Hamish Dibley

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Why Conventional Change has to Change: A Better Way to Improve… Part 1

The No Change ParadoxAchieving great service is straightforward if unconventional: give customers/patients/service users what they need. However, convention dictates that to adopt this approach will lead to expensive ‘gold-plating’ of services (quality service but at higher costs).

Instead leaders and organisations seek to follow convention and manage their activities by protecting budgets, imposing access restrictions via criteria or eligibility introducing service level agreements and focusing on efficiency through reducing transactional or unit costs.

Yet, the real paradox is that an explicit focus on managing activities paradoxically increases the very thing organisations seek to reduce – cost. Convention decrees that the answers to problems are already known and pre-prescribed solutions can be delivered through meticulous plans and reports. As a consequence these change approaches fail to deliver in practice.

Take conventional healthcare commissioning in the NHS – a person as a health and/or social care need; their need is assesses and then sooner or (most often) later a service is first commissioned then provided by different professionals.  Service level agreement met, project milestone ‘green-lighted’ and ticked.

What happens is because services are not designed around the need(s) of the person/patient/service user, they represent to the service in the vain hope that their need(s) maybe better met. Professionally, the response to this problem is to repeat the process of assess, commission and provide. The outcome experience of the person/patient/service user is that they continue to represent and costs rise. Why does this happen? It is because the mind-set is misguided.

Conventional business change needs to change

Conventional change or improvement relies on a wrong-headed ‘back-to-front’ perspective. What is meant by this phrase is a rear-guard focus on removing cost by reducing activity and expecting patients to change their behaviour. It results in an obsession with activity volumes and ‘bottom-line’ costs. The one problem with this approach is that it doesn’t work. Back-to-front thinking always leads to distortion of organisational performance and higher costs.

The mechanics of conventional change follow a typical path. Invalidated hunches, opinions and/or data consisting of worthless aggregated activity, arbitrary benchmarking and/or cost volumes are used to identify problems.

Understanding the patient or service user (as opposed to non-user public) perspective in this process is rarely, if ever sought. Agreeing appropriate governance arrangements typically loom large at this point and take-up not inconsiderable internal discussion, effort and time.

Much time is consumed completing a litany of project management induced paper-chasing reports such as project initiation documents or PIDs. Once signed-off this document helps formulate a project plan which is established to solve the preconceived problem. A business case is then written which outlines time, costs and predetermined outcomes.

These outcomes are then ‘monitored’ through office-based completion of reporting documents such as highlight reports full with activity and cost volumes with ‘traffic light’ systems – green for good, amber for somewhere in between and red for bad. None of this involves spending time in the work and empirically understanding ‘why’ things are the way they are.

Improvement activity is often relegated to time-limited projects and people who sit outside of the actually work. Disproportionate time and effort is then spent on conducting public consultations (‘the blind leading the blind’) which replace the opportunity to generate empirical knowledge of what is actually happening and causing problems at the sharp-end, in the work.

Performance metrics derived at the business case stage tend only to measure activity on whether a project is completed ‘on time’ and ‘to cost’. Little regard is made of how much operational improvement is achieved in resolving the real problem(s).

‘Off-the-shelf’, standardised solutions are mandated that usually involve automation or greater use of technology (sometimes referred to as ‘channel shift’ or ‘digital-by-default’); sharing or outsourcing services; restructuring to establish new ‘target operating models’; rationing buildings and service provision; charging and trading services and/or reducing staff numbers. Here abstract cost-benefit equations are the order of the day.

Unless consultants are engaged, ‘delivery’, ‘execution’ or ‘implementation’ is then solely contracted out to frontline staff who are left to try and make the problem fit the predetermined standardised solution(s). Benefits realisation plans are written remotely and focus on the completion of activity tasks not performance improvement.

Consequently, ‘change’ seeks to solve symptoms not address root-causes. The predictable result of this way of approaching improvement are failing projects, higher costs and poorer service as experienced by patients.

Tomorrow I will outline the more intelligent way to conceive of how to change for better and undertake meaningful performance improvement.

