Category: News

By Denise Lyon

WANTED! Managers who are curious, resilient – and willing to challenge their own thinking first

If you look at the job description of senior managers in any public sector organisation, you will find a long list of requirements – pages of necessary skills and knowledge, which applicants will have to prove and evidence to get the job. From managing staff to monitoring a project, from assessing risk to staying within budget, the list goes on and on.

Then there’s attitude and aptitude. Is it followability, intelligence and tenacity that are top of the list? Or is it integrity, common sense and a dash of derring-do?  Maybe it’s all of these and a few more. The more you think about it, the longer the list becomes.

What do we know about good leadership?

So can we make this a simpler proposition?

When organisations take their first steps in rethinking their approach to the design and management of services, we help them get clear on the kind of leaders they will need to navigate through the change. What is it in leaders that will allow a fundamental shift in organisational thinking and perspective to take place? What sort of person will be able to:

• Challenge their own thinking with a willing heart
• Put in the hard work to change it
• When the going gets tough, keep their eye on the prize – much better service, much lower cost?

 
Here’s what we know.

Open-minded and curious

In the words of the great Frank Zappa, ‘A mind is like a parachute. It doesn’t work if it isn’t open.’ This is absolutely key when it comes to choosing leaders. People recruited to senior posts are not necessarily selected for this trait, and it is important to establish quickly who has it and who is stubbornly focused on defending territory and status quo. The latter will not make a good leader of change, nor indeed in good leader in the new world afterwards.

Truly curious people, if you have them, will make excellent leaders of the system.  A ‘follow-me-and-do-what-I-say’ leadership model is unhelpful and potentially destructive because it concentrates responsibility in one person and absolves others from taking initiative and ownership of problems. Someone who works with people to genuinely understand the issues getting in the way of great service and then resolve them is the kind of leader required.

Strong and resilient

The yin and the yang of transforming a service means there will be highs and lows to contend with. Studying a service as a system uncovers truths about customer experiences that are sometimes uncomfortable and hard for managers to accept. Letting go of long-held management beliefs (‘Targets are good, aren’t they?’ ‘No, they are not, and we will help you understand why!’), takes a robust personality who is willing and able to get over the shocks and move on. As Katharina Haase, Chief Operating Officer at Barclaycard Germany said at the Leaders Summit in March 2016:

You need to change a lot of stuff, be brave about it.

Confronting the waste and inefficiencies a leader has unwittingly introduced into their service design is probably not going to make for their best ever day.

The upside, though, is the joy of ‘getting it’: understanding how to design more efficiently to meet and manage demand, a Eureka moment that will have the convert (and their customers) grinning from ear to ear.

They will also ‘get’ what to measure in order to gauge to what extent the organisation is meeting its purpose, as defined from the customers’ point of view. Owen Buckwell, Head of Housing and Property Services at Portsmouth City Council explains:

It makes your organisation thermostatic. In other words it routinely changes according to how your customers’ demands change.

Good measures help to pinpoint where to focus improvement efforts and quantify their impact when you do. Leaders also learn to ask good questions as Karime Hassan, Chief Executive and Growth Executive of Exeter City Council says:

It’s far more focused and disciplined so that the questions I ask of my managers and the questions I ask of the staff are far more pointed.

Hands on and a bit bossy

Senior people are used to delegating. They need to be good at it to stay sane and keep on top of a demanding job. But here’s the rub. The only way to change a mindset is to experience something personally. Think of it this way: it is no more possible to delegate understanding your service as a system than to delegate learning how to swim. In practice, this means that a leader must stop doing something else in order to free up the necessary time, so a conversation about re-prioritising the work is an important early step. It is essential to get in the pool. Or in the world of service, in the work. Not to do the work, but to study what’s happening in the work, using the Vanguard Method.

Albert Einstein hit the nail on the head when he said, ‘We cannot hope to solve the problems we have created with the thinking that created them’.  Before making any sustainable transformative steps, leaders need to get hands on and understand how their current thinking led to the current service design and delivery.

The brain makes a transformative leap, as Richard Hiscocks, Casualty Claims Director at Aviva UK, found:

Once you realise you’ve been wrong about everything it’s really hard to go back.

Once they do get it, there will be much to do to completely redesign how the service is delivered. This is where it helps to be assured and assertive – even, dare we say it, a little bit bossy. Redesigning to meet demand may entail major actions such as renegotiating contracts, introducing new roles and agreeing different corporate priorities. A well-informed and assertive leader on the case is essential.

