Indiana Lansley and the 18-week NHS target
As Indiana Lansley approaches the altar sweat pours down his face. Lansley tries to control his pounding chest and rattled nerves as he eyes his prize. To get to this precarious spot he ducked the poison darts from the opposition benches, he rolled past the whirling blades of the BMA, he outwitted the deadly collapsing floor of his backbenchers. His companion wasn’t so lucky and his body is still impaled on the wall of the commons lobby as a warning to others to leave things that don’t belong to them well alone.
As Lansley squats in front of the idol created by the Labour tribe, the danger he has faced melts from his thoughts as he is calmed by the simplicity of the creation that sits quietly before him.
He is still.
But Lansley knows that he is not out of danger yet. He steadies himself and mentally weighs the golden object before him. He takes a bag in his right hand and measures the policy ideas it contains. He looks again at the idol and back to the bag. He takes a fistful of directives from the bag and drops them to the stone floor. He glances back at the statue and then discards a few more diktats from the bag. He is ready. His right hand holds the bag as close as possible to the idol, his left hand poised on the other side.
One more breath.
As the last wisp of air leaves his lungs he smartly tips the idol off the plinth, simultaneously rolling the sandbag into its place with a gap that could never be noticed. Or so he hopes.
Lansley pauses. Waits. Listens. His body still taut.
Nothing.
His shoulders drop a fraction and he allows a small smile of relief and victory to creep across his face. He starts to stand to leave with his prize. For a fleeting moment he has done it. He has removed the Golden Idol of the NHS 18-Week Treatment Target. No one thought he could do it. Even he wasn’t sure. He knew it was the right thing to do. But has he forgotten something from the ancient legends?
Lansley tenses. A deep, distant rumble. In a moment the roof of the cavern is crashing down. The floor cracks beneath his feet. The altar explodes in his face. He must run.
As he dodges more darts and nearly loses his Fedora to spear flying out of a wall beside him, his mind rushes back to the warnings of the old man in the village. The sage said that you can’t just remove a target and replace it with sand. “It is right,” said the man, “to remove the 18-week target. The Labour tribe wouldn’t listen when it was said they shouldn’t create the evil target idol in the first place. The problem is that targets appear to magically work even if they are really dysfunctional. But if it is to be removed it needs to be replaced with a proper method. So if you take it away, as you must, you need to leave in its place a sustainable way to treat patients well. Only the timely and appropriate delivery of treatment in the NHS will stop the whole thing collapsing. Only then will the 18-week target not be required, and it can be beaten in in ways no one could imagine.”
All at once, Lansley screeches to a halt amid all the chaos and dashes back through the flying debris. Swinging the 18-week target high he brings it crashing down onto the splintered remains of the altar. “Come on!!” he shouts. Surely putting the 18-week target idol back will stop the pandemonium and collapse? Nothing changes. In fact the disintegration of the NHS seems to hasten.
Indiana Lansley rushes for the fast dropping door. If he doesn’t make it he will be crushed by the rubble of the NHS, never to be seen again. As he runs he can feel the glow of the 18-week idol behind him. Its power burning into his spine as he flees. The door falls ever faster.
He has always got there in time before…
Defence cuts lead to cost rises
The BBC reports that defence cuts ‘led to MoD project cost rise’. In the article, the head of the National Audit Office is quoted as saying that, “These circumstances were largely, however, of the department’s making and the resulting cuts and delays to capability are not value for money.”
This is a classic case where plumping directly for cost-cutting measures in the short term has caused costs to go up in the medium to long term.
If we are to avoid more of this kind of occurrence happening across the public sector we need to realise that the only sustainable way to cut costs is to improve services.
Delaying the delivery of defence equipment won’t save money because there is a cost to changing the course of procurement and production, then the cost of interim measures and finally the cost of restarting the delayed projects. Add to that the cost of getting ever more out of date equipment and materials and the loss of value in addition to the obvious loss of funds is clear.
Finding better ways to deliver the equipment our armed forces need would be a much more fruitful endeavour. Procurement exercises that were tasked with giving just what was needed, when it was required with much shorter turnaround times between identifying the need and the arrival of new capability on the battlefield is the way to cut budgets. And we shouldn’t get sidetracked that this is a procurement problem. More procurement with more checks, “better” specifications and tighter controls will only make things worse. Instead, it is the value that is brought to our defensive capability by what we obtain and how to shorten the time to bring it into service which will lead to less money being spent.
Best,
Rob
A very broken process
They must do this thousands of times a week all across the world and yet the process beggars belief.
They are Ikea and the process is selling a kitchen to be delivered. It starts out promisingly. You can use an online, 3D design program to position your desired cabinets, drawers and appliances with the doors and handles that you want. You can whirl the 3D image around and print top and side views with dimensions on.
But when you go into the store to order the kitchen you designed it starts to unravel. The assistant in the kitchen department spent time with us so we could check that we hadn’t missed anything obvious and she did pick up that we had picked a waste sorting cabinet that wasn’t being used with a sink meaning she could change the drawers to be much deeper. But then she had to manually add text lines in the order that was generated from our design in order that we could see which group of five parts related to which cabinet. After this protracted process we collected the cabinet legs and other little bits from the warehouse and went to pay.
