Telling the politicians how to make the NHS better

This morning, I went head to head with Labour MP John Healey on BBC Look North's news bulletin on the matter of NHS targets. Last night he admitted in a TV debate “We overdid the targets to start with” – sounds good? But unfortunately, Mr Healey qualified this and it all went square… “…but in my opinion, you’ve got to have something … if you want to guarantee patients the treatment”.

Unfortunately, John Healey has got it all wrong. Quite simply there is no good way for the NHS (or any other organisation for that matter!) to set a target, nor is there such a thing as a necessary or good target. No targets will help the patient, and they will almost certainly result in cheating, waste, duplication of effort and demoralized staff… ironically, right at a time when we need public services to be doing more with less!

For example, targets in the NHS represent a whole management factory of internal and external structures undertaking work specifying what needs to be done, as well as monitoring and reporting against targets and explaining any deviation from what has been specified – all this activity is waste which does nothing to improve the health of the nation, but devours resources and demoralises the front line staff delivering the service.

This is because when people know they are going to be judged against meeting of targets, they use their ingenuity and creativity to do whatever it takes to be seen to meet them (and so survive in the system). This can mean cheating, for example by distorting or misreporting data. Let’s look at a couple of examples in maternity services…

So for example, by the end of 2009 there was a government target for all prospective mums to be offered a choice in where their baby was to be born – with home being one of these choices. In reality this doesn’t happen where I live – I was offered a choice of 4 hospitals, and when I asked for a home birth, I was told I “probably wouldn’t be allowed one as they’re only for women who are really low risk” – although there was no medical reason to make me anything other than low risk. Similarly, other mums have reported spurious, emotive, non-evidence based reasons are given to strongly discourage them from home birth (“you’re brave”; “it’s your first birth” “you’re 7 days overdue” etc). When mums to be have dug their heels in, they’ll be lucky to get it - reported stats show that at my local hospital, the homebirth service was withdrawn 42 times between January 2008 & December 2009; midwives are not fully trained in, and are not fully confident in, supporting home deliveries; and there is only provision for one woman in the area to have a homebirth on any one day of the year!

However, if you were to ask the senior managers at the local NHS trusts, they’d probably tell you everyone gets the option to have a home birth. Someone’s not telling the truth, and I imagine it’s not the mums… to me it looks like the frontline staff have to offer a home birth service they’re unable to fulfil due to the way the local maternity care is currently run, so they do what they can to be seen to be offering homebirths.

Another example of cheating is with the target the NHS has to increase the percentage of women who have seen a midwife or a maternity healthcare professional for a health and social care assessment of needs, risks and choices by 12 completed weeks of pregnancy – digging a bit deeper, this seems to be borne out of a desire to get women seen as early as possible in pregnancy so they can access advice to give their babies the best start possible. A sensible target one might think… but what actually happens…?

As I knew I was pregnant ,I rang my local NHS midwives as I wanted to speak to a midwife (as per NHS website advice) ASAP to ensure I did everything I should to give my baby the best start I could. The midwife I spoke to told me they didn’t need to see me for a few weeks as they prefer not to see everyone for their booking appointment until about 10 weeks so they could exceed the government target of 12 weeks. She went on to explain that often babies die in the first few weeks (“it’s heartbreaking really” she said), so it was better to wait a bit longer. Hmmm – so they’d meet their target by seeing me within 12 weeks, and may be saving some time not seeing mums of babies that won’t make it until 12 weeks, but in reality, what they said was against the spirit of the target (see mums as early in pregnancy as you can) and left the patient feeling very upset & without the early advice the target was designed to ensure…

But the staff in the NHS aren’t bad people – they’re just stuck working in a very bad system. Knowing they’re cheating but feeling it is their only option must be awful – no wonder there’s high levels of staff absence, turnover & shortages!!

This is not modernization of the NHS – this is wholesale dismantling of the system we British hold so dear. Moreover, all public services are victims of the same target driven mentality. And what’s frightening is that not one of the political parties seems to understand the best way to make things better!

So what to do? The right thing to do is to abandon all the current targets. Every single one of them! But that doesn’t mean they shouldn’t measure anything – but we need to change the system, design the service against patient needs and measure what really matters to the public: patients, families and relatives! This will lead to a better quality service, systemic improvement of the NHS (rather than its systemic failure), better staff morale, and lower costs – it’s obvious to anyone that it’s in everyone’s interest to do things this way.

In the run up to the election, it’s very easy for politicians of all parties to make promises based on what they think the public want to hear. In the case of the NHS, though, we don’t just want empty promises and the creation of yet more targets and bureaucracy – what we need is a commitment to fundamentally overhaul how health services are designed, delivered and managed.

Politicians and NHS executives need to get close to the work being done on the front line so they can experience first hand the day to day problems encountered by both patients and their carers as well as the things that are going well and not so well.

Patients & frontline NHS staff are the very people that know how to fix the NHS – and the only way politicians can deliver an excellent and cost effective health care service that’s the envy of the rest of the world, is to harness that knowledge. But is anyone willing to listen…? This blogger remains sceptical…

Toyota – once hailed as the right way to work – but is it any more….?

Oh dear – it’s all gone square in Toyota… The company is currently recalling millions of cars due to concerns about a sticking accelerator pedal. A bit of digging behind the scenes of this story, and I’m reaching the conclusion that Toyota have foolishly changed their management focus from quality to growth and are now paying the price… a predicted $2 billion, not withstanding the cost to the Toyota brand!!!