So maybe we can make those job descriptions even simpler.

Vacant:

An uncomfortable but rewarding job

Wanted:

An open-minded, resilient, hands-on leader who is willing to challenge their own thinking.

 

 

 

By Jo Gibson and Brendan O’Donovan

Although providers of public services would mostly proclaim a primary commitment to their service users, the unfortunate truth is that a study of the system from the citizen’s point of view reveals a very different reality. Despite best efforts from dedicated public sector workers and well-meaning leaders, getting a service can often resemble an obstacle race or negotiating a maze.

The maze is a system problem, not a people problem. Many public sector systems have evolved a warped view of their purpose in response to external and internal pressures. As a result of these pressures, organisations often lose sight of what happens to the citizen on the receiving end.  Much to everyone’s frustration; service users, staff and leaders alike, organisations become focused around the needs of the regulator, the commissioner or central government.

Whether the service is life insurance, road maintenance or domiciliary care, we should always start from a deep understanding of what matters to the individual receiving the service. It involves taking a person-shaped rather than an organisation-shaped view of the citizen’s needs, or in Vanguard terms working from the ‘outside-in’. There is thus no better illustration of the principle in action than in what we’ve broadly termed ‘people centred services’ (i.e. public or third sector services such as health and social care, housing, benefits and policing). Importantly, viewing these systems in this way allows us to identify and eventually remove what we call ‘system conditions’.

Why system conditions matter

System conditions are the things that explain why a system behaves in the way it does. They form the framework within which those delivering any service have to operate. They are important for three reasons:

• They shape performance, positively or negatively
• Sustainably improving a process is rarely possible without changing the system conditions that frame it
• As manifestations of flawed management thinking, system conditions point to the strongest lever for change in the system – altering the way people think about the design and management of work

 
Some system conditions are present in any service: for example, the use of measures. What is measured and how, will dictate how a system will work (‘what gets measured gets managed’). Often measures are imposed as arbitrary targets. A classic is the four-hour wait time target in hospital accident and emergency (A&E) departments. The intent of the measure is to help manage perceived high demand for urgent medical treatment. In fact, it leads to people either cheating the figures or cheating the system: for instance, holding patients on trolleys in corridors or in ambulances having first seen a triage nurse and thus officially falling within the four-hour target. This is a great example of what is termed a single-loop solution to a complex problem. Of course, ‘doing things better’ is a classic single-loop solution to a complex problem. A double-loop solution would be ‘doing better things’, in this case working to understand the true nature of demand and then design a system capable of reliably managing it. As those who have studied A&E demand know, most (up to 80%) is demand that shouldn’t be there in the first place and only presents there because other parts of the end-to-end system are not working as they should.

We have clients who, having understood the true nature and frequency of demand, have been able to redesign the whole system to remove much of the repeat and inappropriate demand altogether. This has the effect of releasing system capacity to focus on getting it right first time for the individual. Improving individual resilience leads to correspondingly reduced demand and resource pressure on the service.

Organisational roles and structures are another ever-present system condition. In most people centred services, the system is structured so that an individual’s life is split into segments, each handled by a different professional specialist. In a simple adult social care system this involves many contacts, with the citizen required to tell their story at each one. In one case, an individual was obliged to repeat their history more than 200 times in two years. This is not exceptional; indeed it is ‘designed- in’ in current systems, governed as they are by a perceived imperative to manage cost by embedding costly professional expertise deep in the system where its use by the patient or service user can be strictly rationed. Reaching these professionals means undergoing repeated assessment and referral – often ending with treatment refused on the grounds that ‘your condition is not serious enough … (yet)’.

The alternative is a service structured around the whole individual citizen, with a focus on understanding and responding to their life priorities. Some leaders are reshaping services to remove splits between functions, sometimes even barriers between organisations. To enable this real integration, the purpose of the service is redefined to relate directly to what matters to the citizen and helps them to lead the life they want. New operating principles ensure that they only have to tell their story once and a single individual is assigned to work with them throughout.