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Time for a dose of healthcare heresy

Help WantedRather predictably, the political debate over the latest crisis afflicting the NHS is generating more heat than light. Superficially rules. Discourse reduces itself to a reverse Dutch auction over who can promise more cash whilst at the same time compete to declare unconditional support for the NHS. Stephen Dorrell, former Health Secretary and Chair of the Health Select Committee is on to something when he was quoted in The Economist magazine last year saying that anyone who tries to introduce knowledge and understanding to the issues ‘quickly finds out what it must have felt like to be regarded as a heretic in a more religious age’.

Fast forward to the begininng of a new year and we see numerous acute hospitals triggering ‘major incidents’ in response to ‘unprecedented levels of demand’. Their response is often to hold ‘extraordinary meetings’ that occur with such regularly they lose their original connotation. Hopes that periodic cash injections like the multi-million ‘winter bed pressure’ funding or ad-hoc ‘urgent summits’ will resolve the current predictable morass facing acute NHS hospitals is a fool’s paradise.

In fact, we have worn out all the possible tinkering approaches: from restructuring and merging hospitals to only achieve bigger problems; deliberately fragmenting the healthcare system so that no one reliably knows who is doing what, why, when and where; successive bouts of IT-led change that cost more than the benefits derived by both patients or professionals; imposing arbitrary targets that distort behaviour (such as the ubiquitous 4-hour waiting time indicator or referral to treatment times) and lead to ‘gaming’; increasing capacity which makes performance worse to rationing care (particularly in community and social care settings) that results in a false economy.

Indeed, the belief that we can simply talk or spend our way of trouble is indicative of a paucity of understanding. It is worth remembering that since 2000 we have tripled public expenditure on the NHS but not experienced service improvements consummate with such investment. Years later we still feel the need for calamity talks and emergency bailouts.

Such inertia and belief in extra expenditure is a costly distraction from consideration of the real problem facing the NHS; namely that we have an outdated model of healthcare that is capacity-constrained not demand-led. The current crisis of increasing attendance and admission rates (not the same thing as increasing numbers of people) to A&E is one consequence but not the primary cause of the turmoil.

It is possible to achieve the holy grail of healthcare: better care at less cost but this will require a complete resetting of how we intelligently manage, lead and apportion expenditure across the whole system. The only way that will work is to understand the nature of patient demand that appears and then develop a coordinated healthcare response (through redesigning broken systems, processes and payment mechanisms) that meets local needs – no more, no less.

Demand management: a problem in search of a solution

Understand Your Customers#

Earlier this year a report by the Royal Society for the encouragement of Arts, Manufactures and Commerce (RSA) entitled ‘Managing Demand: Building Future Public Services’ sought to bring ‘clarity to the concept’ of demand management. Yet, upon reading the paper it is clear that it launches into several variations of well-reversed, warm-worded but wrong-headed themes from active citizenry, ‘co-production’ to ‘nudge’ and ‘networks’. That’s a pity as the term itself is relatively uncontested with the focus being on internal cost-efficiency.

Of course, a home truth is that demand management in reality is often made-up of three components. First, it represents a euphemism for restricting access to services. Second, it is used to encourage the growth of self-service approaches to public provision including service automation, colloquially known as digital-by-design. The third element of usage is behavioural change to reduce demand through ‘changing citizen expectations’.

The authors state that demand management is ‘an area of emerging thinking’ and not core work in many local authorities. Yet, they neglect to acknowledge that in practice demand management leads directly to rationing via eligibility criteria and the like, reducing the need for direct provision and pushing self-management back to the service-user. They conflate two approaches – studying customer demand and designing against it with behaviour change. Behavioural insight strategies assume interventions need to take place on the individual rather than the service. Consequently, approaches such as ‘Nudge’ seek to solve the wrong problem.

In service organisations, demand can only ever be understood as person or customer derived. For example, you cannot, as the paper asserts, successfully address ‘failure demand’ – a form of system waste – through prodding people to change their behaviour in response to services that are not designed to work from their perspective. How local public service organisations understand and respond to this demand is what counts. And on that, the paper is both incoherent and lacks detail.