Why better measures lead to better lives

Jo Gibson, Vanguard Consulting

In people centred services such as health and social care, our purpose is to help people to live well. We are not measuring widgets. We are measuring how well someone’s life has improved. We should care deeply about this. Choosing the wrong measures can put vulnerable people’s lives at risk. Choosing the right measures gives us an opportunity to help people to live well.

The go-to measure in most people centred services is targets: to complete an assessment within a set number of days, to spend a certain amount of time with a patient or to ‘fix’ X number of people. Managers set targets with good intentions. They believe that setting targets will improve outcomes for citizens, motivate staff and protect scarce resources. But do good intentions lead to good results?

Setting targets for individuals assumes that:

  • People have a large degree of control over their work
  • Achieving targets means better outcomes for citizens

 
In reality:

  • Targets are always arbitrary, and never a reliable measure of performance
  • Targets do not improve outcomes for citizens
  • The system in which people work actually has the biggest impact on performance

 
When a manager sets targets and people can’t meet them easily, they either cheat the numbers or cheat the system in an effort not to be paid attention to.

The result is the very opposite of the good intention. The focus switches from improving things for the citizen to improving things for yourself. Instead of doing good, staff concentrate on looking good. This behaviour is rational and predictable.

The consequences of setting targets in people centred services could hardly be more serious; people are not properly understood, are misdiagnosed and their lives sometimes put at risk. For example, the seven-day target from contact to assessment used in social services means that the assessment may be done too quickly, missing important relevant information. A GP under pressure to see each patient in less than 10 minutes can misunderstand the true need and at worse, misdiagnose. The hospital target for ‘average length of stay’ can lead to patients being discharged prematurely, or without the right support networks in place.

Does it matter to the individual – or the organisation?

What is interesting is that these measures and many others like them, focus on what matters to the organisation, not what matters to the citizen. They relate to what has become the organisation’s de facto purpose – ‘meet government targets’, ‘achieve foundation status’ or ‘make a profit’, for example. They do not relate to the purpose from the citizen’s point of view, which is very different: ‘help me live my life well’ or ‘make me better’.

Organisation-centred measures are not used to foster learning or to understand the current system. Many of them are so arbitrary and out of context that they mean nothing.

If you spend time on an A&E ward, you may have seen the ‘performance boards’. Ask the staff if they ever look at them. Ask them if they ever use these targets to change the way they work. You will not be surprised to learn that they do not pay attention to them because they are so out of context and unconnected to the reality of the work. Even more informative is to ask the leaders of the service if they use the measures in their routine daily work. Again, you will probably discover that the only time they pay attention to the measures is either when they are in breach of the target, in crisis management mode, or at monthly management meetings, held in a room remote from the place where the work actually happens.

The test of a good measure

So what does a good measure look like?  The Vanguard Method only uses measures that pass the test of a good measure. Good measures:

  • Relate to purpose from the citizen’s point of view
  • Show variation over time
  • Help people to learn, understand and improve the system
  • Are in the hands of the people doing the work
  • Are used by leaders to take effective action on the system

 
In our experience, very few of the measures currently used in people centred services pass this test.

Good measures in people centred services can be split into ‘individual measures’ and ‘system measures’. Individual measures help to show whether an organisation’s service is actually helping people – the human beings, citizens and persons, with names, who needs help. System measures help to identify and remove obstacles that prevent delivery of that help. We call these ‘system conditions’.

Individual measures in people centred services relate to ‘what matters to the individual’ or ‘what a good life looks like for the individual’.

Clearly these are qualitative measures. Qualitative measures rely primarily on words as the unit of analysis and means of understanding. However, you can also use voice tone, loudness, cries, sighs, laughs, and many other forms of human communication. Many services that have applied the Vanguard Method use qualitative measures to show them how well they are helping individuals to achieve their purpose.

Understanding an individual’s purpose is achieved via sustained conversations that are reflected in spidergrams. The individual identifies what matters to them – for example ‘I’d like to be able to cook meals for myself’ – and rates on a scale of 1 to 10 how near they are towards achieving that. The organisation then works with the person to understand and achieve the goal.

This is an example of a spidergram; a qualitative leading measure that demonstrates (over time) how well a system is helping an individual to achieve their purpose.measures-jo-gibsonIndividual measures are called leading measures. Leading measures are the ones we use to understand and improve the system on a day-to-day basis, live in the work. They link directly to what matters to the citizen.

System-level measures

It is also important to have good measures at system level that help leaders to identify and eliminate the system-wide conditions that constrain the system’s ability to help a variety of different people, or in Vanguard terms, to ‘absorb variety’.

Such measures include:

  • Volume of demands in
  • Volume of demands out
  • Number of repeat demands for the same case or issue
  • End-to-end time either across the whole system or for parts of the system involving a specific process

 
There are some system-wide measures specific to certain people centered service:

  • Number of care packages put in place
  • Cost of care packages put in place
  • Number of pieces of equipment issued
  • Cost of equipment issued

 
The measures above help to identify what is happening in the system and importantly why it is happening, so that the system conditions can be addressed and eliminated. These measures are known as lagging measures because they apply after the event – after the real work with the citizen has been done.

There may be certain things common to many citizens that stop them from living the life that they choose. For example, someone might be lonely and want company. Loneliness may ‘present’ itself to the system in many different ways. However, the underlying cause of loneliness is likely to be a lack of family relationships, community support, or friendship networks. If loneliness is a common cause of people not living well, workers can do something on a locality level to address this, such as set up groups, connect people to each other, or improve community transport. In this case, a system-level measure might relate to community networks. The link between the two is that the system measure is derived from the individual measure.

The measurement challenge

The challenge for leaders and indeed regulators is that qualitative measures are not the norm and are often not readily available. They can’t be collected in a spreadsheet or written up on a side of A4 for the management board. The only way leaders can get meaningful view is to leave their office and go face-to-face with individuals to understand at firsthand what matters to them and if and how the system is helping them to achieve it. Some would argue that qualitative measures are less statistically and scientifically sound than quantitative ones. But people-centered services are not about products or machines. The aim is to measure how well someone’s life has improved, in their language and on their terms.