In 2002, the president of Toyota (Fujio Cho) declared Toyota’s intention to be the world’s No. 1 carmaker by 2010 with a 15% share of the global car market.

In striving for this vision, they lost everything that they stood for as a business, and became the same as everyone else in the industry.

Unfortunately, Toyota forgot what it was good at (being the best through its work culture) and focused on growth (just like everyone else) – then suddenly, just like any other car manufacturer, they found themselves looking for ways to cut costs – including a move to common components in multiple vehicle models and outsourcing to and sharing global manufacturing and production.

Toyota always bought all its parts from long term partners - a small group of Japanese suppliers. However, like almost all car manufacturers, Toyota more recently has outsourced much of its manufacturing and production. The recalled accelerator pedals were produced a factory in the Czech Republic - pedals made by Toyota’s original manufacturer in Japan have not had any problems at all.

What is particularly worrying is that the issues caused by the change in direction were raised in 2008 by former Toyota president, Katsuaki Watanabe (now vice chairman), in his speech to Japan’s National Press Club, when he is quoted as stating that Toyota was becoming infected with “big company disease” – arrogance and complacency due to its own success. According to the Associated Press, Mr. Watanabe commented, “The fact that Toyota is growing globally suddenly shouldn’t be used as an excuse [for problems].”

It’s obvious to anyone with eyes that this is all about the basics in management thinking in Toyota. Quite simply, Toyota became the best because of how the company worked – their work culture, operating model and management focus. They had no problems until that focus changed to ambitious growth.

The jungle drums say Toyota once again is being led by someone committed to the traditional Toyota Production System model concepts and who will focus on taking the company back to the fundamentals – that can only be good news for Toyota… even if it does cost them $2 billion to work out that focusing on quality takes you where you want to be, rather then chasing the dollars….

Doing more with less - meeting the management challenge of 2010

This week, FT columnist Stefan Stern wrote an interesting piece entitled “Your task for today is doing more with less”.

Predicting “more with less” as the new management mantra for Stern cites worrying trends in recent research from both Roffey Park (the number of managers that felt performance management was handled badly in their organisation had doubled since last year) and Chartered Institute of Personnel & Development (reported UK job satisfaction at record lows).

Ouch!

The upshot of the article is that the management challenge of these times is for business leaders to get their teams to work smarter & harder by delivering efficiency savings and increased productivity. Stern has really hit the nail on the head with this, which applies equally to leaders in both public, private & third sector organisations– but unfortunately the article failed to offer the answer of how this might be achieved…

Ironically, Stern did allude to the reality that rather than bashing fewer employees to do more of everything they do, doing “more with less” may simply mean taking a proper look at what organisations do, and choosing what to stop doing, and what to do more of.

But in order to do that, your typical business leader will really need to change how they think – they need to stop focusing on the necessity to reduce costs, instead seeking to look at their organisations as systems.

Firstly, and without judgement, leaders need to work with front line staff to understand what they do now and why they do things that way: consider their purpose (what do they exist to do as an organisation?); look at the efficiency & effectiveness of their processes from their customers point of view; and things that get in the way (e.g. traditional performance management, legislation, interpretation and attempts to prevent potential problems).

Only when they have a clear picture of their organisation as a system in this way, can leaders see what needs to change in their organisations – what they can stop doing to improve the work they do to enable them to do more with less.

This isn’t easy though, and it’s certainly not a quick fix – it involves leaders’ commitment and understanding to make a successful change. They need to change the principles they follow in terms of, for example, customers’ experience, job design and how they’ll use measures to continue to improve the work they do in the longer term.

In 2010, these can no longer be leadership choices – they are fundamental to survival of our economy. They are leadership necessities… let’s hope government and business leaders work this out before it’s too late… unfortunately this blogger isn’t too optimistic…

Beating boredom at work - why the role of managers must change!!

This month’s edition of the Chartered Management Institute’s publication, Professional Manager includes an article on boredom in the workplace (http://www.managers.org.uk/client_files/PM%20July%2009%20boredom.pdf).

In the article, Dr Sandi Mann discusses how changes in the world of work, such as the introduction of new working practices like call centres have increased employee boredom – citing that repetition, restricted autonomy & a lack of job control due to “robotisation” and scripting are major factors in the high levels of staff turnover in the industry.

Mann notes the irony that as companies strive more and more to control staff output in order to drive down costs, in spite of the fact that this can severely damage the organisation financially and reputationally because it causes poor work performance, absenteeism, stress-related health problems and job dissatisfaction.

The article goes on to suggest various solutions, including empowerment of staff and elimination of standardisation in the work, arguing sensibly that the cost savings to be made could balance any training needs.

However, this blogger thinks the solution needs to go much deeper, to really get to the heart of the purpose of management.

The current operating model in most organisations (and that which is so prevalent in the dreaded call centre!) is that managers exist to police the work that staff do – ensuring they achieve their set (numerical) targets and conform to procedures & scripts…

Yet what managers really need to do is to optimise their team’s efforts to achieve business aims whilst recognising and understanding individual differences, strengths and interests & the benefits of co-operation and losses of competition.

Instead of encouraging a culture of blame, where everyone conforms, managers need to create trust and an environment in which freedom & innovation flourish.

Then and only then can organisations become truly successful (and have staff that are empowered, with high job control, and doing an effective job)!!