Why do NHS managers want to keep targets?

The Public Service web site reports on a survey where 59% of NHS managers say they want to keep the targets that are being dropped by the new government.

Andrew Lansley has said that the 48 hour GP target, the 4 hour A&E target and the 18 week GP to treatment target are to be gradually scrapped by his department.

Former NHS trust chairman Roy Lilley said:

“Targets have made managers’ jobs really tough. They have taken a lot of criticism about additional bureaucracy and box ticking. I thought they would be pleased to see the back of them. Not so! Managers are proud of the fact they have delivered most of the targets and dumping targets is turning the clock back.”

Targets make managers jobs tough because they prevent managers working on what is important to the patient. They are instead distracted by having to hit the target. They should be glad to see the back of the targets since now they can run their services on the basis of giving value to patients. They shouldn’t be proud of delivering targets that make performance worse.

More importantly with the freedom from arbitrary targets, the clock can move forward apace. That freedom shouldn’t see the clock turned back to long waiting times, rather without having to appease an unjustifiable target they can now innovate to provide services that no-one would ever dream of setting as a target.

Why 18 weeks? Why not 18 days or 18 hours? There was no reason and there is even less reason now with the burden of centrally imposed targets removed.

Another manager said,

“Targets do, at least, stimulate productivity. Areas without targets tend to get sidelined. Without targets, for many people, it is human nature to ‘do what is easiest’, rather than what is best for patients.”

Firstly, targets don’t stimulate productivity, they stimulate activity, which is not the same thing at all.

Secondly, the quote shows a very cynical view of people. This is a view that staff are inherently lazy and don’t want the best for patients. I don’t believe that and I think that the only thing holding back improvement is a lack of sound method. But there is plenty of good ways of improving if managers look for it. It is not laziness that is the problem, is the laziness of thinking that assumes that people are slothful and will shirk the responsibility to improve things for the public. It is just that some of them don’t know how to do it yet.

Best,

Rob

Soldiers kill civilians for bonuses

Indian soldiers in Kashmir are being investigated by the local police because they may be killing civilians and then claiming that they are Islamic militants.

Human rights activist Parvez Imroz was interviewed in an article by The Guardian where he said that soldiers received bonuses for each kill. He added that,

“There are vested interests that have developed in the conflict. The army have been given these incentives and so they kill non-combatants.”

I have heard many stories of people fiddling figures, cheating processes and changing what they do to get rewards, but I think of all the indcidents of targets and bonuses distorting behaviour this is the most extreme I have ever come across.

It just goes to show that the power of rewards to twist how people act should not be underestimated.

Best,

Rob

Outsourced call centre rethink

The Chief Executive of Northern Ireland Water is having a rethink about its outsourced call centre, according to the Belfast Telegraph.

Laurence McKenzie said that,

“One of the things that keeps me awake at night is the impetus we need to give to customer service. We have far too many at the minute, I believe, hand-offs and hand overs for the customer. We have an outsourced call centre who then try and hand the customer’s problem into the organisation and I think we need to look very carefully at that, at our processes.”

Opportunity to learn

This type of situation is predictable. The problem comes when you view parts of an organisation as separate and try to split them up and then outsource parts of them in order to save cost. I have no doubt that the cost per call in the outsourced call centre is cheaper than if they kept it within the water company. But it seems Mr McKenzie is starting to realise that cost per transaction is not the most important measure.

Complaints are an opportunity to learn. You can learn how not to cause them again. What is more cost effective, dealing with a complaint call cheaply, or not causing the complaint and hence not having to take the call at all?

In order to learn you need a tight feedback loop between the complaint takers and the core systems. The closer these are the better. The ideal is if the people dealing with the problems are the people doing the core work. The have a natural sense of ownership and it is in their interest to reduce the problems since then they can get on with their real jobs.

Lock in cost

Outsourcing complaints locks in high cost. It is not in the interest of the call centre outsourcer to reduce the number of calls, taking calls is how they make money. Also the feedback loop is not only long, but must span organisations. The call centre agents have no interest in reducing the call since they didn’t cause them in the first place. Deal with this call, move onto the next. Worse, since call centre agents are measured on average time spent on a call where less time is better, it is also not in their interest to deal with the calls properly. So even if they are dealing with value calls they can create failure demand due to the management style and measures.