This is not to say that quantitative data is not needed, but it does require a different approach to measuring and also a different approach to inspection and regulation. Taking a different view of measurement in people centred services would lead to a significant improvement in results from the citizen’s perspective. At the heart of measurement would be the citizen and what matters to them. This perspective results in improved quality of life for citizens, fewer complaints, more satisfied staff and much less cost in the system.

We have learned what not to measure. Never measure the achievement of targets. Targets are always arbitrary, the data obtained from them is unreliable, and it cannot be used to improve. As W. Edwards Deming put it: ‘What do “targets” accomplish? Nothing. Wrong: their accomplishment is negative’.

Instead, we should measure whether we are helping individuals, on their own terms. The best people to do this are frontline staff and professionals, not managers. System-level measures tell us whether we are succeeding in removing system conditions. Leaders and managers use system-level measures to understand how well the system is performing overall.

But the most important lesson of all is that measurement in services dealing with people at vulnerable moments in their lives really matters. Get it wrong and the damage may be permanent, with huge implications for cost as well as wellbeing. Get it right and the consequences for individuals, their families and community can be profound.

Jo Gibson

Read similar articles in Edition Two of The Vanguard Periodical: The Vanguard Method in People Centred Services. Ask for your FREE hard copy or PDF.

 

My first proper job

Richard Moir, Vanguard Consulting

My first ‘proper’ job was as an e-government programme manager for a local authority in 2004. The job felt an ideal fit for me as I was a certified practitioner in PRINCE2, a well-established project-management methodology, with a degree in electronic engineering and a penchant for technology. I also have a strong belief that technology can be hugely beneficial.

My role was to ensure that the authority achieved the outputs set out by the e-Government Unit (eGU). The eGU was part of Tony Blair’s Cabinet Office charged with securing the savings outlined in the 2004 Gershon Efficiency Review, and one of its chief targets was making 100% of council services accessible online.

It wasn’t long before concerns started to gnaw away at me. PRINCE2 is very clear that projects should be initiated on the back of a project mandate giving the project manager clear direction on what needs to be achieved and why. Very few of the projects had a mandate, and managers set to ‘benefit’ from a project were by no means certain if it was needed or why.

The real mandate for the project appeared to be meeting e-government conditions, along with the plausible but nebulous benefits of reducing operational costs and improving the service experienced by citizens.

As time went on, it became evident that many of the projects would not deliver the expected benefits. This was a common concern shared by e-government programme managers in other councils. I have yet to see a summary or reporting of the actual savings achieved nationally.

Enthusiasm from Whitehall

So why did national support for the programme continue? What did the architects of the programme believe would happen?

The eGU believed online services to be both more convenient for citizens and a cheaper transaction channel. The logical implication was to put all services online and ‘encourage’ citizens to use them.

Although I was not involved in the formative meetings of the e-government programme, I have observed discussions about digital transformation in financial-services companies, which are usually conducted on the basis of opinion and founded on assumptions that a) the current service offering works well and b) digital provision will enhance it.

In the e-government case, that led swiftly to the conviction that services should be ‘digital by default’.

The present government is equally enthusiastic about ‘digital by default’, its rhetoric is similar to that of Gershon, only now with more urgency and greater emphasis on financial pressures.

Thus in November 2015, the Autumn Statement and Spending Review declared that ‘a modern and reformed state is built on the understanding that higher spending does not automatically mean better services, and that by harnessing today’s technological advances, government can modernise public services, saving money and improving citizens’ interaction with the state’. To achieve this it announced a £1.8 billion ‘investment in digital transformation’ of government services.

Health Secretary Jeremy Hunt followed up a few months later by promising a £4.2 billion drive to bring the NHS into the digital age. A ‘paperless’ NHS, he said, would make services faster and more convenient, while the investment would also help the NHS save £22 billion by reducing waste and increasing productivity.

Dangerous enthusiasms

This is a dangerous enthusiasm. Over recent decades a spate of technology-based improvement initiatives has proved problematic for one or more of the following reasons:

  • Delivering unnecessary functionality
  • Not delivering necessary functionality
  • Generating need for follow-on projects
  • Exceeding budget
  • Missing delivery dates
  • Being cancelled before completion

 
These failings have not gone unnoticed by the digital and tech community. Much effort and innovation has been focused on how to become better at producing code, applications and devices. This enthusiasm for leveraging technology to deliver better outcomes for users is laudable. But it can only generate useful results when IT specialists work with those delivering services to first understand the problem from the perspective of the service user. After all, the role of code developers is not to develop code, but to overcome problems through the use of code; if they are not engaged on the right problem they will never produce the right code

The human consequences

The most prominent current example of digital transformation is the Department of Work and Pensions (DWP) Universal Credit. If ‘digital by default’ is not an explicit strapline, it is not far from the surface. As The Guardian reported:

The work and pensions secretary, Iain Duncan Smith, is refusing to set up a freephone number for the estimated eight million people who are set to claim the new universal credit over the next four years.

When challenged on this a junior welfare minister, Justin Tomlinson, stated in a written parliamentary answer that they expect claims to be made online, although the government’s universal credit website did also advertise the chargeable number for the helpline.

Regardless of whether calls should be chargeable or not, the need for a telephone help with online access makes an absurdity of digital by default.

The experience of a Universal Credit claimant predictably looks like this:

Universal Credit – the user experience

  1.  As an applicant for Universal Credit, you apply online (not easy for some) and receive on-screen confirmation that your application has been submitted. Weeks go by. After enquiries and complaints, your MP establishes that there is an intermittent error in receipt confirmation. Your claim has not reached the back office (and will not be back-dated to the time of the initial submission). ‘Please re-apply by telephone’.
  2. You apply by telephone. The agent takes you through the questions you answered in the online application. Three-quarters of the way through, the portal ‘falls over’. The agent assures you that ‘It does this a lot; the data won’t be lost, but I can’t see it or complete the application right now. I’ll phone you back – possibly tomorrow’.
  3. The agent calls back to complete the application. You make an appointment for a face-to-face interview to review your evidence and (with luck) get an estimate of the credit you will receive. You receive a letter confirming the interview time and the four items of supporting evidence that are required.
  4. You attend the interview, at which you are informed that the letters are wrong and a fifth piece of information will be needed before your claim can be progressed. This is inconvenient and expensive (so many people give up), but ‘Can I bring it in this afternoon?’ ‘No, you have to make an appointment. No, we can’t make appointments, you have to phone the contact centre’ – which is busy taking calls from people making applications.
  5. You go back to 3. Having supplied the necessary information, you experience the standard six-week wait, after which you chase up progress, to be assured that things are taking their course.
  6. A letter arrives to inform you that the application is missing some information. On calling the contact centre you are told, ‘Ah, the letters are wrong, it’s all OK’.
  7. You finally receive your Universal Credit, although the amount is not the same as what you were told and it is only backdated to a week after the date your telephone application was completed.

