David Boyle's Blog, page 90

Asking the little boy's question

The little boy in the Emperor's New Clothes, the Hans Christian Anderson story, was the best kind of consultant - outside the structures of imperial management enough to be able to see the truth.  When I wrote my book The Tyranny of Numbers , more than a decade ago now, I suggested we use the little boy's question - actually it was a statement, not a question - as the antidote to fatuous or dubious data and the tickbox systems that spread from it, especially in the public sector.

I was reminded of that this morning by the NHS blogger Roy Lilley, who describes how hospital managers have turned David Cameron's narrow objective of speaking to patients every hour into a particularly meaningless process, quoting a nursing sister:

"Since Cameron decided every patient has to be spoken to every hour (like we don't) the managers have gone barmy. I'm usually responsible for eight patients in a bay. I have to tick and sign a box that I have spoken to each one of them every hour. That's 64 ticks I MUST sign for. Managers are terrified that the CQC will turn up and want us to prove we're doing it. I work six days a week, so I tick nearly 400 boxes a week." 

Here in a nutshell is what has gone wrong with public services over the past decade and a half.  There is so little understanding about how irrelevant this kind of process is.  Anyone who travelled in the USA in the 1980s will remember all those boasts in diners that you will be 'served within one minute' - which meant in practice that you got bunged an iced water while you waited.  And how targets for answering the phone within three rings just then gets you put on hold elsewhere in the system.

Not only is it ineffective, it is hugely expensive - and dangerous too, because there are more important things that nurses need to do to tick boxes.

Roy is kinder to the importance of data than I am.  The problem with data, as far as I'm concerned, is that it is collected for the good of managers not patients.  Hence the IT system brought in at A&E at King's College Hospital some years ago now, which forced nurses to go through 22 pages of questions before they could actually deal with each patient in front of them.

Which brings us to the little boy again, because for every fatuous piece of data, there is a devastating question which needs to be asked.  Yes, the school is top of the league tables, but does it educate?  Yes, the processes have been complied with in the production of this meatball, but will be do you any good to eat it?  And in this case: yes, we speak to the patients once an hour, but are we treating them humanely?

The challenge is to find the combination of leadership and the human scale that genuinely makes these things happen, and knows when it doesn't, without needing to pay a cadre of expensive auditors to crawl all over every objective and approved process (what does it cost? More of that later).

How to provide humane homecare

One of the most amazing people I met during the Barriers to Choice Review, which is where I have been for the past seven months, was an extraordinary and articulate lady in Dorset - who deserves to be listened to for her stories about Atos assessments and other inhuman treatment by the social care system.

She is an a wheelchair, and I especially remember her description of her morning visit by a care worker arriving to get her out of bed and into the shower.  It is nearly always somebody new as she buzzes them in through the front door.  “I say hello to my carer when they put their head round the door and introduce themselves," she says. "Within seven minutes, I am naked with them in the shower. It’s a strange relationship.”

That really brought it home to me the poverty of so much home care, and it was confirmed by the reports this morning that a quarter of social care organisations are failing at least one of the Care Quality Commission's standards.

The CQC's scrutiny is pretty inadequate, and still based on the discredited tickbox system of regulation, so we won't really learn much from that.  Many local authorities are reducing the number of care contracts they have dramatically, so that they can monitor them better.

This makes a lot of sense, but in the short term it certainly reduces choice and diversity - and also probably encourages the kind of pile-it-high-sell-it-cheap style of homecare that we all know about: never seeing the same person twice, rushed care, being put to bed at teatime and all the other indignities of care without any kind of relationship.

Conventional wisdom suggests that this is the only way that the burgeoning costs of social care can be controlled - and social care and children's services alone are due to take up the whole of our local government budgets by the early 2020s (see the famous Graph of Doom).  But I am not so sure that the economics of scale apply here (I'm not sure they apply anywhere much).

The trouble with economies of scale is that, usually, the diseconomies of scale rapidly overwhelm them - and poor, relationship-less care, by massive agencies which would prefer their clients to be more dependent than less, is almost certainly no exception.

I was enormously impressed by some of the micro-providers I met, and by the work Nottinghamshire County Council has led to encourage their emergence (nearly 50 new micro-providers over two years).   They are able to provide proper homecare, by familiar people, with attention to detail and relationship, in a cost effective way.  Yes, it is small scale - that is why it works - but, as they say in the USA: small + small + small = big.  Choice in homecare, via personal budgets, really matters.

Humane homecare doesn't have to be provided by micro-providers.  The big agency Home Instead is one of the more enlightened providers here and manages the same thing.  In both cases, though, there is a minimum price below which it is impossible to go.  The big issue is now how to provide effective care, at scale - but without pretending there are economies in scale - at an affordable price.

