This is a subject that I have blogged on lots before as well. (Most recently here.) In Nathan's blog he outlines a simple course of action when it comes to finding improvements in delivering services:
- Use the data.
- Probe more deeply.
- Ask more questions.
- Don’t stop UNTIL you have identified a problem AND it’s causes.
- Don’t demand “improvement” until the causes are fully understood.
- THEN target the messages and improvement to the people or areas where it is needed
But perhaps people will answer me this conundrum:
If Francis has correctly identified that one of the main causes of the problems at Mid Staffs was an over concentration on targets to the detriment of a focus on what was in the patients' and public's best interest... how will large scale outsourcing in the NHS (or indeed in the criminal justice system) make things better? How will (for example) payment by results not lead to exactly the same cultural problems that Francis is recommending a move away from?!
If you out outsource, you install contract culture. And in contract culture, how do you hold contractors to account? Through an elaborate system of performance management and (wait for it) targets!
It is behoving upon the advocates of 'market solutions' to explain (with evidential support) how outsourcing will not lead to an even greater obsession with short term targets that what we saw in Mid Staffordshire hopsital.
PS if you are into 'Assumed Incompetence' you will be also interested in 'Assumed Competence' too.... see my other blog post here.
I'm interested in the way that lots of commentators are keen to lump PbR in with a target culture given that in theory, at least, it is absolutely the opposite - giving providers the chance to be innovative and work in any way which achieves outcomes. Of course, PbR in practice has proved vulnerable to gaming and target culture but if we really want a better health service, we should be focusing on (e.g.) getting people walking again pain-free, not the number of hip operations...ReplyDelete
I think the fundamental problem is that sometimes PbR is used as a fig leaf for a policy which is more about outsourcing/privatisation rather than achieving better outcomes.
Russell - where there is money (and ego) - there will be gaming...Delete
I am all for an outcome focus - but I do not think that PbR is really all about outcomes... (as you suggest)
It occurs to me that in principle the new, non-target approach (lets call it systems management) should be applicable to all organisations including those who take up government contracts (outsourcing). Active systems management by enlightened senior staff could ensure those organisations are properly run; really delivering what the customer (citizen) wants.ReplyDelete
The problem lies in two key and related areas; whether what the government wants is what the customer (citizen) wants and also how the government holds the contractor to account.
Government itelf has to be clear about what citizens want (more properly need) and, if it manages that difficult task, it could then check to see whether systems management is being applied (hard?) or set targets (easy) in order to ensure the correct outcomes.
I think, therefore, that outsourcing might work given the correct systems management approach is applied through the processes in both organisations. However that would involve a lot of effort that might outweigh any financial gains and degradation of effective management and control of outcomes as the distance between the responsible supplier (government) and citizen is stretched.
So, outsourcing is at best a risky venture and at worst a guarantee of reduced service.
Mostly agree Tom - but I think we have to very careful about applying systems thinking that derives from commercial entities where the focus is on the customer to public services where the notion of 'customer' is at least complex if not totally inapplicable. Whilst I admire much of the work of John Seddon, for example, he still adopts a rather linear transactionalist model of public service delivery. I favour one that is based on whole systems.Delete
This is cool!ReplyDelete