This is what the experience of a single adult with simple circumstances looks like – i.e. circumstances that the system should cope best with. It is unlikely to be the experience that the (then) work and pensions secretary envisioned and hard to reconcile with the idea of ‘digital by default’.

Human by default

The starting point for the effective deployment of technology should not be to decide what technology to use and then how to use it. Before any technology is even considered, it is necessary to analyse what happens when human beings put their hand up for a service. In other words, the approach should be not ‘digital’ but ‘human by default’. When human beings study demand, they learn what other human beings are asking for and why. They learn about the predictability and variety of demand.

They also learn that there is massive variation between people’s experiences of the service, even when they have similar needs. Some people find huge difficulties in getting a service, while others experience none. Some people get the service they need and want, others never get what they need at all.

All this may seem logical and obvious, but in my experience, it is rarely understood.

The traditional approach to understanding how the user interacts with a service is to gather a number of interested parties in a meeting room to map out on a process chart what should happen, rather than what actually does happen.

‘Human by default’ in social services

A typical Special Educational Needs Transport service, under pressure to reduce costs while continuing to fulfil statutory responsibilities, decided to take a radically different approach. Rather than jumping to a procurement exercise or buying off-the-shelf software costing hundreds of thousands of pounds, it studied its service.

They focused on the needs of the individual children and young people, providing them with more appropriate transport solutions and developing, where appropriate, their ability to travel independently. In the old system, no one helped the young people to travel independently, leaving many young adults institutionalised.  In the redesigned service, 60% of young people at secondary school age were identified as having the potential to travel independently.  Others reported an increase in self-esteem and feeling more involved in their community. In the first three years of the new design, the annual expenditure of £3m fell by half. In the years since, many more young people have been helped to learn to travel independently and as a result, the annual budget for this service has remained at £1.5m – all this without the benefit of new technology. Instead, the service changed the logic and assumptions that underpinned the design and management of the work.

As part of redesigning the new service, they discovered that employees needed access to data about service users, none of which was captured by existing software and applications.  So they commissioned bespoke software to enable them to call up the information whenever necessary. That is the rule: redesign comes first, IT development second, and then only if it is needed.

Technology is not to blame

Technology-based attempts to improve service and reduce costs often seem plausible and fit with the rhetoric of modernisation. Unfortunately, because it is so often used to solve the wrong problems in the wrong way, inevitable subsequent failure is typically blamed on technology. This is both inaccurate and unhelpful, resulting in years of multiple repetitions of the same error.

The straightforward antidote is a change in thinking from ‘digital by default’ to ‘human by default’. There is a huge amount of energy and enthusiasm in the digital community to leverage technology to provide useful outcomes for users. Starting with a position of ‘human by default’ ensures that this energy is used wisely.

Looking back on my days as an e-government programme manager, I realise my first proper job wasn’t as ‘proper’ as I first thought. It would have been a far more rewarding experience had our purpose been to ‘design services that work’ rather than ‘make services available online.’ I still have a penchant for technology and believe it has huge potential for good – but my starting point now is always to understand and improve the way the service works. Modernisation through technology will not in itself improve lives and reduce cost. Only human beings can do that.

So beware of naive and dangerous enthusiasms.

Richard Moir

Read similar articles in Edition Two of The Vanguard Periodical: The Vanguard Method in People Centred Services. Ask for your FREE hard copy or PDF.

 

 

Boldness pays off at Fareham

David Puttick, Vanguard Consulting

Boldness has genius, power, and magic in it

At our first meeting, the Chief Executive of Fareham Borough Council, in south-east Hampshire, told me: ‘I want to change the entire organisation to become much more customer focused. This is not about cost cutting. I want to change the culture of the whole organisation. Our customer surveys are showing 92% customer satisfaction, but I don’t believe them. The surveys have made us complacent’. Bold.

He knew he wanted to transform the organisation but wasn’t sure how. He was considering the Vanguard Method, but some of the senior management team, pointing to the high satisfaction score, were unconvinced.  At a three-day introductory Vanguard programme, which the entire 23-strong senior management team attended, they learned more. A major commitment. Bold.

The team gained a glimpse of what the customer experienced. For the first time, they saw what the front line was required to do and the hoops customers had to jump through. For the first time, they had genuine knowledge rather than information, always indirect and incomplete, fed through the hierarchy. There might be, they began to think, a better way.

Some of them got curious. Some got excited. Some went to the Chief Executive and said: ‘Please let me do this in my service’.

We knew that this would be a multi-year partnership and that because of the sums involved it would have to go through a procurement process. Ordinarily, this would take an inordinate amount of time and effort for both council and supplier; often the outcome would be the appointment of a supplier other than the one the organisation wanted. Fortunately, following research, Fareham was able to appoint Vanguard, in compliance with EU procurement rules, on grounds of the acknowledged uniqueness of the method. Bold, again.

When I started visiting the organisation in 2012 I was struck by the feeling that Fareham seemed a genuinely happy workplace. People were welcoming, open and positive. As I got to know the organisation I learned that people tended to stick around. Staff turnover was low.

We wanted to help a good organisation become even better.

What are we here for?

At the outset the Chief Executive decided that he wanted every senior manager involved in the change programme. Every intervention would be led by a head of service supported by a Vanguard guide. In general, intervention teams of managers and front-line staff worked full-time, with the heads co-leading at least three days a week.