I believe it can be done, but not without unleashing the huge resources of neighbours and community at the same time - and this is only in its infancy.  Once again, I am indebted to the systems thinker John Seddon for the basic rule - if you try and control costs directly, they tend to rise; if you look at where the demand is and provide a flexible system to meet it, then costs will fall.

This matters very much indeed, and for selfish reasons - it is our own futures we are planning for.

Beyond the stale Euro-debate

Some way underneath the debate about Britain's place in Europe - which we may be pretty sick of by the time we come to the referendum - is another, far more interesting, debate.  But it hardly sticks its head above the parapet.  Certainly not long enough to ask it any questions.

It is about Britain's role in the world.  Where will we trade?  Where will we earn our foreign exchange?  Where will we export to?  Can we afford to be ourselves?

The pro-European argument is pretty clear about that one.  We will trade with Europe.  The Euro-sceptic argument is a bit more confused.  Sometimes they say we will carry on trading with Europe.  Sometimes there is a sort of implication that we will be closer to the United States (there is a geographical problem about that: my Latin master wrote a book of poetry years ago called Atlantic River, but it isn't actually even a Channel).  Sometimes there is the germ of an idea that we will trade instead with the emerging markets, India, Brazil and all the rest.

These are very important issues, because all four options need thinking about and planning for - and there is precious little debate about Britain's economic future over the next generation, and rather a lot of assumptions that the money is just going to flow in to run our services and schools.

Personally, I'm coming round to the idea that we need a different way of creating money altogether - but that is another issue.

For the time being, who is going to have this debate?  Are we just going to be battered by the Daily Express for the next four years, while we cower in the trenches?  Or watch miserably as Newsnight pits a rabid pro-European against a rabid Euro-sceptic and the argument doesn't even inch forward a few inches?  The trench warfare metaphor keeps popping up unbidden - I can't help it....

How do we really engage people, and help them think about our national future, broadly and intelligently?

Well, my friend Titus Alexander has been thinking about this and has proposed a Citizen's Forum for Britain in the World, designed to spread the discussion in radical new ways - paid for by replacing the current costs of consultation, by out-sourcing and crowd-sourcing some of the costs of policy development, and by strengthening the British case in EU negotiations.

This is how he sets out the case.  See what you think.

The fantasy at the heart of so much regulation

You have to listen through three hours if you missed it on the Today programme this morning, but Christopher Haskins hit the nail on the head about the growing horsemeat scandal.  I sat up on my seat when I heard him talk about regulation, because I think this gets to the core of it.

We have to fill in all this paperwork, he said.  "Everyone fills in forms to say they are doing the right thing but they don't actually look at the factory to see whats going in on the factory."

So this is my excuse for writing about the regulators for the third blog post running, because hidden away here is the clue we are looking for to what has gone wrong - not just with food regulation, but hospital regulation (think Mid Staffs) and banking regulation (think Libor) too.

Because the regulators were re-organised in the Blair and Brown years to make their main focus the auditing of process.

We need to look a little more closely at why this was a problem, because it isn't immediately obvious why intelligent people should think that checking procedures should have automatically meant that regulation had been satisfied.  The was the utilitarian fantasy of the New Labour years, that process was all that counted - worse, that if you got the procedures right, then the outcome was inevitable.

Hence Michael Barber's Deliverology team hunched over traffic lights targets that bore little relation to what was happening in the real world.

Hence the Department for Education's room where all the targets converged, a kind of fantastical dashboard which gave officials the illusion that they were at the controls of a vast education machine.

Hence the bizarre reliance on the auditing of target figures instead of actual leadership in our public services.

It was a capitulation to the discredited ideas of Frederick Winslow Taylor, that there was "one best way" to do any job.  If the procedures were there, then the outcome must follow, or so they believed - encouraged by the Taylorist cheerleaders in the IT and management consultancies.  It was also a system designed to undermine professional judgement: judgement was not required - the numbers and processes were designed centrally.

So there are two problems here, and we need to talk about them.

First: our regulators are designed and structured for that kind of vacuous regulation - a kind of virtual regulation that assumes the real world is like the virtual world, when it isn't.  Simply calling for professional standards is not enough.  The regulators have to be re-organised.

Second: the coalition has still not really understood the mistakes of the public service and regulation system they inherited.  There is still no narrative to explain what went wrong - and explain it to the public or grasp the nettle to do something about it.  Because they haven't grasped it and, in some ways, are still making the same mistakes (shared back offices, digital by default, payment by results).