Substantial change depends on ‘a vital few’

There are many other system conditions, including performance management and incentive and reward schemes, reporting requirements (to ‘feed the machine’), demands of IT, standard policies and procedures, the commissioning process, and regulation and inspection. Yet in any one case substantial change normally depends only on ‘a vital few’. A common one is decision-making remote from the work and abstracted from the end-user’s context. A good example in people centred services is the Department of Health’s Continuing Healthcare (CHC) funding process for people who need ongoing personalised health and care to ensure either a good quality of life or in some cases a good quality end of life.

Under the current system, to get funding requires two 124-page assessments to be carried out, one by a nurse and another by a social worker. A panel then sits every 6-8 weeks to decide. In one health service studied, out of an annual total of 400 cases only 10 were refused on initial presentation; eventually, after much delay, all the cases were agreed and funded. Predictably, the information received by the panel is incomplete and has to be chased up. The governing CHC framework makes it clear that funding decisions should be wholly based on need and not on funding and budget. If that is the case, why have a decision-making process disconnected from the work? From studying the current system, it is clear that, in reality, money is the biggest driver, and the logic behind the design is the need to control spending to meet the budget. Not only is the design an utter waste of time and resource, it removes decision-making from those with knowledge and understanding in the work.

One health and social care system decided to remove this system condition. Instead it is experimenting with the revolutionary idea of letting the workers make the decisions, freeing up time spent on paperwork actually to meet the individual face-to-face and jointly work out what good care for them should look like. The key worker for the case is responsible for understanding the individual’s complete end-to-end story and, with support from an integrated team, for taking informed joint decisions with the individual as to proportionate support. No longer are decisions about care taken by a group of people disconnected from the work and with no knowledge of the individual circumstances. The worker is trusted to do the right thing based on understanding, continuity and trust.

Another system condition responsible for much failure of service to meet people’s real needs (and often make them worse rather than better) is standardisation of response. In current people centred services response to demand is prescriptive and based on pre-set standards. In adult social care this manifests itself in a prescribed assessment of need carried out by a social worker, with standard questions which may or may not have relevance to the person and their needs. On that basis the social worker decides what support, if any, will be forthcoming, in the shape of a care package consisting of up to four calls a day, their timings determined by staff workloads, travel distance and time, rather than what matters to the individual. One consequence is that people who, with the right kind of support, could perfectly well live independently become dependent on the calls. In other words, the care package is over-specified. Or the care package fails to meet the underlying need and breaks down, eventually resulting in hospitalisation. Analysis of hospital demand reveals that this under-specification scenario is played out with depressing regularity.

In some redesigned services, starting from a different set of principles, the organisation delves into the need behind the demand by taking time to conduct a ‘what matters’ conversation. Once a bond of trust and understanding is established, the task is to help the individual help themselves, by identifying with them their strengths and capacities, along with those of their family and community networks. We call this ‘designing against demand’. In people centred services, the value work consists of listening to and understanding a patient/service user’s needs as the only way of understanding real demand and planning an appropriate and effective response.

Removing system conditions: a lever for change

Although it is vital to understand system conditions, we don’t recommend that you start there. We believe system conditions are best understood as the causes of waste. Their importance emerges from the process of studying performance – you learn what prevents and enables services to be truly person-centred. Understanding the biggest causes of waste leads you to the ‘vital few’ that offer the greatest leverage for change.

Identifying and removing, or at least containing, the constraints imposed by system conditions is essential to developing a more effective service. It allows the service to be redesigned around the individual citizen, and enables the organisation to devote its energies and time to understanding and responding to what really matters to them.

Joanne Gibson
Brendan O’Donovan

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.

 

 

 

 

John Little

You may have been one of the many viewers who, like me, watched the Channel 4 series last year, ‘How to Get a Council House’. I watched it because I have an interest in social housing. When it was on air, I received texts from colleagues saying how awful it made social housing look. I replied that it made dismal viewing on so many levels.

It portrayed scenes of desperate people seeking help, bidding again and again for properties, sometimes over many years. We watched people being treated like numbers in a lottery by an uncaring system: shocking to anyone with an ounce of compassion. It seemed that the council employees were as much victims of Choice Based Lettings (CBL) as the housing applicants.

For those who don’t know (lucky you), CBL is a costly and ineffective means of bidding for a social dwelling owned by a housing association or a local authority. It involves applicants having access to an IT system to make a bid. It costs local authorities and housing associations exorbitant amounts of money to maintain service and respond to these IT systems. Many applicants find the bidding process complicated and the computer application unfathomable.