A vital part of the role of heads was ensuring that those conducting ‘business as usual’ felt that they were part of the intervention – after all, they were making it possible, by taking on the load of intervention team members. It is not unusual for an ‘us and them’ mentality to create divisions if those taking care of business get the impression they are left out.

The initial task of the intervention teams was to make the current system visible and clear – to themselves first, and then to the rest of the organisation. The principle is: understand – before any thought of what and how to improve. They would find answers to a number of questions, including:

  • What are we here to do?
  • What does ‘good’ look like?
  • What do we actually do?
  • What are the consequences?
  • What are the causes?

 
In most organisations, both public and private, the question, ‘what are we here to do?’, is remarkably rarely asked – and if it is, it is invariably expressed in a narrow job context rather than from an end-to-end customer point of view. Without clarity on what the organisation exists to do, from the customer’s perspective – its purpose – work can easily drift away into wasteful, valueless activity resulting in poor customer service and unnecessary cost to the organisation.

Fareham was no exception. Take ‘statutory nuisance’, which is about dealing with people who cause problems for others – through noisy parties, loud music and barking dogs, for example.

In statutory nuisance, ‘best practice’, which Fareham dutifully followed, is to send out forms which complainants fill in and return as evidence. Follow-up would be diligently recorded in the IT system. The team quickly saw that the de facto purpose the department was working to was ‘gather information necessary to take people to court’. But how often did offenders get to court? Almost never. Meanwhile up to 70% of an officer’s time was taken up with feeding the IT.

The team quickly worked out that a better purpose for statutory nuisance was ‘helping neighbours to live together peacefully’. This was transformative. Instead of following a legalistic and prescriptive process that rarely helped and often antagonised the parties, officers now spend their time talking with both sides and encouraging them to have respectful conversations with each other. In one case, a neighbour offered to walk next door’s dog so that it could be kept inside rather than in the garden barking when the owner was at work.

In housing and council tax benefits, the team’s eyes were opened when they realised that the value steps (what good looks like) required to achieve the purpose of ‘paying claims that we’re entitled to’ were:

  • Understand the customer’s situation
  • Help the customer understand the information we need to process a claim
  • Get ‘clean’ information
  • Assess the claim
  • Notify and pay

 
In housing benefits, when the team made visible ‘what we do’, they could see that the work was fragmented – a world away from the value steps. Many different officers would work on one claim, with no one owning it end-to-end. Add to this the front-office/back-office split and the default of writing to customers if the claim was incomplete or incorrect and it was easy to see why the process took so long and customers were so frustrated.

The fragmentation of work and the associated activity backlogs meant that much management effort went into managing and prioritising activity rather than doing the value work. In the redesigned system, management and prioritisation of work virtually disappeared. Through experimentation, teams learned that assessors should take end-to-end charge of a customer claim on the principle that ‘if you start it, you finish it.’

Meeting face-to-face

In redesign experiments, teams get to see that the first value step in any flow is ‘understand’. Unfortunately, in many organisations the default mode of communicating with customers (and even internally), ie standard letter and email, has the opposite effect, creating confusion that leads to calls and letters saying on the contrary, ‘I don’t understand’. As team members discover, the best way to reach understanding is through face-to-face contact between the customer and an officer with the expertise and authority to resolve the issue. Failing face-to-face, the next best method is a telephone conversation.

At Fareham, the ‘understand’ work in each service started with a brief scoping exercise by the service head, after which a team of front-line staff and managers would come together to take the understanding to a more detailed level.

Sometimes, scoping alone created the understanding to enable direct action to take place.

In parking enforcement, it was instantly clear that a major issue for the service was the high proportion of challenges to parking charges. Of the 30% of parking tickets challenged, almost 60% were upheld, with the remainder flowing through to formal challenge and eventually tribunal.

Discussion with enforcement officers uncovered the implicit assumption that their purpose was to maximise the number of tickets issued. When this was understood, the head decided to make explicit the principles he wanted officers to work to:

  • You are best placed to decide what is reasonable
  • Use your best judgement

 
When this was put to the enforcement officers in a workshop, challenges to parking tickets fell by half. And they report that their job has now become much more about engaging and helping people rather than imposing fines.

I am reminded of a quote by Dee Hock, the founder of Visa:

‘Simple, clear purpose and principles give rise to complex and intelligent behaviour. Complex rules and procedures give rise to simple and stupid behaviour.’

Reaping the rewards

The transformation in customer service in every intervention at Fareham is clear for all to see. Front-line staff and managers know it viscerally. Customers are happy and appreciative, and staff delighted to know that they are providing a good service. Senior managers are happy because they see staff who are engaged and enthusiastic, and because capacity is released, which opens up choices about saving money or making further investment in customer service.

As an example in just one service, consider the improvements recorded in housing benefits:

  • Average end-to-end times for new claims reduced from 17.3 to 9.9 days (43%)
  • Average change-of-circumstance end-to-end times reduced from 9.8 to 3.6 days (63%)
  • Redetermination requests reduced from 6.9 / month to 1.5 / month (78%)
  • Appeals reduced from 0.7 / month to zero for the past 8 months (100%)
  • Average customer satisfaction score: 9.6 / 10

 
Capacity has been released in management and administrative areas as well as at the front line, the organisation moving from five directors and 17 heads to three directors and 12 heads.

As a result of this work, in March 2016 Fareham Borough Council received a national award from iESE, the Improvement and Efficiency Social Enterprise, for ‘Remodelling Local Services’. In iESE’s words:

‘As a part of the relentless drive to make efficiencies in local services we are all looking for new ways to deliver services. The winners of this category demonstrate this drive to redesign how we deliver services to meet the needs of our residents and businesses’.

Fareham’s ‘Putting the Customer First’ submission was one of three selected for an award from a field of more than 200.|

A final thought

The committed approach shown at Fareham left no one in doubt about the Chief Executive’s determination to change the organisation from top to bottom, creating an inevitability in the minds of everyone involved. The consistent support of senior members (councillors) was vital to the success of the programme too. When we began work in a new service area, we were greeted by people who were enthusiastic and open at all levels of the service. Not everyone, not every time – but with great regularity.

