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.

What is the purpose of purpose?

The first of W Edward Deming's 14 points for management is to "Create a constancy of purpose".  This is still very relevant today. 

For example, I recently listened to a programme called The Charity Business on BBC Radio 4.  In the third episode we learn that some charities are excellent at raising funds, but their impact is minimal.  We also learn there are other charities that make a huge impact, but are not so good at raising funds.  It means we end up giving money to the charities that are good at pulling on our heart strings and persuading us to donate, while other charities that make a difference go out of business. 

It sounds like some charities focus too much on fund-raising, to the detriment of their original purpose.  This is one reason why constancy of purpose is important – to keep everyone focused on doing the right things. 

Here are four more reasons why purpose is important:

1. Alignment.  In Fourth Generation Management by Brian L Joiner, he uses a diagram similar to the one below to highlight the importance of a clear purpose. 

The top box represents an organisation with no clear purpose.  Teams or individuals end up operating on their own – each pulling in their own direction.  It can result in chaos and dysfunction.  The bottom box represents an organisation where the purpose is clear and meaningful.  Everyone is pulling in the same direction

2. Decision making.  In this 30 second clip, Olympic rower Ben Hunt-Davis explains one of the reasons why his team won gold in Sydney.  During training, every time they had a decision to make they'd ask themselves "Will it make the boat go faster?" 

This was the purpose of their training.  It gave them clarity about what they were there to do – even if it meant missing out on trips to the pub.  Likewise, you can ask "will this help us achieve our purpose of...?" when making those difficult decisions in your organisation.

3. Motivation. In Drive by Dan Pink, purpose is one of his three ingredients of intrinsic motivation.  His research finds that "The most deeply motivated – not to mention those who are most productive and satisfied – hitch their desires to a cause larger than themselves".  Later on in the book he also says "If people don't know why they're doing what they're doing, how can you expect them to be motivated to do it?"

4. Measurement.  Purpose defines what your organisation exists to do.  If you don't have measures that relate to purpose, how will know how well the organisation is performing?  John Seddon puts it nicely with this diagram:

If measures are derived from purpose, it allows you to experiment and innovate with method.  You use your measures to see if your efforts are improving your achievement of purpose.  The mistake a lot of organisations make –  which I'll talk about in a future post – is when measures start with an arbitrary number instead of purpose. 

In my next post I'll share the most important lesson I've learned about defining the purpose of a service.  In the meantime, feel free to comment below, or share this with someone you think could be interested.

Why it's all about the thinking

For my first post, I'm going straight to what I think is the most important topic – management thinking. 

One of the biggest lessons I've learned is that if the thinking doesn't change, real and sustainable improvements won't happen. 

If you're familiar with John Seddon or his organisation Vanguard, you'll probably recognise this diagram, showing the relationship between thinking, the system, and performance:

Performance means things like customer satisfaction, costs or revenue, and staff morale.  It comes from the organisational system – rules, structure, performance measures, policies, procedures, roles, IT, etc.  The system isn't there by accident or chance.  It's been designed by people (usually those in charge), based on their thinking – the assumptions and theories about the design and management of work, and about the people who do the work.

Conventional organisations are based on what you might call command and control thinking.  Typically you find top-down control, decision-making removed from the work, targets, functional silos, etc.  Although often well intentioned, it leads to poorer service, increased costs, and a disgruntled workforce. 

Most of my failed attempts at improvement are because I didn't change the thinking.  At best those efforts lead to minor and short lived process improvements.  I've typically made at least one of the following mistakes:

1. Putting too much focus on the analysis, rather than changing thinking.  In the past, my focus has been on gathering data and analysing data. For example, big sample sizes of demand and end-to-end measures, or detailed process maps showing.  Data is important – really important – but on its own it won't change the thinking.

2. Doing all the learning myself.  Or sometimes only doing the learning with  the front-line team, and not with the leader who has the authority to change anything.  This comes partly from the previous point – my desire to get all the analysis.  But if I do all the data gathering and analysis, nobody's thinking will change.  It's also because I've not always put enough focus at the beginning on what Peter Block calls contracting: "an explicit agreement of what the [in my case internal] consultant and client expect from each other and how they are going to work together".

3. Leaving the thinking bit until last.  I used to get all my analysis done, and then finally try to introduce the thinking behind it all at the end.  This didn't work well.  Now I take any opportunity to talk about thinking right from the start.  For example, early on when listening to demand we might discover an average call-handling time target.  Before, I would have saved talking about the thinking behind it until the analysis was done.  Now I'll pause, and start asking questions like "how does this target effect the customers?" "how do your colleagues feel about it?" "why did someone think setting this target was a good idea?" "what are the assumptions behind it – about how we should manage, and about people and their motivations?"

So now you know some of my mistakes.  You might be wondering a few things.  How do you change thinking?  What should you replace the old command and control thinking with?  And how will you know if the new way of thinking leads to better performance?  These are all subjects I'll attempt to cover in future posts.

For now, what do you think about thinking?  Please feel free to leave a comment below, or share this post with anyone who could be interested.