Mr McKenzie has the right idea and his water company would gain a lot from taking back the function in-house.

Shame that more chief executives don’t think the same.

Best,

Rob

Why performance related pay is bad for the public sector

Glyn Lumley has written an excellent blog post entitled 10 reasons why performance-related pay should not be used in the public sector and I recommend reading it before proceeding with this post.

I would like to add reason 11, which is hinted at in Glyn’s reasons 8 and 9. He cites Daniel Pink and Alfie Kohn who have written about extrinsic motivation e.g. performance related pay, and intrinsic motivation e.g. joy in work. They both talk about the fact that extrinsic motivators in the form of rewards divert attention away from the purpose of the work and toward the gaining of the award. So introducing performance related pay would encourage staff to work for the extra pay rather than doing there work better for the benefit of the public.

Here is another nice post from Glyn which dovetails nicely with this topic: Um…I can’t take that, I cheated!

Let’s hope there isn’t an increase in performance related pay because it will lead to worse performance, and some people, sadly, will cheat.

And whose fault will it be?

Best,

Rob

The alternative to ring-fencing

Age UK has called for the social care budget to be ring-fenced like the money for the NHS has been. They claim that social care has an effect on the NHS and cutting its budget will drive demand into the NHS. They are no doubt right, but they are using a classic silo-thinking trick. They are using system wide arguments to protect their patch.

“The system will suffer”, they cry, “help our bit of it, but not theirs.”

Every service, region, council, lobby group and association will be calling on the government to treat them as a special case in the near future and from their point of view they are right. The important thing is to take a different point of view. When genuinely looked at as a system, public services need to do two things

1. See themselves as part of the whole system that is the economic and social complex of the country.
2. While bearing that in mind, look to their own systems of work to see how they can improve and save money.

I believe that focusing on purpose (what they are there to do) and improving the service they give is the best way to save money. It is not a direct route but doing what the service user needs, with no waste, errors or rework, as quickly as possible must be the cheapest way to deliver every service.

Most public services are nowhere near that state. So they need to look to themselves to solve their problems.

The only problem will be is if either the service managers don’t see this or the cuts come so fast that they can’t implement it. Though implementation can be surprisingly quick when people put their mind to it.

Best,

Rob

Surgery targets endanger patient safety

The BBC reports that

About one in five of the nearly 600 surgeons questioned by Bournemouth University reported being involved in incidents, during a two-week period, where patients were harmed.

Using the figures further on in the article of 549 surgeons questioned and 19% seeing harm, that means that in two weeks, 104 surgeons saw a patient harmed. I wouldn’t even like to start extrapolating that figure to all the surgeons and all year long.

Apart from the fact that

When asked about what gets in the way of patient safety, many said they did not feel in full clinical control, because of pressure from managers to get through operating lists.

The report author said that

surgeons often come under pressure to “slip in” extra patients on their lists

These are systemic problems. The management are putting pressure on the individual surgeons to make up for the lack of systemic thinking about how patients are treated. “Slipping in” patients to surgery lists means that not only are the lists tampered with but so is the whole patient flow. There is probably a lack of understanding of demand and little or no flow of patients or continuity of care which is leading to these comments.

Many [surgeons] complained of having to operate on patients they had not seen before

If patients came to see a surgeon and their surgery was scheduled quickly, then this would occur much less frequently.

The bottom line is that surgeons, managers and all staff involved in the care of patients having operations need to be aware of and contribute to the end-to-end system that patients experience. No one section of the flow should start blaming the others, they all have a responsibility to get together to improve. The problem is that there are currently no structures in the NHS that assist them to do that. Combining GPs, PCTs, SHAs, hospital trusts and the other agencies that affect these flows is a mammoth task that is not being addressed yet.

We shall continue to see these kind of articles until something brings these systems all together.

Best,

Rob

Call centres facing self-imposed effectiveness hell

The Mirror has an exclusive report, Call centre staff facing targets hell.