A year into the programme, when the cost savings began to feed through, the Chief Executive and Executive Leader of the council decided to invest the annual savings achieved – about £370,000 at that stage – in the staff. So everyone, except the Chief Executive, received a 6% pay rise from January 2015. Bold indeed! And different.

David Puttick

Read similar articles in Edition Two of The Vanguard Periodical: The Vanguard Method in People Centred Services. Ask for your FREE hard copy or PDF.

Integrated service: does it pass the milk test?

Fiona Catcher, Vanguard Consulting

It’s become a bit of a litmus test for me. Asked what integration meant to her, an occupational therapist told me wryly, ‘Now we get to keep our milk in the same fridge!’ Ever since, I’ve made a point of checking the fridge of integrated teams or services I’m spending time with. She’s right. More often than not I’ll see milk labelled  ‘OT’, ‘Physio’, ‘Social’, ‘Nurses’ – indicative that the system continues to be constrained by professional roles and boundaries and that well-intentioned efforts to integrate result in little more than co-location in practice.

Integration of health and social care is a key priority of the government’s public-services reform agenda. It is heralded as the solution to the problems that the current unjoined-up system provides for citizens and the way to achieve greater efficiency and financial savings. Significant funding has been made available through the Better Care Fund to incentivise agencies to work together to transform care through integration approaches.

The advantages are often expressed in terms of better coordination and navigation, improved communication and information, better outcomes, more patient / person centric, more joined-up, more efficient. The list of proposed benefits is long and compelling. Given the current unsatisfactory state of affairs, who wouldn’t want these things?

The first half of this article describes what happens when you start with the question ‘How can we join up services to get better outcomes?’ In the second half of the article, we look at what happens when we ask a different question, ‘how can we do better things?’ I end by making the case for a radically new and different approach to care with profound implications for citizens, staff and budgets.

Complicated, confusing and frustrating

Everyone agrees the current health and care system is complicated and fragmented. For citizens, the journey through it can be disjointed, confusing and frustrating. It often fails to recognise real need. When demand is studied from the citizen’s perspective, 85% of those who present at a health ‘front door’ are found to have additional social or psychological needs. Yet the system is geared to respond only to the presenting (singular) need, not to understand its contextual (compound) nature.

Health services are separated from social care, adult care from children’s care, and mental health from physical health. In the cause of greater efficiency and productivity, each separate part is further functionalised and specialised – so that even professionals have difficulty navigating the system.

When it receives a demand, each department or service focuses on ‘is this for us?’, and if it is, ‘we’ll do our bit and pass it on’. Needs are identified by formal assessment. To address other needs, the citizen is referred on to another department, at which point the cycle starts all over again, amplifying system-wide duplication and waste. In one town, the 280,000 demands received by eight agencies over a year were 60,000 more than the local population.

While people are cycled around the assessment and referral system – often over years – they become less stable and more dependent on services. They continue to present to multiple ‘front doors’, fuelling the perception that demand is rising. But this is an optical illusion. Analysing demand reveals that typically 80% of demands into health and care services are failure demands (demand caused by failure to do something or to do something right for the citizen).

Criteria and thresholds are key mechanisms for rationing access to services and prioritising those in need, driven by the belief that this will control demand and protect budgets. From understanding the cost, waste, and predictable impact on people of this vicious circle, we learn that it has the opposite effect.integration - catcher - image 1Staff are the system’s most valuable resource. Yet when flow of work is studied, we discover that this resource is mostly used on work that is of no value to the citizen – dealing with failure demand, and the rework and duplication of assessing and referring. In other words, it is waste. In one health and care system 90% of work carried out was found to be waste, consuming 75% of staff capacity.

Integration – starting with the wrong question

In the face of these issues, integration seems a compelling answer.

But in the sense in which it is usually applied, integration simply amounts to doing today’s things better. Asking ‘how do we join things up?’ is to start with the wrong question. It does nothing to challenge the logics of the design and management of the current system. Crucially, it misses the opportunity to pose the anterior question of what’s needed and then to draw up an integrated design to make it happen.

Let’s look at the design of the integrated health and care service our occupational therapist (remember the milk?) worked in. Previously, occupational therapy, physiotherapy, community nursing and social care each had its separate teams, managers and ‘front doors’ (referral desks); performance measures, too. These teams were brought together, with an integrated referral desk, under an integrated manager. The social-care IT system was modified to allow all specialisms to record into the same system.

But from a citizen’s perspective, how much had changed?

Arguably, the single ‘front door’ was an improvement. But as soon as a referral was taken it was allocated to a separate list for each specialism, each with its own professional lead to ensure that professional standards and values weren’t lost in the new set-up. Leads would manage allocation into their profession and performance against the appropriate measures, most carried forward from the previous regime. As a consequence, priorities and perspectives continued to be largely dominated by profession. If a home visit revealed needs outside the professional remit of the visiting team member, they were referred on using the appropriate referral form. The new IT system meant that information was better co-ordinated and easier to find – but since most of the improvements were process-related, in practice the new system was no better able to understand what mattered to citizens and therefore how to solve their problems than before.

Evaluation of many integration approaches, including national pilots, confirm that most improvements are process-related. Tellingly, the assumption that they lead to better actual care is not evidently shared by those on the receiving end.

Most integrated services continue to operate as one of many ‘referral doors’ to the system, with pre-integration thresholds and criteria still in place. The cycle of referring (failure) demand from one professional to the next continues unabated. In a recently integrated primary-care team professionals daily screen referrals from 34 different sources to decide which are ‘for us’ and which can be referred back or on to someone else. Demand pressures mean that even those deemed ‘for us’ are further prioritised according to perceived urgency. The most urgent cases are referred to a rapid-response team that struggles to cope. Others are assigned to professional leads according to medical need and arbitrary response times for assessment. Integration has had no impact on levels of demand.

This is not surprising. The approach used does not seek to understand the drivers of service consumption. Many integration initiatives are aimed at those with complex conditions, judged most at risk of unplanned hospitalisation, assuming that they are the heaviest users. But the episodic and transactional relationship the system has with citizens, together with reliance on ‘system-shaped’ rather than ‘person-shaped’ data, means that others who repeatedly present to services, bouncing between GPs, social care and in and out of hospital, are simply not visible as high consumers to the system. Integration approaches, targeted at specific cohorts and / or for those who have reached specific threshold levels, design out the opportunity to help some of those who most need it.

