Review: Beyond Command and Control (in people-centred services)

"Paul's life fell off the rails.  Over a period of 10 months, he was subject to 179 activity records by public servants, involving 91 staff from 20 different teams.  He experienced 12 assessments and 11 referrals, leading to six hospital admissions with total stays of 81 days, while staff generated seven support plans.  At no time did anyone spend time with Paul to understand what mattered and what 'success' might mean to him."

This is from the people-centred services chapter of John Seddon's new book, Beyond Command and Control.  It sums up much of what I've found when looking at these types of services.

I'm already a fan of John's writing, and have read many of his other books.  It was one of John's books that first got me thinking differently about improving services.

I've kindly been sent an advanced copy of the book.  Rather than covering all of it, I'm going to attempt to review the chapter on 'people-centred services', as it's an area I've worked with in local government.

What are people-centred services?

This is a term John uses to describe services that respond when "people's lives fall off the rails in a variety of ways". For example, services such as social care, domestic abuse, and homelessness are some people-centred services I've worked with.

They differ to transactional services as they usually require a relationship with the person first, in order to understand them and their situation.  How an organisation responds to "can I book a squash court" should be different to its response to "I'm struggling with my debt and my health".

Sadly, as John describes in this chapter, we too often see a transactional response when a people-centred one is needed, causing all sorts of things to go wrong.

What's wrong with the current design of these services?

The chapter highlights many of the problems with the prevailing "command and control" approach to designing and managing people-centred services.  Here are some of them.

• Targets. I've written about the problems with targets before. They're often set by politicians, hide the truth, and lead to sub-optimisation: "the time taken to get 'on target' is actually a reflection of the time it took public-sector managers' ingenuity to work out how to at least appear to be on target by gaming the system". 

In the example of care assessments, meeting targets "simply covers up the terrible truth: the extraordinary time it takes people to get through the red tape, mind-boggling number of people involved, the forms, assessments, reminders..." 

• Functional specialisms.  If you approach a council for help you "may be seen by a dozen or more people" each "considering your needs through their own specialist lens". 

I've seen this myself.  People get assessed and referred all over the place – like in a game of pass the parcel.  Each professional is only allowed to do their 'bit'.  All the activity going on here costs so much money, without really helping anyone.

• Standardisation.  A one size fits all approach which means "services inevitably fail to match the variety of people's needs, providing some things that don't help and others that go further than necessary".  Care services are commissioned on a "time and task" basis, meaning you get "30 minutes regardless of whether 10 or 40 might be better".  

This two minute video powerfully highlights many of the problems with this approach.  

• Managing demand. Or as John puts it "rationing by another name: limiting services, finding excuses to turn people away".  This is done in the name of reducing cost.  But when people's needs don't meet the criteria, they are left for the condition to get worse, meaning they cost more to support later.  

This was backed up recently by some superb research by Dr Rick Hood and colleagues.  It found children "screened out" of social care services are more likely to re-enter the system later on, with more complicated (and therefore costly) problems.  This is an example of failure demand, an important term originally coined by John in previous books.  

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The chapter also explains a number of other flaws with typical people-centred services, including budget management, cost-cutting, commissioning, and a belief in market forces.  

Is there a better way?

Yes.  John describes a more effective design.  It starts with understanding demand and doing only the work that's of value to the citizen.  This consists of understanding the citizen and their need in context, helping them establish what a good life would look like for them, discovering what they can do for themselves to live a good life, and lastly looking at what support they may need from elsewhere.  

By focusing on doing only this, and cutting out the forms, signposting, remote assessment, rationing, standardised assessments, etc: "Lives get put back on rails... costs of services provided fall dramatically... and... as individuals and families are straightened out... overall demand begins to fall away".  

There are examples of where this has been achieved from a number of places, including a county council, a Swedish municipality, and some encouraging work done in Wales between a commissioner and care provider.  

In summary

This is an important read for anyone who works with people-centred services, or is concerned about increasing costs and demand in the public sector.  

It gives a crystal clear account of the problems with the current command and control design, valuable insights in to why that design is flawed, and demonstrates an alternative that's better for citizens, better for people working with citizens, and one that greatly reduces costs and demand.  

For a perspective of other parts of the book – especially the chapter on Agile – I highly recommend reading this review from Bob Marshall.

You can find more about the book, including how to order it, here.