Workers in call centres in Britain claim they are being treated like battery hens and say conditions are getting worse.

The Mirror has uncovered shocking working conditions with some staff allowed just EIGHT minutes for their toilet breaks during an eight-hour shift and others getting warnings for being 30 seconds late back from lunch.

In another case, a woman was refused permission to leave her work station because her child was taken ill at school because it would have left the call-centre undermanned.

With the hyperbole turned down a notch or two, we can see the glaring omission from the article. The thing that is missing is that any company with a call centre where they are doing the things that The Mirror describes, will actually be hurting their own effectiveness. Of course call centres should stop monitoring toilet breaks and reduce bullying for the sake of the staff, but they should also do it because the organisation will perform better.

Just doing more of what you agree with is dogma

If there is a genuine need to get better, why do call centres not try things with an open mind? Why do they not try being open, honest and trusting to their staff to see how that goes?

The reason is twofold. Firstly, the current mindset is all about economies of scale, sweating your assets (staff) and focusing on individual performance. Secondly, they don’t get PDSA. They don’t understand that you have to experiment with every method to see if it works. Just doing more of what you think with no proper evaluation is dogma, not improvement. I can’t tell you the number of times working with clients when a staff member has suggested something that both the managers and I have thought could not possibly work, which worked brilliantly.

Fail fast, learn fast

It is genuine PDSA when staff are trying things that managers are not sure about or completely disagree with. To do that staff need to experiment fast and have a rigorous method of evaluation and implementation. If it works, put it in place quickly, if it doesn’t work, throw it out and learn from it. Managers also have to understand that people learn best by doing, not by being told what won’t work. Staff also need support from managers to do this.

Let them fail. Let them fail fast. See them learn faster than you could possibly have imagined.

Best,

Rob

Local Gov Camp Review – Part Two

This is the second part of the report of the Local Gov Camp – Yorkshire and Humber event. You can read the first part here.

I wanted to break it into two since the first part is quite positive, I was very impressed with the enthusiasm of the attendees to firstly come in their own free time on a Saturday, but secondly in their wish to improve things generally in how local authorities deliver service. Which brings us to the last session of the day…

Get Over Yourself

The last session was suggested by Emma Langman and was called ‘Get Over Yourself’. I didn’t really have any idea what this would be about, but I do know Emma so I knew it would be interesting and it was, but not for the reasons I thought.

Emma was posing a question about why we project school models into the workplace. “Teacher knows best, pupil learns from them”, is translated as “Boss knows best, employee will do as they say.” I would agree with the sentiment of this, that for many managers this is actually a desired model except for the fact that many bosses don’t know best. I thought this was an interesting question and a nice opportunity to discuss it in a quite open environment, but it went a bit ugly for me. The challenge came, “We have been going over this for 50 years, why are we talking about this again?”. I have thought the answer to that was plain, we still don’t have a really good answer and a good answer is well worth searching for.

It got worse. The group descended into a blame fest. “Fifty percent of councillors are rubbish.”, “There are too many fat, lazy b*****ds.” and so on.

I was very disheartened by the general feeling. There were a few positive voices who noted that if you give people a good job to do then they will do a good job and that there is potential in everyone, it just has to be tapped by management.

I was quite surprised since I had pegged the attendees of Local Gov Camp to be quite hopeful, forward thinking folk who would go above and beyond to find better ways to do things and here we were slinging mud at our colleagues and fellow man.

I think that this attitude is the thing that we have to knock down first. The idea that people are fat and lazy who do everything to avoid work and spend their time raising grievances is an interesting observation since it actually takes quite a lot of thought and planning to avoid work and a knowledge of procedure and a considerable tenacity is needed to raise a grievance in a modern council. I think that the potential is there in these people but we just have to channel it. We shouldn’t give up on them or write them off. They want to do a good job, same as the rest of us.

