By Toby Rubbra, Vanguard Consulting
For the citizen, public services are becoming ever more fragmented and hard to navigate. It takes longer for people to get what they want, and more often than not they have to chase or query. The operational result is long end-to-end times, high levels of repeat or failure demand, increasing amounts of waste, and work amplification as one demand is split into many separate activities through referrals. The leadership response is increasingly to devise ‘new’ operating models: a ‘systemic approach’, ‘cross-cutting teams’, ‘co-location’, ‘devolution’ and ‘integration’ are part of today’s service lexicon. The intent is laudable: but as so often the operational reality – driven by budgets based on costs and targets – is about doing things differently rather than different things. Too often the result is doing ‘the wrong thing righter’, as the underlying thinking, which still reflects Adam Smith’s thinking of 250 years ago, remains unchanged.
The Vanguard Method enables leaders to move from this mass-production-orientated, command-and-control mode of thinking to a systems design. A key aspect is grappling with a customer-defined view of the purpose(s) the work is supposed to achieve. Establishing clarity of purpose is a deceptively simple notion that has profound implications for what the service is there to achieve, how success is measured and how work is configured and managed to deliver it.
It all starts with purpose
All too often change and improvement initiatives focus on activity and process, on the assumption that these offer the greatest opportunity for reducing cost. Success is cutting demand coming into a functional area and/or reducing unit costs. The likely outcome of redesigning a process using the same assumptions as before, however, is that it will worsen the citizen-centred measures and wider system economics. Outcomes and costs need to be understood across the whole system, not in functional unit-cost terms.
Alternatively, if the system is driven by measures, a de facto purpose of ‘hit the numbers’ will rule. This leads to methods of working that sub-optimise the system and thus also achievement of its purpose for citizens. Take the government’s hospital waiting standards: 62 days for a cancer appointment, four hours to be seen in A&E, eight minutes for an ambulance to respond. The thinking behind these arbitrary numbers – that people should be seen in a reasonable time – seems sensible. What is not sensible is the unintended (but predictable) consequence: the number is hit, but at the expense of the system’s ability to fulfil its purpose. To meet the eight-minute target a paramedic is dispatched in a car to attend an accident… and then calls in an ambulance to transfer the patient to hospital, a process which escapes the measures, as does the prior wait outside the hospital while A&E refuses to admit more patients for fear of breaching the wait time. The focus is on managing appointments (because this will make best use of resources), not on diagnosis upon presentation (turn up and be seen).Either way, establishing the hierarchical link between purpose and measures is paramount in orientating change and improvement (to method) in the right direction.
What we are here to do
Clarity of purpose having been established as the starting point, it is vital to define it in the right way. Purpose statements should define ‘what we are here to do’, and thereby the operational scope of the system from the customer or citizen’s standpoint. It is important that purpose is genuinely defined by customer, not function; and that presenting demand is distinguished from real need. Let’s explore these issues in more detail.
As noted earlier, increasing functionalisation has resulted in a proliferation of doors into or between parts of the system, behind which an ‘expert’ carries out the ‘specialist’ activity named on the door, which effectively has become the sub-system’s purpose. To fit the door, citizens are obliged to convert their complex real need into a simple ‘presenting’ demand that the system can recognise and deliver against. The system responds accordingly, referring on or pushing back to the citizen that which doesn’t fit through the door. In this way citizens are conditioned to view issues that affect their lives as disconnected activities to be treated as such.
Consider a customer who applies to the planning service for permission to build an extension. From the customer’s standpoint the purpose of the system is ‘say yes to good development’. The purpose is static, being the same for all customers (and stakeholders). Compare this with an application for housing benefit. Taking the demand at face value, purpose could be ‘pay the right people the right money’. However, a more searching question – ‘what is the underlying problem to solve for this citizen?’ – may pinpoint more than one desired outcome. In this case purpose is dynamic, variable according to what is learned about the customer’s real, often compound, need.
In this case, while paying the right money is still necessary, the deeper problem and purpose is to help the citizen back into employment (thus removing the need to claim benefit in the first place). The second purpose widens the scope of the system to encompass other organisations that collectively have a role in providing for the wider need. As such, purpose is driven by the needs of the citizen, not those of the service/and may be singular and static or variable, compound and dynamic.
Clearly, if purpose is only about ‘giving people the right money’, improvements won’t tackle the underlying issue of getting them back into work. There are different ways of articulating compound purposes, but a helpful approach is to design the system to address both immediate and more profound and strategic needs at the same time. Aligning partners to common purposeful systems is key to delivering service across several separate organisations that individually have a ‘fix’-type purpose (‘pay me the money’) but collectively are answerable to a compound ‘get-me-back-on-track’ purpose.
Understanding real need
Reaping the benefits of a truly systemic design depends on first understanding real need and second; effectively carrying out the value work to meet the compound purpose. Creating a system that ‘understands’ the citizen at the first point of contact presents some immediate challenges. Since the functionalised front doors guarding the current system work against holistic understanding, there is a capability-building issue that may in the short-term require the blending of roles, tasks and skills. Simply co-locating existing roles does not lead to the development of new ones best suited to carry out the value work.
Crucially, real understanding requires knowledge of the citizen in their personal context. Take the example an elderly woman in hospital after a fall. Based on her medical condition, it would seem sensible to put in place plans for care and therapy after her return home, thus helping to ensure the shortest possible hospital stay. But there is an invisible but fundamental assumption here that her real needs can be understood in a hospital setting, outside her normal context. What are the chances of getting it right? What are the implications of getting it wrong?
What matters to her (and the hospital) is that she is returned to her normal environment not only quickly but also as sustainably as possible. But that may be only partly a medical issue. In her context, sustainability might be a walk-in shower instead of a bath, better lighting, or greater support from neighbours and friends. So the thinking needs to move to, ‘What is the value work?’ and, ‘Where do we need to do this?’ Answer: in the context of her normal environment.
Learning depends on the right measures
A system that is redesigned to cope with dynamic purposes will only be sustainable if it is underpinned by measures that support those purposes. This is particularly important in designing successful partnerships. Staff and leaders need to work to both operational measures relating to the person’s immediate ‘fix-me’ need and their capability to respond, and to those that foster collective responsibility for the wider ‘get me back on track’. Simply building a better hand-off will not create a system that learns, improves and takes collective responsibility for outcomes. Building a data picture of the citizen and his or her need(s) not only informs these design decisions – it also makes it easier to understand the economics of partner organisations dealing with the ‘fix-me’ and/or the collective ‘get-me-back-on-track’ need. Citizen need drives the ‘pooling’ of budgets as opposed to pooling budgets and then trying to understand whose resource is doing what. This is a challenge to the current system, where there is plenty of volume and internalised activity data (‘we set up or did X’), but very little on real need and capability of response.
In conclusion, defining the purpose of a service system from a functional perspective – or even based on customer’s presenting demand – will end up with just doing the wrong thing righter. As Peter Drucker put it, ‘There is nothing so useless as doing efficiently that which shouldn’t be done at all.’ The key to giving better service at lower cost is designing systems that absorb the variety of citizen need; a system that responds to the singular and the compound nature of need. As such, the purpose of the system is determined from an understanding of the citizen, and the operational purpose and scope needs to adapt accordingly. This requires abandoning the rigidity of highly functionalised and professionalised teams following audited process and procedures. Simply working around these issues by co-location or integration will not deliver. Changing the system, on the other hand, offers a significant prize.
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.