One housing organisation I know spends £1.8 million a year just to service the fallout from the CBL computer system. The fallout includes the time spent by housing officers answering calls to explain why bidders have not been successful and accompanying groups of applicants to viewings, many of whom turn the property down when they see its physical condition.

During the last decade social housing landlords were bullied by the Department of Communities and Local Government (DCLG) to adopt CBL schemes as ‘best practice’. It’s the corruption of a successful Dutch idea that was put forward by ‘bright young things’ in Whitehall to give their minister the word ‘choice’ to sell. Choice was, and is, the Whitehall fad du jour.

As the TV series showed, the senior leadership of housing organisations had little idea of the negative financial and operational impact of acquiescing to DCLG’s bullying and adopting this scandalously wasteful approach. Some do now – sadly, too late.

Senior leaders facing draconian funding cuts realise their organisations can no longer afford these awful schemes. Discussions are under way in many housing organisations to quietly drop them. DCLG knows CBL is a failure.

The real tragedy is that applicants for social housing – ordinary decent people – are treated as an inconvenience because there are too many bidders for too few properties. ’They have no real choice; they choose what we give them,’ to quote one of the senior officers interviewed by Channel 4.

The delusion applicants are fed is that they have a chance of getting a property when, because of their circumstances, many have no hope of being housed in the social housing sector. It is not unusual for there to be 12,000 people on a housing waiting list which will accommodate around 500 families a year. How unfair is that? The housing supply is simply not there.

Shame on you, DCLG.

Senior leaders in social housing organisations cannot shrug off responsibility. The ‘Nuremberg defence’– saying they didn’t understand the impacts, or if they did, lacked the moral courage to tell the emperor he had no clothes – won’t wash. One senior housing manager told me, ‘It would have been bad for one’s career to have done so’.

Still: no senior person in DCLG or housing association will be looking to apply to live in social housing. So why should they worry?

John Little

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.

 

 

Much as I enjoy Ella Fitzgerald’s 1939 recording of ‘T’ain’t What You Do (It’s The Way That You Do It)’, reinvigorated by The Fun Boy Three with Banarama in 1982, it’s not entirely right. Ella probably wasn’t singing about this, but in terms of running service organisations, it absolutely is about both what and how. What service organisations are here to do (their purpose) is inextricably linked with how they do it (what matters) – they are two sides of the same coin. If we want to build thriving communities with people living good lives, and when the time comes dying good deaths, then first we need to understand the ‘what and how’ from the perspective of citizens/patients/customers (from now on referred to as people).

T’aint what you do

So how do organisations typically go about understanding their ‘what and how’ from the people’s perspective? There are three common approaches:

The ‘It’s-always-been-like-this’ or ‘There-is-no-alternative’ approach

One approach is that they don’t go about trying to understand people at all. Instead they do what they (or usually their regulators, politicians, shareholders, other stakeholders) want, however they want to do it. Their actions are often well-intentioned but disappointingly ineffective from the perspective of the people.

The ‘Words-speak-louder-than-actions’ approach

Another approach is to say they listen to the people, and sometimes make expensive attempts to do so, but ultimately they actually carry on as they always have.

The ‘Design-against-demand-and-what-matters’ approach

This approach is all about listening to what people are really saying about what they fundamentally need and how they need it, and then doing just that.

Which approach is likely to be the most effective, in the sense of maximising the satisfaction of people and staff while simultaneously lowering costs? Hint: it’s the third. If you’re not convinced, spend an hour or two listening to the people wherever they interact with your organisation and consider a) how often they interact because of something the system has failed to do, or failed to do properly, for them; b) the steps involved in dealing with that interaction; c) the cost of those interactions and steps.

It’s the way that you do it

I’m assuming that the first two approaches are familiar. As in, ‘Of course we listen to people, our poster says we do, as does the recorded message we play before people can talk to us, and the online surveys we ask people to complete, and the complaints team we’ve put in place, and the people engagement groups we run. Oh, and we’ve got a CRM system’. Engaging with people has never been such big business. And yet this is where Ella is right, it is the way that you do it that gets results. Some typically misconceived ways to do it:

• Regarding engagement as an end-in-itself. We’ve engaged; the box has been ticked. It’s the organisational equivalent of a student asking their teacher ‘Will this be in the exam?’ Rather, engaging is a means to an end, the end being understanding what people fundamentally need from us and how they need it, and then actually doing it.
• The methods used to engage do not enable us to understand the ‘what and how’ from the people’s perspective. For example:

• • They ask leading and/or closed questions. In effect, what they say is, ‘Tell us about what matters to us (not what matters to you), in a way that’s easy for us to report on’.
  • They believe (maybe) that ‘people engagement groups’ (a handful of people who can spare the time, sitting around a table once in a while, sharing their opinions) are a legitimate means of informing organisations about what people (all people) need.
• Confusing effectiveness with efficiency (see also article on p XX). For example, ‘The more people we can (be seen to) engage with, the better. IT will help us do that more quickly, easily and cheaply. Let’s use Twitter to ask people what they think’. This is to mistake quantity of response for quality of understanding and thereby getting neither. Social media is just as much about building relationships as old-fashioned face-to-face methods. Without those relationships (how many of us have a meaningful online relationship with an organisation about our lives, let alone one we are prepared to share publicly?), you may as well be shouting into an empty room. The ceaseless march towards digitalisation, driven by the flawed assumption that it’s more efficient (ie cheaper), has blinded us to the reality of its limitations.
• Misrepresenting and/or misinterpreting what people say (see points above) and using it to maintain the status quo and impose service-led solutions. If you don’t really listen, or choose not to, you don’t really hear. A less amusing version of The Two Ronnies’ ‘Four Candles’ comes to mind.
• Even the most effective understanding is meaningless if nothing (good) is done with it. Using understanding to design and manage your system is the logical, but often missing, next step.

 
That’s what gets results

So, if perfunctory and ineffective understanding of purpose and what matters leads to sub-optimal performance, what’s the alternative? How do we optimise performance to build thriving communities and resourceful individuals? Where do we start? By going to the places in our organisations where people interact with us and listening to what they say. In their words, write them down, don’t précis them. Do it until you don’t hear anything new. Identify the themes and use them to shape your purpose and understanding of what matters. It should tell you everything you need to know but, if more detail is needed, ask people directly what matters to them using non-leading, open questions. Have a dialogue, the old-fashioned way. We humans are quite good at that.

The beauty of doing this is that it’s right there, in the work, freely available, part of the day job, not a bolt-on exercise undertaken at great expense. It’s full-strength, real-time, comprehensive knowledge. Just like sitting by a fire, there’s no substitute for proximity. You can’t sit in another room and ask someone else to sit in front of the fire for you, and expect to feel the benefits. Understanding serves two purposes, both of which enable informed choices about what action to take next. First, it provides valid data. Second, it affords you the opportunity to unlearn old, dysfunctional assumptions and beliefs about the design and management of work, and learn about new, optimal thinking. That’s not something that can be delegated.

Real understanding is the prerequisite to taking action using better (optimal) principles. That’s what gets results.

Resource

http://beyondcommandandcontrol.com/thinking-things/

Emma Ashton

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.

 

Jeremy Cox, Vanguard Consulting

Public-sector organisations across the spectrum are faced with the apparently conflicting challenge of making efficiency savings while simultaneously delivering on a vision of building safer, healthier and more economically resilient communities. I want to deliver an optimistic but counterintuitive message: to improve efficiency, the last thing a leader should do is to focus on efficiency. Understanding this paradox is the first step to delivering great public services at the lowest possible cost.

The efficiency paradox

For managers at all levels, this goes completely against the grain. Surely it is the manager’s role to maximise the productivity of their unit or organisation? Yet when we study past efficiency-boosting attempts, we find that, notwithstanding the good intentions, they routinely have the opposite effect. Thus:

• Call-handling has been centralised into a single point of contact, yet rising caseloads in the back office prevent costs from coming down
• To protect expensive professional resource (planners, benefits assessors, social workers, clinical staff…) the process is functionalised and screening and admin tasks allocated to lower-grade staff; but constant backlogs mean there is little overall benefit
• Managers in the highways department put pressure on repair crews to do more jobs per day, so how come the number of defects in the road network keeps rising and only the high priority jobs get done?

 
Why is the direct focus on efficiency counterproductive? Because efficiency is an effect, a by-product, not a cause. When we learn to see efficiency as an emergent effect of doing the right things right, rather than an objective to be achieved directly, the way forward becomes clear.