After paying we queued at the Home Delivery desk, where to our shock a very nimble fingered man took the printed order sheet that we got from the kitchen department and proceeded to re-key all the stock numbers and quantities for each one of the 45 individual parts needed to put together our kitchen into the picking and delivery system. Why the kitchen systems and the delivery system don’t talk to each other is amazing to me.
He was a bit put out when I asked to check his duplicate entry, but I knew that five minutes to spot a mistake was better than weeks to try and get Ikea to send the correct part. In fact it was all correct – this time – but I wonder how may orders get copied over incorrectly given the number of kitchens Ikea must deliver every year in all their stores.
To top it off we couldn’t choose a day for delivery. We ordered on Sunday so they pick the next day and deliver the day after that. So it was Tuesday or we wait three weeks. The reason given was that they don’t like to pick an order then have it lying around waiting for delivery. That I understand, but I see no reason that they can’t put our order on the Thursday pick schedule so they deliver to us on the Friday that is most convenient.
I wonder if any of their senior staff has walked through the process as a customer like I had to do this weekend? I’ll wager that they can’t have, since if they did they would want to change it quicker than I could say, “We’re missing half our kitchen.”
Best,
Rob
To save public services we must think in Russian
SPOILER ALERT: This post gives away all the exciting bits from the film ‘Firefox’.
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I like the film ‘Firefox’. I recognise that it is not a great film but it has Clint Eastwood and I like that kind of watchable, post-cold war thriller.
The basic plot is that Mr Eastwood plays Mitchell Gant, an elite ex-fighter pilot who is brought out of retirement because his mother was a native Russian speaker. His mission is to go deep into Soviet territory to steal the latest high-tech Russian MiG fighter – code named Firefox – which has a thought-controlled weapons system.
After many adventures Gant is hidden by the very scientist, played by Nigel Hawthorne, who designed the thought-controlled weapons system that the Americans want to get their hands on. Hawthorne tells Gant that in order to operate the weapons system that he, “must think in Russian”.
Cut to Gant flying over the Ural mountains in the stolen Firefox with another MiG fighter on his tail thinking, in English, “Fire the rearward missiles. Fire the rearward missiles.” Obviously nothing happens until Nigel Hawthorne’s floaty, accented voice is heard saying (of course) “You must think in Russian.” Quick as a flash, Gant repeats his thought but in Russian and the rearward missiles fire, destroying the dastardly Soviet foe who is on this tail. America wins again!
(Nearly there with the relevant bit…)
When I was taking my final exams at university I knew that not only did I need to answer the questions correctly but I also needed to think like the examiner in order to get maximum marks. Given that these were mathematics exams that meant showing lots of clear working and getting the maths jargon in that they liked. So just before the invigilator would say, “You may now start,” I would repeat, under my breath, “You must think in Russian,” to remind myself think about what the examiner wanted.
What has this to do with public services? Well if we are to save services from the cuts, we must think in the right way. That right way is to think like our customer thinks. Thinking like ministers, accountants or even public sector staff won’t do it. In fact that could very well make things worse. We must understand what our customer thinks of when using our service and design the service to maximise that. Forget internal customers, forget auditors, forget management whims, focus on the customer to deliver fast, error free services which in turn will remove waste and cut costs.
Anytime we are thinking of making a change, pause (but not long enough to let the following MiG shoot you down) and listen for Nigel telling you that, “You must think like your customer.”
“You must think in Russian.”
Best,
Rob
Unions and government are both wrong about cuts
Yesterday at the Trades Union Congress (TUC) conference, Ed Miliband, the leader of the Labour Party, got heckled when he suggested that the strikes in June shouldn’t have happened while negotiations with the government were still in progress. Those strikes were about pensions but there is talk of much larger strikes about cuts in the coming months. So we could argue about the relative merits of strikes versus negotiating, or cuts versus investment.
However, the problem is deeper than cuts to budgets. The problem is that the government, the Labour party and the unions are still stuck in the model that says cuts to budgets means cuts to services which in turn leads to negotiations or strikes to fight those cuts.
We need to step back and challenge the assumption that cuts in budget require cuts in services. In fact the opposite is true. Improving services is the only true, reliable and sustainable way to reduce budgets.
Many services are full of waste, delay and errors. It is not because staff aren’t trying hard. As W. Edwards Deming said, “We are being ruined by best efforts.” The problem is that we don’t manage services as systems so trying hard to optimise one corner of the public sector will sub-optimise the service to the public as a whole.
In place of negotiating or striking about this cut or that cut, unions, management, staff and government need to work first on improving services to remove the costs that litter processes. This will bring them together to work on the problem of providing better value to the public instead of fighting about how to remove value altogether.
Best,
Rob
When you mix healthcare and money
Bupa thinks the surgeons are doing operations to make money and the surgeons think Bupa is undermining their clinical judgement and suspect that it might be simply to save costs.
The Guardian reports a spat between a health insurer and the consultant surgeons that are operating on its clients knees. We can’t know who is right, all we can say is this is the kind of thing that happens when you mix economic and service incentives.
People paying out money will always want to reduce it and those being paid will always want to maximise it. Of course the vast majority of surgeons want to give just the right care to their patients, but you can see how some might have their heads turned. You can also see how a health company would rush to protect its business model by trying to cut costs.
In the middle is the patient wanting the right treatment for their knee. With all the money floating around no wonder they get forgotten sometimes.
I just hope these kind of spats don’t get more common as the health landscape changes in the next few years.
Best,
Rob
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
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