If we don't do anything about this, the following will happen:

1.  There will be more scandals in every area of public life, wherever the approved procedures were organised before anyone could imagine what else might go wrong.

2.  The sheer expense of regulation will rise exponentially.  In social care, for example, local authorities already have their own regulation structures because they know the Care Quality Commission isn't up to the job.  If you have inadequate regulators, you get over-regulation.

3.  Professionals will not recover their room for manoeuvre or their sense of responsibility, because the regulators are still trying to measure their compliance with processes and procedures - rather than the effectiveness of their judgement.

So now you know!  I've written more about Taylor in my book The Human Element.

Horse meat and Mid Staffs

The news that rather more frozen lasagne are 100 per cent horse than we realised is really no big surprise, is it.  The story will run and run (as they say in horse racing circles).  But it does shine a light at the problems with regulators - and it reveals exactly the same problem that the Mid Staffordshire Hospital scandal does.

Does anyone really believe that the horse meat adulteration would have been brought to light by the Food Standards Agency if the Irish regulator had not stumbled upon the problem?  Regulators don't take a punt on these things normally because they are not set up to do so.

Here is the problem.  Our regulators were designed and structured in the age of targets.  They are designed for a world of tick-box regulation, the inspection of procedures, and the collection (though not distribution) of large amounts of data.  The Care Quality Commission still gets its figures from care homes around the country once a month by fax.

They were constructed in the New Labour period when regulation was all about targets, procedures and tick box auditing.  It was the height of the great fantasy that the screeds of figures that poured out of the new IT systems bore some relation to reality.

If we are going back to the basic idea of inspecting professionalism, rather than figures, as David Cameron implied, it means we are going to need professional inspectors, not automatons operating software.  We are a long way from there at the moment.  So pause a moment and think about these scandals - and the banking scandals too - not as isolated tragedies, but as the unravelling of the regulatory system.

In all these cases, the scandals were about abuses that were widely known about by managers.  In all these cases, these were ways of doing things that had become accepted, if not publicly known.

That is why public debate has not quite caught up with the problem, as I said yesterday.  When the Francis Report has nearly 300 recommendations, it is too much for any administrative machinery to swallow, too much for any one minister to lead.  We needed a big idea - professionalism rather begs the question: this needs to be a policy idea.  An proposal about where the big levers are.

Why is why I also agree with the indefatigable NHS blogger Roy Lilley when he says: "Francis is complicated when the NHS needs simple. Francis is a jungle and the NHS has a reputation for hiding in the undergrowth."

It is time we looked at solutions to the basic problem: the regulatory system inherited from the last government was precisely what undermines professionalism.

Why the Francis Report doesn't cut the mustard

Julia Neuberger has had a varied career, as a rabbi, as a Lib Dem peer, in the health service and as Gordon Brown’s volunteering tsar.  But she provided a fascinating insight into why some institutions feel human and some don’t, and it could do with revisiting in the light of yesterday’s Francis Report on the Mid Staffs Hospital scandal.