Neurology – from efficiency to effectiveness

The neurology department of an acute hospital had been trying for years to reduce length of stay for stroke patients – an effort straight out of the efficiency paradigm. Using the Vanguard Method, the department shifted its focus to purpose (swift recovery) and the smooth flow of value work (diagnosis, treatment and rehabilitation) through the end-to-end hospital system.

The shift in leadership thinking from efficiency (‘reduce costs by reducing length of stay’) to purpose and value led to dramatically reduced mortality rates, fewer admissions to non-specialist wards, freed-up bed capacity, and improved staff morale. And guess what happened to the problem they were trying and failing to solve in the first place? Length of stay shrank, turning a ‘loss’ per patient for the hospital into a surplus.

Cameron was in the efficiency trap

By contrast, here is David Cameron in a speech in September 2015:

…Businesses are always looking at ways to streamline their functions so they can become more effective. I would argue it’s an imperative – a moral imperative – for government to do the same. When money is tight, it’s simply unforgivable to waste taxpayers’ money.

But then he walked straight into the efficiency trap:

…Take our emergency services. Right now we have a situation where in most towns, the police, fire and ambulance services all have different premises, back offices, IT policies and systems, and procurement policies – despite all their work being closely related… Places like Hampshire have shown the way forward, where the emergency services have brought functions together to save millions of pounds a year. We need to see that sort of thinking in other places.

Nothing in the ‘shared services’ approach is about understanding or improving the system’s ability to do useful work or achieve purpose related to citizens. Sharing services is a crude attempt to gain efficiency through scale, under the mistaken assumption that all demand coming into the service and all the work done in response to it is of value. In fact these systems are full of failure demand (non-useful work), and their failure to deliver improved service is well documented.

I worked with a local authority which redeployed half of its HR capacity after designing for value in much the same way as the stroke service, completely transforming the service. If you knew you could drive efficiency from effectiveness in this way, would you try to make it more efficient by sharing?

Turning it around

Consider the knotty issue of how to deal with individuals and families who present repeatedly with demands that aren’t serious enough to be treated urgently. In studies across police, local authorities and healthcare, 40% of overall demand typically comes from people with a combination of issues (depression, alcohol, debt, housing, childcare, domestic violence) but who are consistently screened out, referred on or only given symptomatic help because they are ‘below threshold’ or ‘not our responsibility’.

For example, a family may have been referred by police to a domestic violence team but can’t get mental-health support until alcohol problems are dealt with; meanwhile school is applying pressure over class attendance, Job Centre+ has sanctioned benefits after a no-show, and the social landlord is pursuing arrears. Each agency attempts to make itself efficient by focusing rigorously on its own remit, but because the family situation is never addressed in the round, the demand just keeps coming.

The overall effect is that this ‘below-threshold’ group amplifies demand and cost across all agencies. Between half and three-quarters deteriorate over time, eventually triggering the need for ‘high-end’ services. Thus the efficiency focus costs everyone more in the long run, and it is no surprise that total demand into health and social care services is growing.

To turn this around requires a shift in focus from organisational efficiency to effectiveness from the citizen’s perspective. For the organisation, new assumptions for the design and management of work are key. Leaders have to set up and protect multi-agency intervention teams able to meet the various needs of ‘below-threshold’ individuals and families in their own context, and realign budgets, boundaries commissioning and governance accordingly. Where they do this, demand and costs fall, health and wellbeing improve, staff see greater value in their work and communities benefit.

It can be done – so do it

Ultimately this is an optimistic story, for two reasons. First, to make the difference we don’t need to replace all the managers or outsource services to the private sector. Everywhere I go I find dedicated, hard-working managers trying earnestly to build safer, more resilient communities and help individuals live better lives, who are hamstrung by conventional organisational thinking about efficiency and trapped in roles that require them to attend to the wrong things.

Second, designing and managing work from a different perspective is something that can be learned. The shift from managing efficiency to leading for effectiveness is what Vanguard is all about. Thus, a client in adult social care eliminated a persistent backlog and reduced the volume of wasteful casework in the system by 50% overnight by making just this shift, helping staff to redesign the work to focus on value, and constantly testing and learning using measures of what matters to service users.

In short, there is a way out of the efficiency paradox. When we learn to see that doing things right always makes things cheaper, and trying to improve efficiency always costs more, we deploy new methods for the design and management of work. So where will you start tomorrow?

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.

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.Individual 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.