Hunt promises culture change

Jeremy Hunt, secretary of state for health, promises a ‘change in culture’ following the Mid-Staffs report (last newsletter), but everything he is doing will only serve to maintain a culture of fear in the NHS. Perhaps, like Michael Portillo, with whom I had a brush on Radio 4’s Moral Maze, Hunt thinks a bit of fear is a good thing.

Despite the many examples of ‘star ratings’ being invalid, and senior people in regulators breaking ranks to say they have no confidence in inspection, Hunt has announced an NHS league table. Despite the palpable failure of regulation, Hunt proposes more. Most incredibly, Hunt has announced that NHS personnel will be held criminally liable if they ‘fiddle the figures’. If we put every public-sector-figure-fiddler in jail we’d have a major crisis, for there would be hundreds of thousands of them. It’s just one of the things Hunt doesn’t get: if you manage by attention to output, people cheat. End of.

Wrongly believing that neglecting patients is a training problem, Hunt has announced that nurses will spend an extra year’s training in providing basic care. It didn’t take BBC reporters more than a moment to find nurses who want to tell Hunt that they already get plenty of training in basic care; just the thing to motivate nurses.

And his promise that underperforming hospitals will be put into administration is merely icing on Hunt’s fear cake. The only good news in his basket of wrong-thing-righter proposals is the idea that department of health personnel will spend time on the front line. My only worry is they won’t know what questions to ask or where and how to look to understand the considerable scope for improvement.

Culture is a consequence of the system, and Mr Hunt propounds a system of fear. No change there then.

It’s the system, stupid!

If Hunt were a client we might help him see the relationship between the systems and culture by studying a different system. A good example is on our new web site – a telecommunications sales example.

You can watch the video here: https://www.vanguard-method.com/v1_lib.php?current=748

Through studying the system they learned how adherence to central directives drove poor-quality service and higher costs. Meeting targets only served to create failure demand, aside from its impact on morale. By instead designing the service against demand, performance and morale have been improved, massively.

In any system top-down targets, incentives and inspection will only serve to increase fear while driving in massive amounts of sub-optimisation. Control versus purpose, where the work is done, liberates people and drives improvement through innovation.

The consequences of a top-down fear culture in telecommunications are merely unhappy customers and higher costs; whereas the consequences for the NHS are, as we have seen, neglect, denial of dignity and unnecessary deaths.

The truth from an insider

A reader writes:

‘The ‘post Francis’ article in your newsletter prompted me to write. When I last saw you, I was commercial director at [an NHS Trust]. Mid Staff’s highlighted an extreme case of the consequences of the behaviours that are far too prevalent in the NHS, and I agree that Francis fails to identify the true root causes. I look back in amazement at how much executive team time was spent thinking through issues such as:

– If we can get ‘X’ types of patients reclassified, that will get us close to 18 week, and 62 day targets
– If we invest in a ‘Y’ unit close to A&E we can move certain groups of patients into it as they approach the magic 4 hours. (We later found out via a nurse whistleblower that doctors would retrospectively adjust the discharge/ admission time on the symphony software used in most A&Es. To their credit, the non execs universally said that they were delighted doctors had done the right thing for patients and fiddled the target.)
– We need to do Z to move our Monitor financial risk rating from 2.4 to 2.6 to get it rounded up to 3.

I was also amazed at how few performance measures there were which were not required by regulators, and how little we understood about performance measures which were meaningful to patients or clinicians treating patients, and the reaction by non medical managers to the suggestion that we should.

None of this will surprise you, or with the benefit of hindsight would surprise me. The paradox that I grapple with is that many intelligent people within this system (but not in Nicholson’s inner cabal, or not openly) understand that so much is wrong; but that no-one does anything appropriate to change it.

Many in the NHS talk about how do we create a culture where managers ‘look out to their communities’ rather than ‘look up to the Kremlin’. Even David Nicholson has been heard to say something along these lines, but apparently Stalin said similar things (and then proceeded to shoot anyone who didn’t do what the Kremlin wanted). I had seen this failing as a result of Blairite control freakery, and was optimistic that the new government (with rhetoric about putting professionals back in charge) would change this, but they don’t seem to get it either.’

Clearly Hunt would have the management team of this trust put into jail. That’ll do it.

Gilson on targets

As Ian Gilson of Perfect Flow remarked when he sent me this link, ‘Jeremy Hunt made me do it!’ He is talking about his recent blog on targets, which you can read here:


Hunt should read it.

A culture like Google’s

At a round-table on the NHS ‘reforms’ I couldn’t stop myself from interrupting the chief executive of the King’s Fund, a health think tank. He said the NHS needs a culture like Google’s. My immediate riposte was that he must spend too much time in Whitehall. It’s the kind of unthinking claptrap you hear there.

Here is a link on why Google employees quit. Top amongst the complaints is low pay relative to what they could earn elsewhere, disappearing fringe benefits, too much bureaucracy, poor management, poor mentoring, and so on. Clearly that’s what we need in the NHS:

I followed my challenge with a high-level explanation of the way in which the culture in the NHS is driven by the system. If you are a nurse, the three primary system conditions that affect your behaviour are working to targets, filling in forms and working within the constraints created by managements’ focus on cost. Then add to that the fact that the majority of demand into the health service is what we have come to call ‘help me’ demand, which the system doesn’t help, and, as a consequence, people who need help represent in alarming volumes (failure demand); cycling through repeatedly and being treated in an episodic fashion, without any continuity in the relationship. Now think of how you would behave, when you work in a factory that processes people repeatedly, that also prevents you from having a relationship with them and fails to help them while matrons and managers operate, as we saw from the Mid Staffs enquiry, as bullies, just ‘doing their job’.

Fear in job centres

Hunt should visit Job Centres to see what a culture of fear can do. Targets to increase the number of benefits claimants being sanctioned, i.e. punished, will only create more misery in Job Centre staff and benefit claimants. See the story here:


Apparently ministers in the DWP are denying that these targets have been set. No doubt some lower manager will get the blame.

Intelligent policing

Inspector Guilfoyle’s book ‘Intelligent Policing’ is now published. It is a must-read for police leaders and, for that matter, any leader who is curious about improving performance. More here: http://www.triarchypress.com/pages/Intelligent-Policing.htm

I am a big fan of Inspector Guilfolye, he did it under his own steam, tackling opposition with data and knowledge; a robust and courageous innovator. We need more like him.

Kittens are evil

The ‘Kittens are Evil’ event – everything you need to know about the perils of payment by results and outcomes-based commissioning (saying these things won’t work is like saying kittens are evil) – was so popular it sold out. People have been asking us to run it again, so the next Kittens are Evil event will be in Wales where this disease is called ‘Results Based Accountability’:

Wednesday 10th July at the Metropole Hotel, Llandrindod Wells, Powys.
10 am – 4pm
Cost: £45 (plus VAT)
To register follow this link:

Simon Caulkin attended the first Kittens are Evil event. If you are a subscriber to his web site (I recommend it) you can read his summary here: http://www.simoncaulkin.com/article/394/

A date for Canadians

I shall be speaking on public-sector reform in Canada on June 13th. Here is the link:

Call for beta-testers

We are still accepting beta-testers to help us develop the subscriber area of our new web site (vanguard-method.com). You have to be a group of people in housing, local authorities of the voluntary sector and you have to agree to work with the site to study and redesign a specified service. The object of this phase of development is to ensure the new site can do what it says on the tin.