Integration is not enough. Unless there is also a shift from managing illness and eligibility for services to problem-solving in the context of people’s lives, it will not meet the challenges facing today’s public services. Meeting this challenge means starting in a different place and doing better things, not today’s things better.

Beyond integration: starting in a different place

When citizens present to a health or care ‘front door’, they are asking for help to solve a problem or problems that have pushed their life out of balance. Understanding what’s needed to rebalance a life requires a radically different approach to care – a move away from providing services and towards problem-solving with citizens and communities.

Designing against demand means fully understanding what a citizen wants and designing a system capable of absorbing variation in demand. Designing roles to understand demand and to help citizens solve problems means dissolving boundaries between traditional professional roles, not just blurring them.integration - catcher - image 2What does the value work in a ‘help me to live my life’ system look like?integration - catcher - image 3Creating value for the citizen starts by taking the time necessary to properly understand them, their aspirations and assets in the context of their lives.

When citizen demand is understood from this perspective, a surprising truth emerges. The problems most affecting their lives and most driving their consumption of services are not directly connected to health or care. For example:

  • A man suffering from diabetes and alcohol issues presented to A&E seven times over 63 days following falls. He was admitted five times, spending 44 days in hospital was assessed 32 times and had 13 lab tests. No one thought to see where he lived or asked him how he wanted to live. When a team did, they understood that his real problem was living conditions in a hostel. With help to move out and establish routines for looking after himself, he no longer needed services.
  • An 86-year-old man who lived alone after the death of his wife was resigned to a future of meals-on-wheels, twice-daily care visits and regular nursing support. He was lonely. What mattered to him was to feel useful and connected with people. He was helped to do this and now supports himself and others around him in the community, without any service inputs.

 
Understanding and rebalancing a person can take several iterations. Often working out and solving the most urgent problem is critical to building the trust necessary for an individual to share their issues or even recognise them for the first time. Sometimes this is enough to create the space for the person to resolve their other issues. Establishing relationships and continuity means that if a person is subsequently pushed off kilter, it is easier, quicker – and cheaper – to help them get their lives back on track.

Doing the right thing

The implications for roles in this way of working are profound. Staff no longer lead with their profession – they are part of a seamless problem-solving team. Understanding is a core competency. If a problem lies outside an individual’s skill set, instead of referring the case on or reaching for a service, they pull the expertise required to solve the problem.

The demands of learning, or relearning, how to give someone ‘a right good listening to’ should not be underestimated. Repeatedly following prescribed assessment processes has effectively deskilled many staff, and they need support in regaining confidence to initiate and build good conversations. As they relearn, staff quickly discover that with good understanding and problem-solving, the need for assessment by default goes away.

Staff no longer spend most of their time doing work of no value to the citizen. Thresholds and criteria have been abandoned. Instead, working purposefully to new principles, they are liberated to help people who need it in a way in which has ironically returned them to their professional values. Most would not contemplate a return to the previous way of working. Citizens who have felt its impact are astonished by the comparison with the past.

And the overall result? Demand and cost fall.

Those working in this way typically report reductions in whole system cost per citizen of around 50% with consequential reductions in social care and GP contacts, non elective admissions to hospital, and where admission is required, reduced length of stay.

In one pilot area, the impact of redesigning services around the citizen has reduced activity costs for those citizens to the local authority and NHS by 42% and 67.8% respectively, saving an average of £15,000 per citizen per annum. Demand for public services in the area fell by 12.8%.

Applying this way of thinking to a Youth Protection Service achieved regional savings of £22.9m and halved the number of families under the care of the service from 8,000 (20,000 children) to 4,000.

The outcomes of doing better things? A re-invigorated workforce, satisfied citizens able to get on with the real job of living their lives with less or no need for services, and effective public services costing less.

Curious about how far along your service is on its integration journey? You could do worse than to start by taking a look inside the fridge.

Fiona Catcher

Read similar articles in Edition Two of The Vanguard Periodical: The Vanguard Method in People Centred Services. Ask for your FREE hard copy or PDF.

Making history, one life at a time

By Simon Pickthall, Vanguard Consulting

Five years ago in a small conference room in a South Wales hospital, 12 people made history – although, as is often the case, they did not realise it at the time.

In April 2016, the Social Care and Wellbeing (Wales) Act enshrined in law the principle of understanding ‘what matters to citizens’. This may not sound important. But it completely transforms the practice of social care in Wales.

It would be too much to say that the link between the two events was direct. But the meeting that day triggered a winding journey that began with discovery of a radically different method of working that forever altered their view of what social care could be. The Vanguard Method has at its core the need to understand ‘what matters’ in the lives of people who receive services. Part of it requires those delivering the service to ask those receiving it how it matches what matters to them. When the group posed the question to those receiving social care, they found it was far different from what they were getting.

What they wanted was simple – a system that listened to them rather than pass them from one professional to another. They wanted help with things that were important to them, not standard packages of services picked off the shelf of the social care supermarket.

The things that people felt important in their lives were simple, too: meaningful and loving relationships; a sense of contributing to society, rather than being a burden and feeling in control of their own decisions. These responses brought some to tears. Those in need of social care wanted the same things we all do.

For the 12, comparing what their system delivered against what mattered to citizens receiving them was a shock. The system gave them all the impersonal processing they didn’t want and none of the basic human requirements that they did. It dawned on them that, with the best of intentions, they had created a system that removed people’s choice, made them dependent on statutory services and drove impersonal services into their homes. Studying the system revealed that repeat demand was very high – the services handed out were not treating the root causes of why people needed help. Counterproductively, when money was short, the threshold for receiving even this help was raised, so that when people finally qualified for care, their condition had deteriorated and their cases were correspondingly more complex and difficult to treat.

