Pass the patient

The president of the Royal College of Surgeons lamented the fragmentation of the health service having a detrimental effect on the doctor-patient relationship and, thus healthcare. For, as people are finding out when they have reason to get help from the NHS, the doctor is no longer looking after you as you go through the system; instead your doctor is just one of many transactions you will experience. No one is concerned with your relationship with the system, it being managed by computers. So if you want good help from the NHS you’d better be ready to manage the relationship yourself.

See: http://news.bbc.co.uk/go/em/fr/-/1/hi/health/7839235.stm

Transactions as ‘efficiency’

It is the same with all public services. The ‘efficiency’ agenda treats all service work as ‘transactions’. Thus they think call centres are good for ‘telephone’ work (not realising the telephone work should be thought of as a service or part of a service). They think ‘back offices’ should be used to process ‘tasks’, not realising that many extra ‘tasks’ get created by thinking this way. And they turn poor service delivery people into ciphers, ‘I process benefits claims’.

Whereas if the work is designed from the point of view of helping customers (i.e. designed against demand) the design brings peoples’ brains to work, they enjoy what they do, its far cheaper and citizens appreciate the service and develop respect for their local authorities, housing organisations and so on. We will be building lots of evidence of how well this works and guidance on how to design against demand in our new public-sector web site (see later).

Standard times: ‘should take’ vs ‘does take’

The obsession with transaction management began in the private sector. Typically customer demand is split into a series of tasks, each having a standard time. In some organisations the standard time is called the ‘should take’ time. But when you study the work (in ‘check’) you find a huge difference between what it ‘does take’ and the ‘should take’ times: it ‘does take’ a long time from the customers’ point of view (the true end-to-end time) and while you may find the ‘should take’ times are being met, the fragmentation of the work and the focus on standard
times creates more work (more ‘tasks’ in this way of thinking). It is a peculiar form of demand amplification.

Also, when you are working in re-design, you focus on designing against customer demand(s), learning how to do only the value work (no fragmentation etc). The result is a massive fall in ‘does-take’ time and a big improvement in customer service. ‘Does take’ is profoundly more useful than ‘should take’.

Failure demand is a systemic phenomenon

On top of the results achieved through designing against demand, you don’t get the failure demand created by the front/back-office standardised designs. Because the public-sector ‘reform’ regime fails to appreciate the systemic nature of failure demand (it is caused by the targets, among other things, they impose on public services) I wrote a paper explaining all. It is an incredible irony that the regime should set targets for reducing failure demand.

You can get the paper at: https://www.01handshake01.com/v1_lib.php?current=674

Audit Commission gets it wrong

A reader writes:

‘I thought that you would be interested in this area for improvement suggested by the Audit Commission in their latest report on [my council]: ‘The Council should take steps to increase the availability of information about service standards so that all members of the public are aware of the standards they can expect to receive.”

As the reader knows, setting standards makes performance worse; it is in the nature of an arbitrary measure. Far better to use actual measures, related to the purpose of the service from the citizen’s point of view and ensure they are in the hands of the workers along with method(s) on how to act for improvement. But doing the right thing will mean you will get bullied by your inspector – just doing his job.

Will CAA be the Achilles heel?

We are now at the dawn of CAA, the new inspection regime. The Audit Commission behaves like the worst of managers – change things with such frequency that you never get found out. Best Value, Star Ratings, CPA and all the other associated regulations have not delivered, but the Audit Commission narrative is each did its job and was needed for the presenting circumstances; all rationalisation.

The Audit Commission announces CAA with a plethora of meaningless blather. ‘Partnership working’ ‘sharp learning curve’ ‘flexible’ ‘not a one-size-fits-all’and councils should be ‘more resourceful, innovative and determined’ in a world where ‘less will have to be more’.

When I talk to people at the sharp end, their ‘sharp learning curve’ has been how little confidence they have that anyone really knows what they are doing. They still feel the pain of the overly-bureaucratic CPA regime and as CAA arrives they doubt that ‘light touch’ will mean anything, that anyone can be confident about what ‘risk-triggered’ inspection means, they worry about being held to account for services for which they have no responsibility, they worry about the (stilltoo many) various inspectorates agreeing on what to inspect and what to mandate them to do, and they fear that CAA will mean more inspection, not less.

Many of these people have been engaged in the ‘consultation’ process. Imagine the scene. You are sitting in a room with people from the Audit Commission trying to work out what CAA will mean in practice. Everyone has ideas/issues/thoughts and so on, and the Audit Commission people join in, for they too are in the dark.But as things go along you start to realise that even though the consultation exercise did not come to sound conclusions, the people from the Audit Commission will be making their own decisions about how to inspect. Is that the way to do it? We’ll take the ideas we liked best?

And while all this is going on we get a report of the ‘trials’ of CCA in 10 local authorities, which concluded it was too early to say if inspection burdens will be reduced. So, we learn nothing from the trials but we go ahead anyway.

CAA has stumbled big-time into Deming’s trap: operational definitions. Will it be the Audit Commission’s Achilles heel? I hope so, for all our sakes.