Manufactured outrage won’t help elderly patients

John Humphreys was apoplectic when interviewing Ann Abraham on the Today programme.  She has produced a report detailing several cases of appalling treatment of elderly patients in the NHS.  How on earth can these wonderful dedicated NHS staff we keep hearing about allow such abuse?  Ms Abraham did not try to give us any insight into how such things happened, merely echoing Mr Humphreys’s anger.

Not long after the interview there was a rather interesting counterpoint in the sports report.  Garry Richardson was interviewing the trainer of one of the horses killed at Newbury over the weekend, asking him about how he and his staff felt about the whole thing. This was clearly designed to bring on the normal outpourings of emotion that are now the expected face of public grief.  Such a a beautiful horse; a real character; we’re all devastated; we need answers….and so on.  Instead all he got was, more or less, just a bad day at the office and life goes on.

That would be a more helpful attitude in the NHS case.  Whatever Mr Humphreys and Ms Abraham are suggesting, it really isn’t hard to reconcile the dedication of NHS staff to systematic abuse of patients.  It’s what Richard Adams in Hitchhiker’s Guide to the Galaxy called the “SEP field”, which guarantees a cloak of invisibility.  SEP stands for Somebody Else’s Problem.  Anybody who has worked in a large organisation is familar with the idea of bad things happening while everybody involved is convinced they are doing a highly professional job.

The SEP field arises from the way we organise work, splitting it up into separate bits for which individuals can take responsibility.  We only look at our bit.  Bad things happen between the bits.  The first reaction is to blame management, who are supposed to be making sure the whole thing adds up.  And the quickest and easiest response for management is to make the process yet more complicated by adding in more bits, with checks and controls.  That’s how they tend to behave when people get outraged.  But it doesn’t really help, because the main problem is complexity; nobody wants to take wider responsibility because they don’t understand what’s going on.

This is an old problem, and solutions should be familiar.  You simplify processes, empower staff to act outside their normal remits, and engender team-working attitudes.  Simple but hard.  It means telling people comfortable with their narrow jobs, who think they are doing wonderfully well, that actually they are part of the problem.

But for NHS managers that should be another day at the office.  We, the public, should be encouraging them to be braver.  Instead we stoke up the outrage, and even start suggesting the NHS doesn’t need managers at all.

The NHS needs better leadership at ground level.  We should be demanding it.  Perhaps we should even ask ourselves, as Jeremy Laurance does in the Independent, whether our beloved NHS is capable of ever managing itself properly ever.

Public services are different

As he left office as Prime Minister, and age ago in June 2007, Tony Blair wrote the following in The Economist:

Public services need to go through the same revolution – professionally, culturally and in organisation – that the private sector has gone through.

It is easy to understand how politicians become frustrated with the leaden ways of so much of the public sector.  And the private sector has indeed been revolutionised in the last two decades.  Recently I’ve experienced this private sector revolution full on.

Somebody has been setting up mobile phone contracts in my name.

The first I heard of this was when a welcome arrived through the mail.  My daily post hasn’t been this exciting for years (well since the last time somebody did this).  Then comes the difficult bit: I have to phone the company to stop the contract.  Since I don’t actually have the phone and the free service line that goes with it, this usually means phoning a premium number and then wading through the various options.  Funnily enough none of the options says “If you want to report a fraudulent transaction press 3” – it’s always “other” at the end of the list; one company only lets you in if you have a PIN – not easy if you didn’t actually set the contract up.  Eventually you speak to somebody with a script, sometimes in India; actually this bit usually works OK: these people are polite and know what to do; only once was I just passed round the office. And there it seems to end; somebody gets a free handset and a few days worth of free calls.  Just another business expense.

It is a huge, horrible impersonal nightmare of systems, procedures, filters and scripts, with the minimum human contact.  The fraudster doesn’t know who I am.  The company allows the fraud because it is worth the expense.  I have to wade through the system to protect myself.  This is the dark side of the private sector revolution of which Tony Blair writes.  The personal element is sucked out and crime lurks in the fringes.  Perhaps Prime Ministers are cocooned from this.

The process is relentless.  I should know, since I used to manage a financial services operation that underwent just such a transformation.  The starting point was a clumsy labour-intensive operation, not easy to manage; the service may have had lots of human interfaces, but you didn’t really know what the staff were doing: not until too late and you had an irate customer.  Then along comes a salesman with a system that helps you control all this and keep proper records.  He or she would be gushing: you would save money, improve the quality and customer satisfaction all at once.  So you implemented these wonderful workflow and customer relationship systems, and indeed you could improve controls and improve quality of service.  But if you wanted to reduce costs as well, then you had to keep the customers away from the workforce and build barriers.  And then came a process called “de-skilling”: using less skilled staff, usually in a location were wages are much lower, and giving them simpler procedures to follow.  And the pressure to reduce costs is absolutely relentless, not least because mostly the public chose lower costs over better service.

Clearly there is a big upside.  The public can consume more and (usually) gets more choice.  No doubt this is what Mr Blair was thinking of.  If everybody is going to get richer, or even just have more leisure, then we must produce more per person.  This is just another way of saying that the personal content in the goods and services we deliver has to be less.  Sweden is often cited as an example of a society that is well off without rampant, exploitative capitalism: but try finding a member of staff at IKEA.  And, we shouldn’t view the past with rose-tinted spectacles: services may have been more personal, but they were often shoddy and high-handed.  Overall we are better off.

But public services are different.

Personal contact, and understanding the user’s individual needs is often of the essence for public services – think of schools, doctors, social workers.  And simply deciding that somebody is too difficult to deal with is not an option.  If people fall off the edge they create even bigger problems.  In fact so many of societies problems are the result of lack of human contact and understanding – think of antisocial behaviour or mental illness.  Public services should be more human not less.  If they were, we’d need them less.

What we need is a complete rethink of public services, not copying blindly from the private sector.