I sincerely believe that everyone wants, down deep, to contribute to a meaningful purpose. It is just that management often does their level best, not always deliberately, to block them. It is the enlightening of staff at all levels, from councillors down to street sweepers, that will open up thinking and wipe away prejudice. It is in the work that purpose is achieved and I think that the propensity to focus on individuals as things to be fixed when broken and used when performing that is wrong.

The reaction of staff to a bad system of work by withdrawing and rebelling is a natural thing that should be expected. Management are responsible for creating the system that creates the bad staff member and it is management’s responsibility to fix it. Another attendee noted that management hired “good, intelligent, self-starters with new ideas”, so if they are not like that any more, either management are incompetent at recruitment or they are incompetent at designing a system of work to keep new hires the way they were when they arrived.

But lest I fall into my own trap of starting to blame management. I am not. I don’t think it is their fault. They learned what they know from their managers, who learned from their managers. Like a cycle of abuse, it needs to be broken and it only with optimism, belief in people and an open mind that this will change.

All in all I am glad Emma ran that session since it is clear that we need to keep airing these issues until it becomes a non-issue by virtue of us fixing all the problems.

Someone once said, “The most depressing thing in life is to have hope.” Well I hope he was wrong, since I think things can change for the better we just have to look to ourselves, to the system of work and stop blaming others.

Best,

Rob

Local Gov Camp Review – Part One

Local Gov Camp Review – Part One

Today I went to Local Gov Camp – Yorkshire and Humberside to find out about social media in local government. The day was run on an unconference format which is quite like Open Space but even looser, if you can imagine that.

Digital Vision

The first session was about a digital vision – where do we see technology in local government in five years? We watched a video from Cisco that was a little cheesy but I thought was interesting in the way that it depicted ordinary people and council workers having needs that were helped or supported by being better connected. There was the thought that “technology becomes interesting when it becomes boring because it disappears” and so becomes part of the scenery. That is a thought that I think is key – that technology should be pulled into service provision when it is needed, rather than the usual way round where a technology is pushed in to a situation because it looks clever. The best example of this is call centres. They exist because networking, call routing and CRM systems can be knitted together. Thus you can build a call centre, so people do. The fact that call centres make service worse doesn’t seem to figure in most people’s evaluation of them. The technology works so it is a success.

Enterprise 2.0

This was a session about putting social networking software onto a council’s internal network to give them functionality equivalent to Twitter, Facebook, Wikipedia and instant messaging all in one. It was interesting from the point of view, not of the technology but of the attitude to the policies around it. They have basically said that council staff can use it for whatever they like, work, gossip or the football scores if they want. It is designed to flatten hierarchies and allow people to come together who wouldn’t have been able to before. The hope is that while discussing Sex and the City 2, people will also collaborate with new people to innovate new ways of delivering council services, or even new services. Anything that breaks down walls to open up collaboration and innovation is worth a try. I wish the project success and look forward to seeing similar projects in the future.

Online Engagement

The focus of this session was the new Let’s Talk Central web site. This is a site to allow the residents of Bedford Central comment, praise and criticise what is going on in their new authority. People in the session were worried that it would replace other methods of consultation, but it was designed as an addition, not a replacement. I liked it since it was a simple way to interact with the council and was not heavily branded as a council site. It was interesting to hear that the internal IT department wanted to deploy the site in the council web site initially, but the spec was too complicated for their CMS to cope with. Actually the site is not too complicated at all. Just goes to show.

Best,

Rob

Local Gov Camp Review – Part Two

A target is not a plan

In the News section of the May 2010 edition of Qualityworld (who I have written for) there is a report on a vote by readers on which of the political parties have the best appreciation of change. I noted that one respondent wrote,

The Tories’ critisism of targets indicates that they do not understand the basic quality principle of plan, do, study, act.

I would counter that the writer of the statement above does not understand that to set a target is not a plan. There is no proper ‘do’ other than set the arbitrary target then stand back. The ’study’ is reduced to the useless, “see if we hit the target” and the ‘act’ can only be to change the level of the target, drop it or add a new one to counter the perverse unintended effects of the first one.

A proper plan has method. Things you are going to study to understand your situation so you can make changes with knowledge. Targets do not give knowledge, only fear and pressure.

Best,

Rob

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