There's No Efficiency Without Effectiveness

There has been some debate about the workload faced by GPs over recent weeks.  Claims that the level of demand is unsustainable were given a boost by the recent publication by Deloitte's which concluded that primary care needs to work differently if it is to survive the onslaught.  Yet our studies show that getting in doesn't mean getting help and the relentless pursuit of improving access has destroyed value from a users perspective - creating the very problems the report highlights as needing to be solved.  This post details the experience of someone who has studied GP practices and, perhaps surprisingly, shows how a focus on the patient, the doctor and the problem to be solved not the implementation of conventional management approaches might be more effective.

It is so engrained in our society that it almost feels like a basic human right – the ability to see your GP when you need to. However, so dire is the crisis facing our NHS that even this appears to be under threat with Deloitte claiming that soon there will be so much demand for GP consultations that there is an urgent need to change the system. Well, whilst innovation is all well and good, and the unnecessary use of GP time should no doubt be designed out, I still find it hard to read this news without a tremor of moral disquiet. Can it really be possible that things have got this bad? Perhaps more ominously, can we really believe that those who have presided over us getting to this point have the perspective and wherewithal to turn things around?

In the past 18 months I have had the chance to study 3 separate GP practices. In each I have seen the same thing – significant levels of failure demand, that is demand caused by failing to do something or failing to do something right. It is not too much to say that our general practices – alongside our hospitals, ambulances, police stations, benefits offices, citizens advice bureaus and whatever else you care to mention- are swamped by people who are only there because the systems which are meant to be helping them are failing to do so effectively.

Let me quote a few numbers.

In each general practice studied I have seen obvious failure demand running at about 20%. That is, of every 5 or so consultations around 1 will be because of something which was a clear failure in the health or care system (NB not necessarily a failure of the practice itself). Now, I’m not talking about complicated stuff here, just simple, honest to goodness failure such as, “I was discharged from hospital yesterday with these drugs and I’ve no idea what they are for or how often to take them”.

Then there is the more complicated stuff. Scratching the surface of the remaining demand – the demand which doesn’t at first pass look like failure – I’ve found myself wondering at how much of it too may be avoidable. Take this example, which was related to me by a patient waiting in one of the practices (reproduced with permission):

A 9-year-old boy (the son of the lady I was speaking to) had warts on his nose and was very self-conscious about them. Friends at school had commented on them. He had visited the practice 5 times in the past 12 months about the problem but hadn’t seen the same GP twice. Until his 5^th appointment the boy had been told by each successive GP that no treatment was possible and that no referral to a specialist would be accepted. The GPs were adamant that the boy just needed to wait for the warts to go away on their own and to stop bothering them in the meantime. At the 5^th appointment the boy’s parents had insisted on a referral being made and the GP had grudgingly agreed. Within 2 weeks the specialist had seen the boy, treated the warts and they were gone.

Anecdotes can be misleading I accept but they do make me wonder. So too did the data revealed by a sample of the last 90 patients to be consulted at one of the practices I visited. Of these 90 patients only 1/3 had attended just once with the same problem in the past 12 months. The remaining 60 patients had attended on average 4 times but it was statistically normal for them to have attended up to 15 times in 12 months for the same problem. I repeated the same analysis in a second practice and found the average to be 6.8 consultations per year with an upper control limit of 20!

The third practice studied was different to the others. It was a single-handed practice for one thing but more than that, the GP there was truculent about much of what he was encouraged to do by others from outside his practice. They wanted him to have fixed appointment times, same day booking, triage and more besides. He preferred to simply tell his patients to turn up when they needed help and he’d see them as soon as he could and for as long as it took to do a good job.  Despite his practice list being nearly 2.5 times larger(!) than the other practices I’d visited, he conducted the same number of consultations per year (when both the list size and the consultations are normalised to take account of the number of GPs in each practice). It was a straightforward, indisputable fact that this guy's patients simply did not turn up nearly as often as the patients of the GPs at the other practices.

