Does Pickles understand systems?

The Observer reports that Fly-tipping is on the rise as council charges for skips soar. From the article,

A survey of 148 council boroughs across the UK reveals that they have raised the cost of skip permits by as much as 650% over the past five years, rises that have corresponded with increases in illegal dumping.

and

Experts suggest there is a clear link between the costs of rubbish disposal and an increase in fly-tipping.

But right at the bottom,

Last month the local government secretary, Eric Pickles, criticised councils that introduced charges at recycling centres, saying they would be “utterly counterproductive”.

Pickles said: “People already pay £120 a month in council tax for local services”, and warned that the move would create “perverse incentives” to fly-tip rubbish.

Maybe Eric Pickles understands that concentrating on costs means that total costs go up.

I hope so.

Best,

Rob

Like asking accountants to practise medicine

The primary job of General Practitioners is to see and treat patients. That is what they spend years at medical school learning. That is what the general public and patients expect them to be expert in and do.

Of all the arguments over the government’s proposed reforms of the NHS, there is one argument that sings out.

General Practitioners are not trained to do commissioning.

That is not to say that some GPs wouldn’t be good at it and some might be keen to give it a go. But it is the case that if management and budgets were the GPs driving joy then you might have expected them to have taken a different career path.

As final year medical student, Tom Riddington, writes on the Guardian website,

The years I’ve spent at medical school have taught me nothing about money. I’m taking one of the few degrees that still guarantees a job and a wage the second I qualify. The only financial management I know is balancing my tuition fees against an ever-increasing overdraft.

But the health secretary, Andrew Lansley, wants me to use £80bn of Treasury money to buy hospital services for patients. I didn’t go to medical school to ration people’s healthcare. It goes against every instinct I have: find the symptoms, make the diagnosis, identify the right treatment – then explain to the patient why I can’t afford to provide it.

As Riddington says, “It is like asking accountants to practise medicine.”

Currently commissioning is done by someone other than the GPs. It is done by the Primary Care Trusts. If PCTs are abolished and the GPs do the commissioning then if GPs are to still see and treat patients, then they will have to ask someone else to commission on their behalf. They will hire private companies or former employees of PCTs.

So the NHS will go through years of upheaval and expense to move from a system where professionals other than the GPs do the commissioning, to a situation where… erm… professionals other than the GPs do the commissioning.

If the government wanted more clinical input into commissioning, there are much easier ways to achieve that.

Best,

Rob

I can’t tie my shoes

I love to follow the talks on TED.com. They are always interesting and thought provoking. But little did I know that Terry Moore’s talk from 2005 would tell me that I have been doing up my shoelaces incorrectly all these years.

If you have laces on your shoes, you have to watch this, it is only 3 minutes.

Once I had come round to the idea that I couldn’t tie my shoes I wondered if there was an even better way of executing the knot and there is. At Ian’s Shoelace Site you can find out how to tie the shoelace bow in a third of the time.

The discovery this late in life that I had been tying the wrong knot, badly, since the age of five sharply reminded me that we can always learn to do something better, especially when we thought we had it nailed for years and years.

I’m off now to ask a doctor if I am breathing correctly. Wish me luck…

Best,

Rob

Local Council Legal Challenges Mean Waste on Waste

The Birmingham Post reports that High Court rulings in two cases about the budget cuts by Birmingham City Council, mean changes have been halted. Referring to the social services case, the article says that,

The financial implications from the latest court case could be serious. The council expects to save about £53 million by 2014 from limiting social services provision to adults with critical needs and may now have to find the money from elsewhere.

Waste Upon Waste

There are many examples of waste here. But the primary error is leading to an explosion of waste as a consequence.

That error is that the council seems to be trying to save money by cutting services and grants. Taking the social care aspect, this causes money to be spent re-assessing people currently in receipt of care. Some of those people will still require care after the assessment. Others will be reassessed at a lower level of service or none at all. In some of these cases the lower level of care will mean they place extra burden on family, friends and neighbours. In cases where other people can’t fill in, in the situation will deteriorate increasing the likelihood of hospital admissions and the need to receive a higher level of care than they currently receive much sooner.

In taking these measures Birmingham City Council have been taken to court. I dread to think how much that case cost to bring and for the council to defend. More waste. Add in the waste of the planning and implementation of the changes that are now halted and add onto that the cost of changing those plans.

There is more non-financial waste in the stress that is caused to the cared for. Stress and worry caused by firstly being told they would be reassessed and now being told those plans are on hold. This stress and worry may cause physical problems in the future which means that their care needs increase. The non-financial waste becomes financial.

Another Way

So what should the council have done instead?

If they had looked to improve their services first before cutting, they would have found that giving better service, more quickly, cuts the cost of providing the service and keeps people well for longer, reducing the need to increase the level of care. The court case could have been avoided and the stress and uncertainty would have been removed. Instead, people will have been happier with the improved service.

It is the art of not doing what is obvious, but instead doing what is right.

Best,

Rob

NHS information – local decisions

On the 18th May The King’s Fund published a report entitled “The future of leadership and management in the NHS – No more heroes”. It is the result of nine months of research, seminars and consultation into the state of management in the NHS. Broadly, it is supportive of NHS managers and it is against too many cuts in management numbers.

There is a lot of interesting topics covered in the report and I will be writing more about it in the future, but I wanted to start by focusing in on one of the recommendations (on page viii), which reads:

There is appreciable evidence that the NHS is over-administered as a result of extensive, overlapping and duplicating demands from both regulators and performance managers. There has not been a substantive review of the information demands placed on the service and its providers for many years. A review leading to a rationalisation of those demands is essential.

The words “substantive review” should always strike fear into the reader. A substantive review always seems to be a centralised exercise. They are run from the centre, by the centre and usually promote the needs of the centre. Government studies into what information need to be gathered by Whitehall, start from the premise that they need to determine what Whitehall and the government need. It would be a breath of fresh air to see a study that started with the needs of local work and worked the other way.

How might that work?

Instead of a study group gathering submissions about what data is collected, the starting point would be what data is needed to run the service locally? What data is needed to improve the delivery of value to patients? I would go so far as to say that there is a place for separating the production of data for government and the production of data for local delivery. Most larger trusts have statisticians, they should take over all responsibility for reporting to the centre and relive local managers to collect the data they need. Then locally you can decide how the two data sets differ. Only then should government be notified of the differences. This would have the added benefit of quickly relieving local managers and clinicians of much data collection and reporting responsibility, giving them more time to deliver and improve the care of patients.

If the cause of localism is true then the government will welcome local decisions on what data is collected, for what purpose and what is then reported centrally.

Best,

Rob

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

« Previous Page — Next Page »