In her book about older people, Not Dead Yet  she described how her uncle was neglected in three of the four hospitals in which he lived his final weeks.  She explained that the one exception was also the hospital which was most cash-strapped:
"When my uncle eventually died, in the hospital which really understood and respected his needs and treated him like a human being, there were volunteers everywhere.  In contrast, there was barely a volunteer to be seen in the hospital which treated him like an object, although it was very well staffed.  At a time when public services are becoming more technocratic, where the crucial relationships at the heart of their objective are increasingly discounted, volunteers can and do make all the difference.”
She was writing shortly after the Mid Staffs deaths first came to light, and suggested that volunteers might be an antidote.  In wards where older patients might otherwise be mistreated or ignored, she said: “the mere presence of older volunteers are the eyes and ears that we need.”  Human beings provide that kind of alchemy, however target-driven the institution is around them.
It isn’t quite clear why this is.  Is it because the presence of outsiders is a reminder to staff of what is important and how to behave?  Is it because it stops them getting too inward-looking, or prevents that brutal contempt for customers that – as we have seen – can emerge in target-driven organisations, public and private?  I don’t know.  
So I thought about Julia's uncle again when the Francis Report came out yesterday, because the question of how to humanise some hospitals – those which have had aspects of their professionalism and humanity surgically extracted – is at the heart of the problem he is trying to solve.
Having volunteers on the wards, working side by side with NHS staff is a critical part of the solution.  Having patients and relatives there isn’t enough – that remains an 'us and them' relationship.  So does having volunteer regulators or patients sitting on boards.  Same problem.  But patients working alongside staff to deliver the services does seem to humanise.  That is why the co-production agenda is absolutely critical.
But I am still sceptical about the Francis Report, and for the same reason it is hard not to be sceptical about Sir David Nicholson’s media performance yesterday – the list of solutions is too long, the list of measures the NHS is already taking is just too labyrinthine.  They are both too ambitious and not nearly ambitious enough.
None of them quite seem to nail the real issue at the heart of this, which is a big one.  It is this: over the past generation, we have systematically taken the soul out of the organisations we depend on, with targets and tickbox systems and procedures, encouraged by the big consultancies - and McKinsey particularly - that organisations are great big humming machines which can be managed by numbers (McKinsey's slogan: everything can be measured and what can be measured can be managed (it is nonsense)).  That is a far bigger problem than whatever happened at Mid Staffs, though up to 1,200 dead is a big enough reason to take this seriously.  That is why Mid Staffs may actually be the tip of the iceberg.
Cameron was right that we need to bring back a sense of responsible professionalism.  Of course we need to put patients first (strange that it has to be spelled out).  Francis recommended a range of important measures; changing the shape of hospital boards, making one senior manager responsible for patient care.  But we also need to recognise that all our public services have been hollowed out in the same way.  So have the regulators: they date back to the New Labour era, where McKinsey's slogan ruled - they are structured for tick-box inspections.
So the Francis Report may have added a nail to the coffin of targets and tick box procedures, but it has bot yet slain the monster.  The government is cutting back on targets, but the regulators are not – and we are also introducing a new generation of targets in the form of  payment by results contracts (basically numerical targets with rewards attached).  They all tear the undermine professionalism and effectiveness because they reduce success to one-dimensional measures.  They spread inhumanity.  They also spread failure.
So when Nicholson talks about the two million people who are members of foundation trusts, you have to ask if this membership has any depth.  What do they do?  How exactly do they hold professionals or boards to account?  None of this was included in the original legislation and it remains unfinished business.  Julia Neuberger's story, and my experience too, suggests that their influence will be felt with patients 'doing' stuff not 'saying' stuff.
What the Francis Report does do is to put effectiveness on the agenda.  Because, in the end, this is about whether or not our organisations have become too stupid to make a difference.  It isn't just about deaths, though that is the core issue.  It is about making things happen, and how the ability to do this slipped through our fingers with vastly expensive reforms which were supposed to bring accountability – but have actually torn the heart out of our organisations, in more ways than one.

Health IT and the coalition's great systems failure

Th systems thinker John Seddon has a talent for confronting ministers with unpalatable truths.  His latest newsletter describes how he confronted Health Secretary Jeremy Hunt as he announced that all patients records would have to be digitised.  Has anyone met a doctor or ambulance man who actually faced a problem that digital records would have solved, he asks?  He suggests not.

But the confrontation with Hunt ended with Seddon pointing him in the direction of an American report which explained that computerised records were intended to save the US health industry $81 billion, but now turn out not to have done so.  Worse, the hospitals which digitised the fastest have cost more.

I hope Hunt really considers this report because there is here a fundamental truth, which Seddon has been pedalling but successive governments have been deaf to.  Expensive IT solutions that prevent systems from dealing effectively with diversity - the range of human requirements that different people come up with - will end up locking in costs.  Customers who don't fit start bouncing around the system and creating costs with each bounce, what Seddon calls 'failure demand'.

What is infuriating about all this, from a UK point of view, is that the coalition understood that the New Labour regime had introduced inflexibilities into the way public services ran.  They realised they made services more expensive, and they began to remove the targets which were at the heart of the inflexibility.

But there was a big BUT.  They failed to construct a narrative which explained what had gone wrong with services in the Labour years - and why they were so expensive and ineffective.  And worst of all, they swallowed whole the Labour caboodle of massive IT solutions and merged back office services which were the source of so much trouble.

So the inflexibilities continue, and they harden and the costs rise - and, just when services most need to be able to deal effectively with diversity (delivering the Universal Credit, for example), the disastrous old solutions are trundled out again.  Often what deals with diversity most effectively, and cheaply, is a human being with the responsibility to act as they see fit.

IT has a critical role to play, but not everywhere. In the wrong place it builds in organisational stupidity.

Over-optimism and the Huhne legacy

Years ago, sitting over lunch while Iain King sketched out my horoscope in return for an omelette, I watched him peer suspiciously at some marks on the paper.  "Yes," he said.  "I see this in a lot of Liberal Democrat charts.  I think it means unreasonable optimism."

