesser ideas – Lean, digital by default, payment-by-results – into history”.
John Seddon was a witness on the well known BBC Radio 4 programme, Moral Maze.
Listen on Saturday 9th March 2013 at 22:15 to hear John talk about the damaging effects of targets, form filling, cost management and a culture in the NHS concerned more about how you are seen by the hierarchy than you are concerned for the patient. Instead John calls for different type of measures that inspire people to do good things.
Combative, provocative and engaging debate chaired by Michael Buerk with Michael Portillo, Kenan Malik, Melanie Phillips and Claire Fox.
Witnesses: John Appleby – Chief economist, Health policy, The King’s Fund, Dr Martin O’Neill – Lecturer in Political Philosophy at York University, John Seddon – Managing Director, Vanguard, Rev. Prof. Alister McGrath – Professor of Theology, Ministry and Education at King’s College London.
Listen again here.
The 1,782 page Francis report into the Mid Staffs tragedy is a mass of detail. Hugely disturbing detail, you can’t fail to be moved by the evidence. But Francis, perhaps because he has a legal mind, doesn’t get behind the facts; he doesn’t question assumptions, he doesn’t even open the door to matters of theory.
As a consequence his recommendations represent what we would call single-loop thinking. The NHS is subject to massive amounts of regulation, but Francis recommends more, wrong thing righter. He recommends a ‘zero tolerance’ approach to breaches of fundamental standards but doesn’t question why the system as currently managed, might produce such neglect. He calls for a culture that puts patients first, but doesn’t consider why the current system fails in this regard.
If it is true that we have reached a level of dystopia that requires us to articulate a ‘structure of clearly understood fundamental standards’ – his top recommendation – we should despair. He thinks inspection for compliance will drive sufficient fear amongst healthcare professionals, yet he points to the fear culture that is already pervasive and dysfunctional. He argues for openness and transparency but fails to understand that the current use of gagging clauses (which he says should be banned) and shocking treatment of treatment of whistle-blowers is, too, symptomatic of the culture of fear. He does nothing to explain the reasons we have a culture of fear.
Francis thinks the answer is training, failing to appreciate how the current system drives peoples’ behaviour. He thinks that better leadership will instil a better culture, without understanding what currently drives leaders’ behaviour. Like Ed Balls did with social care, he recommends the creation of a leadership college, as though we can train that too. He thinks better information and benchmarking will act as a stimulus to improvement, showing no understanding of how benchmarking will lead to mediocrity, not innovation. It is perhaps ironic that the Francis recommendations on health improvement treat the symptoms, not the causes.
When Francis gets close to the causes: acknowledging a form-filling, target- and cost-driven culture, he fails to question them. He cannot see that form-filling bears no relation to and will detract from quality, he doesn’t know what targets do to systems and why, he wouldn’t believe that a focus on costs is driving costs up. Francis has a legal mind. He gave us the facts. You should read his report; you will be moved.
Politicians move in
The minister for health, Jeremy Hunt, takes up the Francis theme on excessive box-ticking, bureaucracy and burdensome regulation by announcing a talking-shop whose purpose is to reduce the regulatory burden by a third. I can hear Deming in my head: ‘why a third? Is it the right third? Why is it not two thirds? What benefit ensues against the cost of compliance? The best we can expect is less of the wrong thing; that’s still the wrong thing.
The right way to have gone would have been to order all leaders in the NHS to review their box-ticking and form-filling to ask: what of any of this is important to us in understanding and improving healthcare? And thus NHS leaders would make their own decisions about changing the nature of control and, as a necessary and urgent consequence, the nature of regulation.
The minister says we need a culture that puts the patient first, not knowing how the current system obviates any attempt to do that and announced a review of complaints procedures. You couldn’t make it up really; it is as though he read the Beano guide to management.
The prime minister, David Cameron, strides in with announcements about handing the Francis report to the police in order to find people to blame, giving performance-related-pay to nurses, sacking the bad ‘uns and making nurses fill in forms to prove they have spoken to every patient every hour. Clueless, wrong and damaging.
In short, while the minister promises to remove the dead hand of micro-management from crushing people, the hand is, in fact, warming up for BOHICA (bend over, here it comes again).
Closing one of his presentations with a literary flourish, the minister said: “Let me finish with words from TS Eliot we should not forget, when he said, “It is impossible to design a system so perfect that no one needs to be good.”
I’m no literary expert, but when I read Eliot’s ‘Choruses from the Rock’, I experience a man regretting society’s alienation from God; in the NHS, alienation from a worthy purpose:
‘What have we to do but stand with empty hands and palms turned upwards in an age which advances progressively backwards?’
Eliot (writing in 1934) describes how man is facing a tremendous flood of meaninglessness because context has been removed. Man has created an artificial world based on the new gods of reason, money and power. This is what has happened in health, the minister and his predecessors are responsible for a system that worships false gods.
It’s the system, stupid
I went to be a ‘witness’ on the Moral Maze (Radio 4) to try my best to make this point. We have a choice: to run our organisations in ways that encourage bad behavior, or in ways that encourage good; behaviour is a product of the system. I say ‘try’ because, for those of you who don’t know, the Moral Maze is something of a bear-pit. Ex minister Michael Portillo was my ‘opponent’ – an intelligent man who, nevertheless, thinks a bit of fear is a good thing. Having roughed me up he was at least decent enough to acknowledge my arguments in the summing up.
You can ‘listen again’ here.
John Seddon’s article in LGN on the damage caused by back offices is one of the most read and commented on articles on the localgov.uk website.
Where did the idea of a ‘back office’ come from? And what problem was it designed to solve?