- On health and horsemeat
- Ask a legal
- Politicians move in
- It’s the system, stupid
- Horsemeat is the same
- How markets drive costs up in care
- Politician = instant expert (just add power)
- Sorry is too late
- A bright spark
On health and horsemeat
The health and horsemeat scandals hit the news at about the same time last month. I put a note out to journalists offering an article on how the two have similar features to a systems thinker. The response was ‘we’re not interested in health, but can you write something about horsemeat?’
No one died from eating horsemeat; almost 1200 people died in Mid Staffs. But horsemeat, apparently, is a story that has legs, if you’ll excuse the pun.
Robert Francis’s 1,782 page report into the Mid Staffs tragedy is a mass of detail. Hugely disturbing detail, you can’t fail to be moved by the evidence. But Francis, perhaps because he has a legal mind, doesn’t get behind the facts; he doesn’t question assumptions, he doesn’t even open the door to matters of theory.
As a consequence his recommendations represent what we would call single-loop thinking. The NHS is subject to massive amounts of regulation, but Francis recommends more, wrong thing righter. He recommends a ‘zero tolerance’ approach to breaches of fundamental standards but doesn’t question why the system as currently managed, might produce such neglect. He calls for a culture that puts patients first, but doesn’t consider why the current system fails in this regard.
If it is true that we have reached a level of dystopia that requires us to articulate a ‘structure of clearly understood fundamental standards’ – his top recommendation – we should despair. He thinks inspection for compliance will drive sufficient fear amongst healthcare professionals, yet he points to the fear culture that is already pervasive and dysfunctional. He argues for openness and transparency but fails to understand that the current use of gagging clauses (which he says should be banned) and shocking treatment of treatment of whistle-blowers is, too, symptomatic of the culture of fear. He does nothing to explain the reasons we have a culture of fear.
Francis thinks the answer is training, failing to appreciate how the current system drives peoples’ behaviour. He thinks that better leadership will instil a better culture, without understanding what currently drives leaders’ behaviour. Like Ed Balls did with social care, he recommends the creation of a leadership college, as though we can train that too. He thinks better information and benchmarking will act as a stimulus to improvement, showing no understanding of how benchmarking will lead to mediocrity, not innovation. It is perhaps ironic that the Francis recommendations on health improvement treat the symptoms, not the causes.
When Francis gets close to the causes: acknowledging a form-filling, target- and cost-driven culture, he fails to question them. He cannot see that form-filling bears no relation to and will detract from quality, he doesn’t know what targets do to systems and why, he wouldn’t believe that a focus on costs is driving costs up. Francis has a legal mind. He gave us the facts. You should read his report; you will be moved.
The minister for health, Jeremy Hunt, takes up the Francis theme on excessive box-ticking, bureaucracy and burdensome regulation by announcing a talking-shop whose purpose is to reduce the regulatory burden by a third. I can hear Deming in my head: ‘why a third? Is it the right third? Why is it not two thirds? What benefit ensues against the cost of compliance? The best we can expect is less of the wrong thing; that’s still the wrong thing.
The right way to have gone would have been to order all leaders in the NHS to review their box-ticking and form-filling to ask: what of any of this is important to us in understanding and improving healthcare? And thus NHS leaders would make their own decisions about changing the nature of control and, as a necessary and urgent consequence, the nature of regulation.
The minister says we need a culture that puts the patient first, not knowing how the current system obviates any attempt to do that and announced a review of complaints procedures. You couldn’t make it up really; it is as though he read the Beano guide to management.
The prime minister, David Cameron, strides in with announcements about handing the Francis report to the police in order to find people to blame, giving performance-related-pay to nurses, sacking the bad ‘uns and making nurses fill in forms to prove they have spoken to every patient every hour. Clueless, wrong and damaging.
In short, while the minister promises to remove the dead hand of micro-management from crushing people, the hand is, in fact, warming up for BOHICA (bend over, here it comes again).