It made me think. What is the real problem that GPs need to solve? Is it that they need to manage access to their service or is it that they have to manage the success of their consultations for their patients? You see, the defining feature of the single-handed practice was that, whilst anything else was up for grabs, the patient consultation was sacrosanct. Nothing could compromise it. There were no arbitrary rules such as ‘one problem per appointment’ or ‘8 minutes only’. There was no handing over between clinicians from one consultation to the next. There were no barriers to access – not even appointment times. Just the patient, the doctor and absolute clarity for both that, by the time the patient left the consultation, everything in that doctor’s power would have been done to understand their problem and to help them to understand it for themselves.

So what can we learn from this? Well, perhaps nothing conclusive without further study but nonetheless it does beg some interesting questions. Has our health system put access ahead of success? Has a preoccupation with productivity replaced or obscured clarity of purpose? Does good doctoring look like going slow to go fast - a focus on end-to-end effectiveness rather than transactional efficiency? There are more besides but perhaps it’s all just as simple as saying that there really is no substitute for taking the time to do the right thing. 

How to motivate people

A recent study from the University of East Anglia found that the expectation placed on local government employees by central government policymakers had led to uncertainty, anxiety and an erosion of professional confidence.  The study, which focused on the experiences of senior public sector staff, also found that the pace of change is so rapid that it has created incoherence and inconsistency, which in turn has sapped motivation and encouraged risk-aversion in work.  My experience is that this hypothesis seems to hold.  Not great though when you have at least £20bn of savings to make.

So, in the face of poor morale, what does good leadership look like?  You would expect a good leader will want to rise to this kind of challenge and use this as an opportunity to show some great leadership.  They may ask the question "how do I make my staff happier and more motivated?"  They might be concerned to boost morale among remaining staff and to build an environment of creativity and fresh thinking.  Sounds plausible, sensible even?

With this question in mind ("how do I...") they may commission a staff survey, or suggestion boxes.  This gives them information - staff are unhappy.  There then might follow a number of schemes; run "be happy" days, write a newsletter or communicate more in other innovative ways, provide therapy, deliver employee engagement programmes, set up incentive or bonus schemes - then run another survey.

Unfortunately the reality is that, as the evidence shows, these approaches are largely pointless.

This has not stopped the NHS system being based on the idea that ever more sophisticated ways of motivating and incentivising people need to be found if performance is to be improved.  QOF, QIPP, CQUIN and any number of other burning platforms are deployed despite it being a conceit that you can motivate people.  This is because true motivation is intrinsic.  As Herzberg said, "if you want people to do a good job, give them a good job to do".

Take incentives.  It seems straightforward enough.  You would expect the evidence to clearly show the link between pay and performance.  It doesn't.  A typical incentive is a "contingent" one - you do this, you get that.  But instead of getting more of the behaviour you want, it turns out this kind of approach delivers less of what you want.  It drives people to focus on the "get that", not the "doing".  In other words, the incentive devalues the task.

For a thorough summary of the research read Alfie Kohn’s ‘Punished by Rewards’ (1993).  Among many examples, Kohn cites research on children being 'rewarded' for reading with tokens which can be exchanged for hamburgers. When the arrangement stops, so does the reading. They are effectively teaching children to not value reading.  You can hear Dr Stian Reimers, a psychologist at the City University, London, talk about financial incentives and performance here too (start at 2 mins 30 secs).

Despite the evidence against incentives, managers still worry about letting go of them.  They fear people will stop working.  However, companies which remove incentives find that:

• people work harder

• people are more inclined to co-operate

• people develop more concern for the whole system (now the system serves the customer's needs)

• turnover of people goes down

Its a paradox.  Incentives worsen the performance of the system.  Removing  them improves it.  The challenge for management then becomes how to move to commitment from compliance.  From extrinsic to intrinsic motivation.

Daniel Pink summarise the three conditions that need to be present in a system to maximise personal commitment rather than compliance (you can see more by clicking on the link below):

•    Autonomy – the ability for individuals to be able to act with choice.

