I must apologise to readers who have wondered about my newsletter silence over the last two months. The fact is I got the blues. In late June I arrived back in the UK from Canada. I’d been well received at a local government conference, but went home with the depressing news that ministers there were keen on lean – the wicked disease – and ‘Deliverology’ – the most egregious intervention guaranteed to make things worse while kidding ministers through data up the hierarchy they’d bought a solution; tampering on a massive scale.
This depression was only compounded by events in the UK public sector; voluminous evidence of failure and, worse, the way politicians reacted. Universal Credit, HMRC, out-sourcing, commissioning and so on all made the news with shocking revelations of what, if one were generous, might be described as unintended consequences. Ministers react to the fact that their initiative is failing by denial – the evidence is wrong or out of date – rationalisation – we know this and that is why we are doing x’; but ‘x’ is no solution, or ‘it’s working’, despite that fact that anyone with a brain would say then how do you account for the evidence which clearly shows it isn’t. A most shocking revelation of the latter condition is the work programme, where ministers have been caught cooking up a story for us with spin-doctors who work for the private-sector providers.
I reflected on the fact that I had written about these failures ad-nauseam in past newsletters and even gave the nasty ‘Deliverology’ a whole chapter in my public-sector book. I felt I had nothing to say, and so I took the Yorkshire option: If you’ve got nowt to say, say nowt.
It was a radio programme that spurred me to write. Brendan, our head of research, told me to listen to it as, he said, it encapsulates everything that is wrong with centrally-promulgated scale designs. It was an edition of ‘Face the Facts’, ironic as ministers never face facts, and it concerned ‘111’, the new telephone line for health care. Our prime minister, David Cameron, reacted to the debacle by saying he was confident the service would improve. How can he know?
111 was set up because ministers were worried about the volume of demand on accident and emergency and GP surgeries; they were also obsessed with the idea that people should be kept out of hospitals and last but by no means least, ministers believe that service over the phone is cheaper.
If only ministers knew that the health service suffers from enormous volumes of failure demand – and the big clue is in the definition: demand caused by a failure to do something or do something right for the customer. If they knew that, instead of exacerbating the problem with 111, they might have turned their attention to why the NHS doesn’t work for patients.
111 started life in the last Labour government. Labour ministers had set up its predecessor NHS Direct and for the same wrong reason, that services are cheaper over the phone. 111 was to take a further step up the wrong-headed efficiency ladder by putting the brains into a computer and hiring ordinary people to follow scripts. The phone conversations played in the radio programme make you want to cry. Demand into health services exhibits high variety, rules in computer systems won’t absorb that, no matter how much money you spend with health experts and IT developers trying to make it work, and ministers are spending millions.
While opposition politicians jump at the chance to criticise government, they offer no alternative; they have no insight into the reasons for failure and merely join in the wrong-thing-righter debate. For example, NHS Direct cost ï¿½24 per call and 111 contracts have been let at ï¿½7 per call. The consequence is a debate about the proportion of more expensive clinical staff to sit behind the computer-driven dumb front end. It is to entirely miss the point. The cost of service is end-to-end, the total number of transactions it takes to complete a service. NHS Direct earned the sobriquet NHS Re-Direct, for good reason. But just like the managers of NHS Direct of old, managers of the new 111 services crow about the volume of calls they receive and their ability to answer them in sixty seconds; pathetic.
111 service providers are plagued by low staff morale and high turnover. It is hardly surprising. Imagine how you would feel if you had someone on the other end of the phone and you were obliged to take them though time-consuming record-making procedures while they want to talk about their problem; and then you have to follow scripts that mean you will ask stupid questions instead of actually listening to what people have to say. As one user said, it seems like the questions are designed to be delaying tactics. 111 staff described their state of panic, trying to get help for people who clearly need it.
NHS Direct has pulled out of some 111 contracts before starting and has announced that nine other contracts they are working to are unsustainable. To achieve lower costs NHS Direct is sacking managers (‘changing the management structure’); ministers say they got their sums wrong whereas the fact is that ministers got the whole approach entirely wrong.
So, as Brendan said, it has all the features of centrally-promulgated scale designs: no understanding of the problem, a belief that transaction costs equal service costs, a belief in computers being capable of dealing with high-variety, turning a blind eye to the demoralisation of workers and ignoring all evidence of failure: more demand on GPs and the ambulance service, people not getting help and some even dying. If you wonder how many deaths it will take for ministers to wake up, consider children’s services where deaths run at three a week while service providers tick their boxes with assessing, form-filling, closing cases, protecting budgets and ‘managing risk’.
Will ministers face the facts?
You can listen to the programme here: http://www.bbc.co.uk/programmes/b0384815
As I was writing this I got notified that Simon Caulkin has posted an article on 111, a similar lament pointing out that the programme failed to draw the obvious conclusions from its own story and offered no hint of a way out of the vicious circle of rising demand and rising cost.
In his previous post Caulkin wrote about the Berwick report, which promoted a systems view of health services. It went down badly in Westminster because ministers wanted Berwick to report on their ‘big issues’: patient safety, holding people to account through legal sanctions, minimum staffing levels better regulation and so on. As Caulkin noted, these are not the issues, but it brings us back to ministers, who want reports to deal with what they want them to deal with.
I went to the minister for health’s presentation at a think tank a couple of months ago. I told him (Jeremy Hunt) that we’d been studying the NHS over the last couple of years and what we found was high levels of failure demand caused by fragmentation, specialisation, working to arbitrary measures and so on, and I suggested the way we should go would be to design a service that meets demand. He said he agreed with everything except my conclusion for, in his view, computer systems will fix the problem of integration. So there you have it. Policy amounts to what the minister will agree with. I think I’ll go back to my favourite mood.
I expect I’ll have cheered up by the time I speak at the next Kittens are evil event – the most popular event we have put on for some time. Its purpose is to explain why outcomes-based-accountability or payment-by-results will always fail (saying that is like saying kittens are evil). And it is my turn to take a speaking slot.
I shall be speaking at this one: Hampshire, 30th September, Ferneham Hall and there will be another in London: 28th October, LGA Smith Square Conference Centre. For more information and to book: https://www.vanguard-method.com/events/?story=29
To read reviews of previous events see these: Kittens are Evil – What happened in Manchester? http://www.simoncaulkin.com/article/406/ Kittens are Evil – What Happened in Wales? https://blogs.ncl.ac.uk/nubs/2013/08/01/kittens-are-evil-what-happened-in-wales/
I shall be speaking for the Call Centre Managers Association on 2nd October, at Olympia, London. Information and booking here: http://www.ccma.org.uk/news/systems-thinking-seminar