Closing one of his presentations with a literary flourish, the minister said: ‘Let me finish with words from TS Eliot we should not forget, when he said, ‘It is impossible to design a system so perfect that no one needs to be good.’
I’m no literary expert, but when I read Eliot’s ‘Choruses from the Rock’, I experience a man regretting society’s alienation from God; in the NHS, alienation from a worthy purpose:
‘What have we to do but stand with empty hands and palms turned upwards in an age which advances progressively backwards?’
Eliot (writing in 1934) describes how man is facing a tremendous flood of meaninglessness because context has been removed. Man has created an artificial world based on the new gods of reason, money and power. This is what has happened in health, the minister and his predecessors are responsible for a system that worships false gods.
I went to be a ‘witness’ on the Moral Maze (Radio 4) to try my best to make this point. We have a choice: to run our organisations in ways that encourage bad behavior, or in ways that encourage good; behaviour is a product of the system. I say ‘try’ because, for those of you who don’t know, the Moral Maze is something of a bear-pit. Ex minister Michael Portillo was my ‘opponent’ – an intelligent man who, nevertheless, thinks a bit of fear is a good thing. Having roughed me up he was at least decent enough to acknowledge my arguments in the summing up.
You can ‘listen again’ here: http://www.bbc.co.uk/programmes/b01r0yt8
Like health, the horsemeat scandal occurred because the means of regulatory control are form-filling and cost-management. In my article I argued that it is a system problem and the key failure was with manufacturers and retailers failing to work in the right way with their supply chains. I argued that better methods in the supply chains would lead to lower-cost production and better quality control.
Simon Caulkin passed me a link that proves my point. Research shows that UK pig farming has declined and we now import pork from the Netherlands and Denmark, where wages are much higher than ours. How do they do it? Better management of the supply chain; in short, cooperation. Similarly, Morrison’s, the supermarket, drives cost down and quality up by taking a ‘vertical’ approach to their supply chain. Both are examples of pull systems, producing at the rate of consumption, optimization drives costs out. QED.
And what is the government’s response? To leave it to the market; regulators and ministers think competition should rule. More horsemeat all round while our economy goes down the pan. What is the purpose of government?
You can read the research here: http://goo.gl/4QLWk
You can read my article here: http://www.guardian.co.uk/commentisfree/2013/feb/13/horsemeat-scandal-japanese-car-manufacturer-lesson
I have written about the perils of commissioning in health and social care here before. The same arguments have been published in Public Service Europe:
I have always beefed about the way politicians, who know nothing whatsoever about the management of service organisations, drop into a space I know a lot about and do stupid things. David Mellor, an ex minister, talked about this problem on Radio 4:
‘I think the lack of capability of so many people who get cabinet jobs in British politics today – i.e. they not only don’t know anything about the subject when they get there, but they find it difficult to ascend their learning curve – makes me think we are testing to destruction the theory that … a prominent politician can master any brief.’
And aside from the need to know about whatever it is they are responsible for, the way they will approach it will be based in unsound economic theory.
When Winston Churchill was prime minister he had time to build walls and lakes in ministerial homes. He didn’t have thousands of bright young things dreaming up ideas in his Cabinet Office; he wouldn’t have spent his time on the digger mastering briefs. When did we go wrong?
While ministers consider it a sign of weakness to say they got it wrong – much like private-sector managers I meet who have spent a fortune on ‘lean’ only to discover they got no benefit (in their case they say ‘lean was a step on the journey’ – ha) – the architect of ‘personal budgets’ a major plank of wrong-headed policy in social care, owned up to getting it wrong. You can read more here:
Do you suppose minsters will act to undo the madness and waste of funds?
A police officer who, against all the natural resistance, employed systems principles to transform policing has written a book to share his experience. You can get a taste for his style and know-how in his blogs, here is one I like a lot (on targets):
His book will be out soon. If you can’t wait for a notice here, put an order in with Triarchy Press.