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their heels in, they’ll be lucky to get it - reported stats show that at my local hospital, the homebirth service was withdrawn 42 times between January 2008 & December 2009; midwives are not fully trained in, and are not fully confident in, supporting home deliveries; and there is only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…

What's happening in charity fundraising is what's happening in many call centres - and it needs to stop!

Last Sunday, the News of the World ran an exposé on the “shocking hard sell tactics” used by call centre company Pell & Bales to raise money for some of the UK's biggest charities.

The story told of lowly paid workers being put under massive pressure by commission driven bosses to meet their targets. The tactics reported by the News of the World as employed by Pell & Bales are unfortunately the same as those you’d find in a majority of the call centres you might deal with in your day to day lives: heavily scripted conversations, monitored constantly by managers giving “feedback” on how better the call centre worker might have handled the call in order to achieve the desired outcome (in the case of Pell & Bales getting someone’s bank details for a charity donation).

Maybe the charities concerned should look at a different way of working…. Perhaps using a call centre with a different approach, and look at paying a daily rate rather than £60 per donation. Whilst it needs to stack up financially for the charity and the call centre operator, it needs to be a sustainable approach in the long term for all concerned too.

As for the call centres, they should actually trust their staff to get on and do their work –Don’t get me wrong, I’m not having a go at Pell & Bales here – I only know what I read about them in the News of the World and what their former employees commented on the story. Rather, I’m having a pop at call centres in general!

This is because how staff do their work is decided by senior management that aren’t close enough to the front-line and team leaders monitor and control their staff, and measure individuals’ performance against arbitrary targets that have been derived from what the company needs to deliver in its financial plan (in the case of Pell & Bales, this is probably the number of £60 commissions it needs to get for each man day). But whilst that’s useful for the bean counters to know how profitable the work they do is, it really doesn’t help operationally at all.

Since call centre companies like Pell & Bales manage people in this way, they spend a lot of management time ensuring staff to meet their targets and follow scripts (the News of the World reports a former employee as saying “But one boss, who monitored nearly all the calls, said I should have asked her for money at least three times”). Unfortunately, since meeting targets is often outside of staff members’ control (after all, they can’t influence who they call next – for example, if they have no money, don’t support charities, if it’s convenient time to talk to them and so on), so achieving targets becomes more of a lottery. Moreover, constant monitoring and management pressure to perform better puts staff under stress, de-motivates them and has an adverse effect on staff turnover, sickness and absenteeism. A quick read of the comments at the bottom of the News of the World story gives a real insight into how call centre workers often feel - hating the work, listening to heartbreaking stories, staying because they need the money and so on.

To survive in such an environment, call centre workers need to do something – if they don’t leave the situation (which of course in the current economic climate isn’t so easy), they have to either fight (a dangerous strategy whereby you could lose your job)or submit to the system in which they’re operating. In submitting, however, the unfortunate worker (and their line managers or team leaders who are often subject to the same pressures) becomes desperate and often has to lie, cheat or bully. And when the client (in this case Cancer research) comes to listen in to calls “to ensure that our strict supporter care criteria are met at all times”, everything will be done differently. That’s not because the line managers or front line staff are bad people – they are simply operating in a very bad system. Precisely what the News of the World describes in its article.

As the News of the World says – this IS shocking! However, it is not unusual.

We need to see a bit more common sense in call centre management to improve this situation – for charity fundraising as well as every other sector: surely it’s better to trust people and allow them to take the time to just get on and do their jobs properly, allowing them to have the conversation that’s right for the person they’re talking to with the purpose of generating the best they can for the charity?

And if then it doesn’t stack up financially for the charities, then everyone involved should simply admit that an outbound call centre approach doesn’t work in this case, and revert to more cost-effective approaches. Surely that would be Better for Everyone?

Things can only get better in the Student Loans call centre.... or can they?

The media this week have been awash with stories of the review by Professor Sir Deian Hopkin of the Student Loans Company and its inability to meet the demands placed on the call centre. There were incredible statistics being banded about, such as the company answering only 5 per cent of attempted calls at one stage!

The crux of the problem is no surprise to this blogger, and is highlighted early in the 49 page report - “the Company insufficiently prioritised the customer experience and remained inward-looking and process-driven. The impact of failing to achieve this cultural change lies behind the more specific and technical failures identified throughout this report.” I’ve got to admit I was impressed – the professor seemed to have it sussed! Then I continued to read the report, and was woefully disappointed.