Legislation got in the way

This powerful experience – the real force of the Vanguard Method – had a profound and lasting effect on the 12. Determined not to let the status quo endure, they led the redesign of their system explicitly to deliver what mattered to people in their local communities. But they kept hitting against the obstacle of current social care legislation. The legislation forced practice to be ‘deficit-based’ – focusing on people’s needs and weaknesses, rather than building on their strengths. In addition, the services people received were what had been commissioned by commissioners, not what mattered to them.

At this point the leaders could have accepted the legislation as it stood, doing their best to work around the current constraints. Embracing their ambition, however, they resolved to bring ministers and civil servants into the work to experience what they had seen themselves. Step by step their work, and that of others pursuing a similar journey, led to the fundamental change in thinking around how social care and health should be delivered that we see today: legislation that makes delivering social care and health according to ‘what matters’ a legal responsibility. Transforming thinking to tackle and then alter legislation, the ultimate system condition – this is a staggering achievement.

The right thing to do?

As these responses show, there is no doubting what people receiving services think about the new approach:

  • ‘The last social worker used to come once and then we’d never see them again. It’s lovely to know you have somebody to contact’
  • ‘In 20 years, you’re the first ones who’ve really listened to me’
  • ‘It’s been helpful and efficient. We feel happier that we’ve seen the same faces throughout. You may not think you have done a lot, but you’ve really supported us’
  • ‘He’s talking to me for the first time in years’ (a carer talking about her husband)
  • ‘We would have been in a terrible state without you. I’m sure my husband would still be in hospital now’
  • ‘If I had not known about this service, I would have admitted this person into hospital’ (GP)


The effective thing to do?

But is it an effective use of resources? Through focusing ruthlessly on what matters to citizens, public-sector organisations in Wales have:

  • More than halved the percentage of referrals leading to statutory funded packages of care, from 24.1% to 10.9%
  • Reduced residential and nursing care placements by 28%
  • Cut average domiciliary care packages from 12 hours to 9.7 hours a week
  • Reduced contacts into social services by 48%
  • Underspent community care budget for three consecutive years
  • Reduced the number of assessments by 30%, and re-referrals from 46% to 10%

 
In other words, focusing on what matters is not only inexpensive: it provides better outcomes for less resource. Not just more but better for less – who could be against it?

How to do it

Here is not the place to go into detail about how to do it. But by now you get the picture. You study the system. You ask those whom you exist to serve ‘what matters’ to them; how they would like to live their lives? Compare their answers with what your system currently delivers. What would have to be true for you to be able to deliver the desired outcomes?

The answer is both less and more than you think. Consider the group meeting in the South Wales hospital. It took a long weekend to challenge all their previous assumptions about social care in practice. It took six days to understand what their system was delivering from the perspective of citizens and build a plan to transform it. It took five years to make so much difference to people’s lives that legislation was changed to institutionalise a different way of thinking and working. To change history. So where to start? Try 12 people in a room.

Simon Pickthall

Read similar articles in Edition Two of The Vanguard Periodical: The Vanguard Method in People Centred Services. Ask for your FREE hard copy or PDF.

The work is not the problem

Jeremy Cox, Vanguard Consulting

Managers think their job is to manage change. Real leaders know that the real task involves changing the way we manage our organisations. Two systems, one organisation

There are two systems to act on to bring about change in organisations. The first, ‘the system of work’, is the way everyday work is carried out: how customers access services and the way work processes operate to fulfil customer demands. For example, this could be mortgage processing in a bank, supporting vulnerable adults in a social care service or responding to emergency incidents in the case of fire or ambulance services.

There is usually significant scope for improvement here, and when staff and managers work together to redesign the system of work using the Vanguard Method, organisations achieve improvements way beyond anything that would be expected from a conventionally managed organisation: lending and claims decisions made in minutes, housing repairs and benefits applications done in a day, vulnerable lives turned around, demand turned off in healthcare, – all at lower cost and with higher staff morale.

But there is another system, deeper and often invisible, which is ‘the system of management’. It is made up of the assumptions and thinking behind everyday management decision-making, and manifests itself in the organisational infrastructure that brings these assumptions to life. Its components are ‘hardwired’ processes for how staff are rewarded, how performance is monitored or how services are commissioned, and there are governing assumptions behind these processes too: what do we believe about what motivates people? How should measures be used? How do we set and monitor performance against budgetary goals?

Making the distinction between process change (which managers always say they want) and management system change (which they usually haven’t thought about) allows for a profound insight –throwing new and sharp light on where and how to take action, and creates a giant step towards becoming a more effective leader. The opportunity is this: managers think their job is to manage process change, real leaders know that their job is to change management.

Think about the annual business-planning process in your organisation and draw it out on paper. The process is based on traditional command-and-control assumptions that separate decision-making from work and assume organisations are best designed as top-down, functional hierarchies. In a typical organisation, the picture will show an annual cycle with a ‘golden thread’ linking corporate strategy to business-unit plans and targets, and then down to individual performance objectives. There will be scheduled reports and meetings to feed ‘management information’ back up the food chain. There will be rating and reward systems for staff, with associated form-filling, appraisal meetings, and HR staff to co-ordinate them.

If you stand back from the picture, what you will see is the outline of the system of management, and how that governs the system of work. The diagram below is a simple yet powerful model of how the two systems work together.

Figure 1. A simple conceptual model of the two systems

Just as there is significant opportunity to drive improvement through redesign of the system of work, the system of management is ripe for recasting too. In a large financial services organisation, we saw business change and IT projects where we found that 80 per cent of the change budget was spent on management overhead and only 20 per cent on designing, testing and implementing changes to core flows. The change that this system delivered was, in the client’s words, typically ‘late, expensive and wrong’. We often refer to the ‘management factory’, a place where meetings happen, reports are discussed and budgets are tracked against plans. These are elements that in themselves create no value for customers and rarely contribute positively to the core work.

The problem is not the managers, it is the system of management

A key opportunity to improve is sadly hidden to most managers because like the water a fish swims in, the system of management is invisible to them. Managers typically change the system of work in an attempt to improve performance, for example by encouraging channel shifting or automation of processes. But changing the system of work will not yield sustainable performance improvements if the management system that governs it remains flawed.