•    Mastery – the individual having a clear sense of the developing personal competence and contribution to the whole.

•    Transcendent Purpose – The individuals clear sense of a purpose larger than themselves to which they make their contribution.

So rather than acting on the evidence that people are more motivated when they work in systems over which they have control, command and control management assumes people can be motivated by extrinsic forms of motivation.

Leaders then seek to answer the question "how do I make staff more motivated" when, as Ackoff would counsel, they should instead ask "why are my staff demotivated?"  In doing so leaders would understand that morale is a symptom.  If leaders tackled the causes instead of the symptoms they wouldn't invest in engagement programmes and many similar schemes because they would understand that they don't have that problem to solve.  No amount of engagement will help change the fact that the system stops staff from helping people.

So how should managers motivate staff?  Acknowledging that this is not possible is a good place to start.  Then act on the system - remove all the things that prevent people who do the work from being able to do it well.  Lead a system that understands the purpose from a users point of view, uses measures that relate to the delivery of that purpose and designs from studying and experimenting rather than "planning" or "specifying".  Doing this will not only improve morale but will drive out costs by managing value far in excess of anything that could be conceived of through conventional thinking.  When that change occurs the culture changes, because now everybody is cooperating around the same purpose. 

References

Kohn, A 1993  “Punished by Rewards” Houghton Mifflin: NY p189

Herzberg 1987 “Workers’ Needs: The Same Around the World” Industry Week 21 Sept 1987: 29-32 p30 quoted in Kohn, A 1993  “Punished by Rewards” Houghton Mifflin: NY p189

Its the system stupid

Another report has been published today, this time highlighting the thousands of errors that occur in the treatment of diabetic patients every week.  3,700 diabetic patients of the 12,800 that were in hospitals during one week in October when the audit was performed experienced a medical error.  

2% of patients (68 in the week studied) developed diabetic ketoacidosis, something the audit lead clinician Gerry Rayman said there could be no excuse for.  17.4% of patients had a severe hypoglycaemic attack while in hospital too.  Seddon calls this failure demand, the failure to do something or to do something right for (patients).  In other words, its work we do but not work we have to do as it is avoidable.  There is a lot of this type of demand in the NHS.

There have been countless reports like this, possibly a reason to explain why they seem to pass unnoticed through our collective consciousness as we rationalise the reasons for it away.  Most typically we focus on the people delivering the care - it is they who must be at fault.  In this case the conclusion is

"training needs to be mandatory to improve diabetes control"

It is entirely plausible that we would think this.  After all, how can anyone be expected to care adequately for someone if they have not received basic training?  Yet it misses the more important point; that in most systems 95% of the performance can be attributed to the system itself (the design and management of work).

That is why the units concerned didn't know these facts themselves and weren't continually trying to improve against them.  Or if they did know they chose not to do anything with this information.  It is why, by not understanding the type and frequency of demand, they failed to train against demand so that they could reliably respond to the demands the patients typically and predictably make.

More to the point, I would hazard a guess that not one board report or directorate report would have any measures of performance relating to this either.  Why would they?  After all virtually every KPI used by the system bears no relation to what matters to patients.

It is a major problem.  Our measures in practice do not reflect what matters to patients.  This means we cannot hope to improve in a way that is meaningful to patients.  

We are expected to believe, as Hayley does in the following video, that performance is down to individuals.  As a result we need to be incentivised with targets, penalties or bonuses.  We then think managers should spend their time coaching and training their workers to improve.

The reality is that as much as 95% of performance is directly linked to the design and management of work.  As little as 5% is affected by the behaviour of the individual.

To paraphrase - its the system stupid.  And my studies are showing that changing the system is as simple as understanding the purpose of what we do from the users perspective.  How change in the NHS is currently conceived will not deliver the transformation desired.  The good news is that this failure demand is predictable and what is predictable is preventable.  There is a better way.

The relevance of #HCSM

This post is a contribution to the #hcsm review #4: The Global Edition.  The purpose is to offer reflections on the use and relevance of social media.