How right he was.  It is a defining feature.  That is what keeps the Lib Dems pushing when all about them are losing theirs, and so on and so on.  It keeps them cheerful in the most depressing circumstances.  It isn't necessarily a useful attribute, but it is better having it than not...

I thought of that conversation today when I heard the news about Chris Huhne.  It explains why I was told, on the highest authority, that he would not be charged.  It also explains why I was told, on equally good authority, why he would be acquitted.  The downside of having unreasonable optimism is that you believe the good news and ignore the possibilities of bad.

I have to say I felt terribly sad when I heard that Chris was stepping down from politics.  I will miss his sharp intelligence and tiggerish manner.  He brought a huge amount to the Lib Dems and, since they are in government right now, to the nation.  I may never have known him terribly well, but I feel like I've known him for ever - certainly back to the strange days when I was trying to make sense of running New Democrat.

It would be possible now to be hypocritical about guilt and otherwise, and I suppose one should be - since goodness knows who will read this blog.  But my main feeling is a sense of tragedy.  What must have seemed at the time like a simple error, compounded by a relationship breakdown badly handled, ends in - well, we don't really know the end yet.

So, since I am an unreasonable optimist, here are my three top things from the Huhne Legacy:

1.  The Green Deal, for all its short-comings, which is an ambitious programme to bring energy-saving at scale to every street in the nation.

2.  Mutual public services, the main recommendation of his ground-breaking 2002 report to the Lib Dems on the future of public services (which could do with re-visiting).

3.  An ambitious vision of renewable energy for the UK: perhaps in practice still not ambitious enough, but a good deal more ambitious than if there had been no Huhne.

I hope that I will continue to know him and work with him for many years to come.

Why girls do better

It is a strange reversal of fate that makes you worry a little about your son, at the hands of an educational system that is more geared up to deal with girls.  Until 1990, it used to be the other way around.

An important new piece of research in the USA by Christopher Cornwall shines some light on the problem, and finds that - if boys were not marked down for poor behaviour - then they would achieve similar results to girls.  That is where the roots of poorer performance seem to begin.

There was a fascinating article about this in the New York Times today by one of the first academics to warn about the problem, Christina Hoff Sommers.  She says that the first developed nation that can solve the problem about the under-achievement of boys will reap huge economic benefits.

This is a somewhat American point of view, but there is no doubt that there will be economic benefits bringing in more wasted knowhow and imagination.  Even more so for the nation that first solves the even bigger problem of male delinquance.  But I was struck by the end of the article where she points to the UK as the example to be followed.  Is it?

It is true that the problem that the educational system doesn't really suit boys is recognised here.  Boys are nudged towards reading things online, as if that will really help the basic problem.  The basic problem still seems to be unaddressed, which is that a great deal of education at primary school level is not designed to capture the imagination of boys - by which I don't just mean that it isn't full of technological gizmos.  That a great deal is staggeringly dull, and that crucial parts of the educational establishment seem to believe dullness is a sign of high standards.  That the sins of boys - restlessness, frustration at being cooped up indoors - are frowned on more severely than the sins of girls.

It is true that we have not yet succumbed, as the Americans have, to the drugs industry - pumping inattentive boys full Ritalin.  But that does not yet mean we have taken the intellectual leap necessary to tackle the problem.  I only repeat what Christina Hoff Sommers says, quoting Richard Whitmire and William Brozo:  “The global economic race we read so much about — the marathon to produce the most educated work force, and therefore the most prosperous nation — really comes down to a calculation: whichever nation solves these ‘boy troubles’ wins the race.”

The iron law that will sink nuclear energy

The news that Cumbria County Council has vetoed a further search for a deep nuclear waste storage site is definitely a setback to reviving nuclear energy in the UK.  The fears that people might imagine the Lake District and immediately think of radioactive waste - rather than Wordsworth or Ruskin, for example - was enough to put the dampeners on things.

It isn't the final nail in the nuclear energy coffin.  The authorities have proceeded so far without a solution to long-term waste storage, so I expect they will carry on.

But there is an iron law which will provide that nail, and when civil servants at the Treasury understand it, I think the nuclear programme will quietly disappear.

It is this.  The costs of renewable energy generation are bound to fall over the next generation, as technical advances and new manufacturing methods kick in.

But the costs of nuclear energy are bound to rise.  Every time there is a scare about the safety of nuclear waste storage, and every time there are nerves about terrorists getting hold of plutonium, the precautionary and security costs will rise, and probably enormously.

It depends on how you compare the costs of nuclear and renewable generation but, these days, they seem to be level pegging.  The iron law says they are bound to go different ways.

I humbly submit this as a whole new Boyle's Law.