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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

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

If there are NHS staff who wish to find more about the better way then they are invited to come to the Lean London session on 25th May 2010. More information and registration here.

Best,

Rob

In summary, enforced targets do appear to have been successful in improving aspects of NHS performance, particularly in relation to waiting times, but there is some evidence of unintended consequences – for example, distortion of priorities or neglect of other non-targeted activities. However, it is important to recognise that such unintended consequences may not be the inevitable result of targets in themselves, but rather of the particular way in which those targets were designed and enforced.

Regular readers will know that I disagree with any use of targets. They are arbitrary and they skew behaviour to hit the target rather than delivering high quality care.

To say that unintended consequences may not be the result of targets but the way they are implemented is to miss the point that the setting targets necessarily constrains the methods used to improve. Worse, the methods excluded are precisely the ones that could far exceed the targets while completely avoiding the malodorous consequences and save money to boot. The use of Lean Service techniques along with Systems Thinking will get you further, faster and with a lot less hassle and effort.

The improvement seen from setting a target is like the progress seen when you bang your shoulder against a door that opens towards you. You might make several dents in the door and it may even bend slightly in the desired direction if you really give it some welly. But much more effective is to step back, turn the handle and step through the door. You achieve your aim of getting to the other side of the door faster, without bruising your shoulder and with no damage to the door.

There is no doubt many aspect of the NHS have improved, but that is in spite of the target regime and not because of it.

Best,

Rob

It may be useful to read the report of the Total Place Roundtable in The Guardian since I will reference some comments from it there.

The sub-title of the article is:

Total Place is a new initiative to examine how cutting out duplication in public service delivery can improve quality and reduce costs. But is this really a ‘magic bullet’ solution?

Well nothing is ever a silver bullet. As W. Edwards Deming said, “There is no such thing as instant pudding.” But the general idea to join up services to remove duplication and concentrate more on prevention than cure, is a a good one that most people would agree with. There are some encouraging comments, such as:

Hospitals have been trialling specific units for patients with alcohol related problems, where they can be given preventive treatment, with co-ordinated interventions from across a range of agencies.

Figures from the police reveal that a single murder costs around £1.1m in services, from investigation to the legal and social services work, so the scale of preventive cost savings – especially in reducing gang violence, for example – is parallel with the moral gains.

“The focus needs to be on changing the culture and behaviour within public services, rather than fixating on financial outcomes.”

These are encouraging but one comment from one of the participants worries me.

The table first heard an account of the Birmingham pilot, where £7.5bn of public sector cash had been mapped out. “The idea was to follow the money, and see where it led us,” a participant explained. “Families are facing a range of issues, some not interconnected, but the challenge was to dismiss short-term thinking to analyse the £7.5bn coming into Birmingham every year.”

If you follow the money, then you will come to the wrong answer. Budgets and costs are an output. First you should seek to understand the demand on the system and if you do that with the whole system in mind, for example how mental health services, social services and hospitals can work together on chronic alcohol problems, then that is all the better. But we shouldn’t be starting with the money. That is using the tail to wag the dog.

Efficiencies in the these type of systems can be made, but we must ask,

• What is our purpose?
• What is of value to the public?
• How can understand demand for that?
• How can we design service to meet the demand, designed for the value and removing the waste?

If you do this properly you design public services that the public like and as an output you save money. You also get improvements in results that far outstrip anything that anyone would have dared to set as a target.

One more little niggle from the article:

Kent, a two-tier authority with a £10bn budget, now has a single phone number and single web portal for all local government services.

It goes on to say that “getting even this far was an uphill struggle”. Well instituting a call centre isn’t providing value but it is certainly following the money. Trouble is the failure demand that will ensue will cause costs to rise, not to fall. Having one place to call does not mean that the services delivered will be joined-up, in fact quite the reverse. Whereas, previously you might have had the call answered by someone who did the work in the department you called, now you get a call centre agent who is, by construction, removed from the work and only connected to it by workflow systems.

I wish the Total Place idea well. I just hope the practice would match the intent.

Best,

Rob