My use of social media can, I think, be best described as naive but improving.  The purpose of entering into the virtual world for me was quite specific.  With others, I was beginning to apply the Vanguard Method in health settings for the first time and wanted to share learning and create curiosity amongst people for a unique approach to change that has evolved over 20 years of application in the private sector and 10 years in the public sector.

My use of #hcsm is fairly limited.  I have a blog, a Twitter account and use LinkedIn, but that is pretty much it, although the blog does link  to other Vanguard resources.  The purpose of using social media was three fold:

• create curiosity in the use of the Vanguard Method and the changes that are being achieved
• stimulate a new and credible debate on how to address the pressing issues facing health systems in the UK and globally through a mixture of story telling and evidence of change within a strong theoretical framework
• provide some insight into how leaders might start to understand their organisations as systems and how, as challenging as it might at first appear to be to apply systems thinking methodologies there is a practical way to do this

The question, then is has the use of social media helped this.  Well, its hard to say.  There are some obvious measures like traffic to the blog, where that traffic is coming from, comments, followers that kind of thing.  One thing is for certain.  I have not changed anyone's thinking - not fundamentally.  The written word is, ironically, an inadequate method to describe what we do.  Better is to hear it, better still is to do it.  I can write the most brilliant piece with the most compelling evidence but it remains easy for people to rationalise arguments or evidence away.  Fortunately I don't start with the idea that I can convince anyone.  The best I can hope for is that people may start to get curious and want to find out more themselves.

What it has helped with is to create connections that previously didn't exist.  I feel like I have made some very good virtual friends whose company I enjoy, even if I don't know them!  Although I am aware that I tend to link with like minded people.

It has helped me learn.  Both in terms of what is important to people and how they define what "good" looks like as well as the generosity with which people share their thinking and work.

It has also shown me how it needs tending and regular contribution to which can be time consuming.  You can see how for some people it is a natural environment and how they can produce work of incredible quality.  But better to turn up to a party with a bottle of wine rather than help yourself to what your host has to offer, even if you are not sure that anyone will drink it.

It has also proved to me that most people turn up to work wanting to do a good job, but the system often manages to prevent them from doing that.  And I really like the fact that i can join in a conversation with anyone from anywhere in the world regardless of their position - an opportunity that is particularly helpful if you remember that the fact that you don't get a response is nothing personal.

I enjoy using social media.  It remains a source of fascination seeing where in the world people are reading the blog and it has been an incredibly helpful way of getting almost instant access to a wealth of knowledge as well as insight into the pressing matters of the day.  I also know that it is creating an opportunity for people to learn about a different way of doing things, whether or not it feels relevant to them.

But it doesn't change the fact that the best relationships are personal, ideally face-to-face and developed over time.  For all the perceived benefits of being able to share and communicate with people through virtual media, actual physical contact wins every time in my book.  The temptation is "digital by default" as it seems so easy.  The reality should be "people on purpose" because that is what matters.

Cultural change is free

In this 50 min video Professor John Seddon (starts at 9 mins) explains why targets make organisations worse, controlling costs makes costs higher and by abandoning conventional management thinking organisations can genuinely transform.

He describes how, through studying your organisation as a system, cultural change happens naturally.

It is an elegant dissection of the organisational madness that pervades our culture and what needs to change to enable any service system to deliver what it is that people want and need.  Better services, happier staff and users and lower costs.  It will make you wonder why we ever created the machinery we have.

From Mindfields College on Vimeo.

Going round in Circles

An interesting article appeared in the Guardian at the end of last week.  It was about Hinchingbrooke Hospital the first NHS Trust to be run by a private company and asked the question "3 months on, what's the prognosis?"

Hinchingbrooke, described in parliament by ministers as a "financial and clinical basket case", has had a troubled history.  The article describes a hospital which, since 2006 has been in deep trouble.  Five CEOs in as many years, 2 external reviews leading to the colorectal department being moved to another hospital and £40m of debt.  According to the article there is now a sense that the Trust is moving away from its unenviable reputation.