Many organisations remain wedded to the idea of targets. Unfortunately, we know that the use of targets in a hierarchical system only engages peoples’ ingenuity in managing the numbers rather than improving their methods. People’s attention turns to being seen to meet the targets – fulfilling the bureaucratic requirements of reporting that which they have become ‘accountable’ for – at the expense of achieving the organisation’s purpose. In simple terms, all this effort constitutes and causes waste – inefficiency, poor service and, worst of all, low morale.

The notion of a target is plausible. In principle, there is nothing wrong with individuals having targets that they may set themselves – lose weight, run further, get another job, earn more money. But targets in a hierarchical system are imposed with authority by people who are generally detached from the work being carried out. Targets are therefore arbitrary. They may suit a plan, but they do not start from a knowledge of capability – what the system predictably achieves and why.

When targets produce unintended consequences, as they always do, managers react to the symptoms by doing more (adding targets) or less (subtracting targets, de-coupling incentives from targets) of the wrong thing. But doing the ‘wrong thing righter’ is not the same as doing the right thing. Unfortunately, leaders who grasp the damage wrought on their organisation’s performance by targets are forced to confront a dilemma because doing something different at the level of work requires de-constructing the system of management that creates and underpins the target regime. Arriving at this insight is by no means guaranteed – it is impossible for most managers (and government ministers) to imagine an alternative because of the degree to which targets have become embedded in our collective mindset.

The financial services sector has had its own well-documented problems with targets and incentives leading to dysfunctional – and indeed illegal – behaviour. Systemic mis-selling ranging from private pensions and endowments to PPI has led to multi-billion pound compensation pay-outs and huge reputational damage. The solutions from companies and regulators alike have been consistently to bear down more stringently on the system in which people work through regulation, control of bonus payments and by encouraging team-based rather than individual rewards. A fundamental re-think would require both the acceptance of the counterintuitive truth that it is inherent in targets to cause sub-optimisation and the active dismantling of the organisational infrastructure that creates, sustains and enforces the target regime. I recently met a manager whose organisation used targets and incentives to drive sales of PPI compensation claims to people who had been mis-sold PPI by banks using targets and incentives to manage their sales operations. If you worked in that system every day, do you think you would get the irony of your situation?

Three key issues with the system of management

A flawed system of management causes many problems.

First, it damages everyday performance of the core work. Consider the following examples:

  • Top-down performance management causes systemic sub-optimisation and demotivation, as ‘what do I do to get the sale (and meet my target)’ invariably wins over ‘what is the right thing for me to do for the customer?’
  • Supplier relationships based on contractual specifications or Service Level Agreements (SLAs) drive processes that are aligned to contract requirements rather than customer needs,. This has the effect of worsening service and increasing costs (for example ‘variations’ in IT or facilities contracts used to generate revenue).
  • The productivity focus of operations often has the paradoxical effect of reducing efficiency. In a telecoms company’s repairs operation, managers paid attention to productivity data in the belief that higher fault closure numbers would equate to a higher level of performance for their customers. When examined over time, it was clearly demonstrated that this behaviour was in fact driving up demand: it was discovered that faults were being reported to be closed on the system without actually being fully completed. Customers were thus re-entering the system and becoming increasingly irate that their problems remained unresolved.

 
Each of these issues has underlying structural ‘system of management’ roots. Improvement requires that the underlying management structures are re-designed in parallel with process (system of work) redesign – the two must be treated as indivisible if permanent improvement is to be achieved.

Second, the way managers change or ‘improve’ the ‘system of work’ damages performance tomorrow:

  • An experiment with redesigning insurance sales demonstrated that sales could be increased with a 1:14 return on investment. Investment was impossible, however, since annual planning, budgeting and bonus systems demanded operating expense reductions, not investment, and could not be challenged.
  • Frontline work in financial services and other organisations is frequently offshored/outsourced to reduce operational cost. Redesign of work from the perspective of customer value predictably results in improved service at lower cost, with work being repatriated. The top-down drive to offshore persists, however, since an unreformed system of management continues to mandate counterproductive cost-driven change initiatives.

 
The counterintuitive takeaway from these examples is not that we need to do change better, but that we need to change the way that we approach change. Instead of separating decision-making from work, managers must learn to both study ‘how the work really works’ and then lead improvement activity in situ, with emergent change based on knowledge.

The third problem lies in the cost of a misfiring management factory. Organisations routinely waste vast amounts of money on management capacity devoted to doing the wrong thing. One client discovered that much HR resource was being consumed by programmes that contributed no value to the service delivered to customers. Through redesign focused on only doing value work, it reduced the strain on HR capacity by 50 per cent. Outcomes of this order are not unusual, but are only achievable by changing the system of management.

The intervention challenge

To act on the system of management, leaders need to study the impact of the system of management on both customers and the system of work that delivers service to customers.

Our examples illustrate that the ‘system of management’ is hardwired through organisational processes for planning, objective-setting, performance monitoring, managing change and the like. Those physical processes and system conditions are themselves a product of ingrained management thinking, and to change this is to engage people in discovering counterintuitive truths. The intervention challenge is thus not two- but threefold: to help leaders learn how to redesign the ‘system of management’ in parallel with redesign in the ‘system of work’, and to gain the counterintuitive insights that reframe their underlying assumptions about the design and management of work.

The hardest of the three is the last – opening leaders up to the ‘eureka moments’ that in turn trigger a rethink and redesign of the two systems that govern the way that all of the organisation’s work operates. It’s all very well to tell colleagues that all they need to start the process is to be willing to change the way they think. In itself, this is a perfectly correct analysis of the situation, but it is not very useful as an approach to intervening to get people to change. The first golden rule of intervention is that if the an issue is likely yield counterintuitive conclusions, the starting point is without exception what the Japanese call ‘Genchi Genbutsu ‘: going to see for yourself, figuring out what is going on in the system of work and therefore what is causing it in the organisation’s system of management. The second golden rule is to resist the temptation to explain your revelation to others and insist that they too must go and see things for themselves. Only when they have discovered for themselves the connection between change in the system of work and change in the system of management can the tantalising potential for transformational organisational improvement begin to be realised

Read similar articles in Edition One of The Vanguard Periodical: The Vanguard Method in Financial Services. Ask for your FREE hard copy or PDF.