The professor makes 14 key recommendations – all of which are pretty wordy, relatively predictable and focusing on, for example, resource planning, contingency arrangements and training.

But knowing that the internal focus and conformance to processes at Student Loans Company was at the root of all the problems, I was surprised to find I had to read as far as recommendation 11 before this fundamental issue was addressed.

And then I couldn’t believe my eyes!!

“11. The Company’s leadership must place the customer experience at the heart of the organisation, reflected in the personal objectives of all employees. Targets and performance measures should reflect the customer experience and ensure the delivery of a significantly improved level of customer service.”

NO!!!!!

Personal objectives and targets will only exacerbate the problem – I wondered if the professor was simply trying to dress up common sense in language that government would understand, so I continued to read the detailed issues about performance measurement…

OK. I was wrong – I’m sorry. The professor doesn’t have a clue how to run a call centre effectively…

But before I tell you what he recommended, let me tell you that Professor Sir Deian Hopkin has a background as an educationalist, whose expertise lies in the labour history and the history of computing. More recently, the professor has got involved in educational policy and the UK skills agenda.

IS THERE ANYONE OUT THERE THAT CAN EXPLAIN TO ME HOW ON EARTH THAT QUALIFIES THIS MAN TO ADVISE ON HOW A CALL CENTRE SHOULD BE RUN????

The professor suggested that the company’s SLAs weren’t typical (i.e. their “minimum standards” were too low), and suggested “a much simpler and more widely used metric to measure contact centre performance is to set a target for answering 90 per cent of calls attempted at all times.”

Oh dear – here we go again!!!

Whilst it’s important that as many calls get answered as possible and it’s useful to understand how many callers hang up, this shouldn’t be a target, nor should it be the key metric used to measure and improve the service.

Measures like this can help call centre managers the means to manage resource in response to volume. But they overlook the most critical aspect of performance measurement: they fail to address why people call and how well (or otherwise) the call centre responds to that call. More worryingly, such measures do not demonstrate calls that could have been prevented by getting things right first time!

So unfortunately for students (and workers in the Student Loans Company call centre), this blogger thinks that things can only get worse in future years because the management of the Student Loans Company have embraced the report and has committed to implementing the professor’s recommendations. This means that both call centre agents and their managers will need to work hard to meet this new target – and in “making the numbers”, they will simply focus on getting the calls answered….

Police call centre hits targets - should we cheer or be worried?

Last week, the Edinburgh Evening News reported that figures have been published to say that the police call centre at Bilston Glen has exceeded national targets (for example in terms of time to answer and the number of calls abandoned by the caller) for answering 999 calls.

Oh dear – they clearly don’t understand how dangerous having targets like this might be….

In a nutshell, whilst we’d all agree that emergency calls need to be answered quickly, the target that is in place (to answer 90% of emergency calls within 10 seconds) is at best arbitrary and at worst life threatening!

This is because setting targets like these changes the purpose of the people doing the work - effectively the focus of their work is moved from ‘do the job well’ to ‘meet the target’.

If the target is difficult to achieve, then the emergency call handlers may only be able to reach it by ‘cheating’. And they will; they will do all they can to avoid failing to meet work targets – especially if, like the call centre at Bilston Glen, they’ve been heavily criticized in the media since they opened! Don’t get me wrong, though - this isn’t because of the people – I’m sure everyone working on the phones at Bilston Glen just want to serve the public well. They just need to be allowed to!

It is imperative to a caller to 999 that their call is dealt with properly and completely, with the appropriate follow up activity delivered by the right people at the right time – not just that their call is answered quickly! After all – someone’s life could depend on it!!

On balance, whilst it’s important to understand how long callers are having to wait and how many callers hang up (after all, they are calling in an emergency, so in an ideal world we’d really like to answer all calls immediately!), they shouldn’t be a target, nor should they be the key metrics used to measure the service.

Measures like this (and others such as call volumes – offered and answered, and calls answered per call handler) help call centre managers the means to manage resource in response to volume. But they miss the most crucial aspect of service measurement: they fail to address why people call and how well (or otherwise) the call centre (or in this case the call centre and other emergency service providers) responds to that call. More worryingly, such measures do not demonstrate calls that could have been prevented.

The managers at Bilston Glen need to start listening to what their callers say, and measuring what matters to them and how well they respond to what callers say. Then and only then, will Bilston Glen become a call centre worthy of public acclaim in its local newspaper!

But will that ever happen? – This blogger remains skeptical….