A&E performance has moved from being one of the worst performers in the region to one of the best in the country.  Headhunting one of the best A&E doctors in the NHS and giving him a free rein to find solutions, patients now find there are consultants at the entrance to ensure better decisions about patient care are made.

Average length of stay for hip and knee patients has improved because senior clinicians now attend a key meeting at 8.45am they had previously routinely missed.  So with theatres now starting when planned 55% of the time compared to 38% of the time fewer people wait unnecessarily longer.

Where there were 100 patients in beds longer than 10 days, now there are only 30.

Permanent staff are being hired, reducing the reliance on flexible labour and saving the additional 20% it costs for agency staff.  And the foods better.

It all sounds great and must be music to the Secretary of States ears, particularly when the last franchising deal of Birmingham's Good Hope hospital to Tribal Secta in 2003 was terminated 8 months early after the hospitals deficit increased from £800k to £3.5m.  Proof, if any were needed, that competition works, isn't it?

Well, no.  What it is proof of is that improvement is about method and has nothing to do with ownership.  And that the improvements that Ministers expect or demand actually fall well short of what is possible to achieve or that could ever be considered to be included in a "plan".

Without in any way wanting to appear to undermine the efforts of the staff involved, even in conventional management terms, in the case of Hinchingbrooke, the examples quoted of "betterment" are not just picking off the low hanging fruit, but picking up the stuff rotting on the ground.  It is great to know that people doing the work are being allowed to solve the problems they have.  Parsa, the CEO, must have been a breath of fresh air and no doubt something of an inspiration for people who have been used to a different method of working.

Reading the article the method seems to be, get clearer on purpose from the users perspective, listen to staff and let them provide the solutions to the problems that get in the way of doing the right thing for people.  All good stuff.

Yet it is a method that neither goes far enough (focussing as it does on trying to fix one part of the systems problems), nor does it need cost £20m over ten years (the profit Circle will make if all goes well).  This equates to 30% of the surplus the hospital will need to make to clear its debts.

Those in search of policy based evidence will, no doubt, want to talk up the success of Circle and extol the virtues of competition.  Looking for evidence to support plausible but wrong headed policies which create costs to the system overall that are unknown and unknowable.  Competition as the answer to the pressing problems the NHS has to address is the wrong place to put the screwdriver.  In the case of Hinchingbrooke the hospital will not only do things better but it also plans to make money by attracting the 5000 patients who go to hospitals in Peterborough or Cambridge.

It is sounding very much like the familiar core management paradigm where the focus is:

how much work is coming in

how many people do I have

how long do people take to do things

The potential for a de facto purpose to emerge where the purpose is "generate revenue", not "solve my problem" is high.  Time will tell if this happens and what effect this will have on either the viability of the neighbouring Trusts or, if the economists are right, improvements in the quality of care in these units.

Despite the train wreck that is the US system in terms of cost, coverage and outcomes, the Government clings to a couple of pieces of research that seem to suggest that, in some cases there may be some benefits to competition.  If Circle succeeds (however this might be defined), it will add more ammunition to the supporters of competition as a way for the NHS to address the issues it faces.  

However, it misses the opportunity for a bigger prize.  Atul Gawande makes the point that it is harder to get people together to design solutions that solve peoples problems if the de facto purpose of the system (my words) is to maintain or grow revenue.  It hasn't stopped various academics coming over from the US telling us how we should run our system.  I don't think so.

The challenge for policy makers is to move from opinion to knowledge based on a profound understanding of what works, gained from experimenting.  What is needed is a pathological focus on purpose from a users perspective, not competition.  What we design should, therefore, be a consequence of knowledge, not an inevitability of policy.

I hope that Hinchingbrooke does well.  The staff deserve it and it sounds like there is a motivated management team trying to do things better.  Systemically and systematically though, competition is not the method by which this will happen and to place our bets on this being a winner really is a gamble - but with the odds stacked against winning.