Tackling backlogs - a conversation with Andy Brogan

Recently on the Next Stage Radicals Facebook group, fellow 'radical' Adrienne Rogers started a conversation about backlogs.  At the hospital where she works, lots of activity has understandably had to pause because of coronavirus, meaning backlogs are growing.

Backlogs will be a cause of concern for many of us at the moment.  This crisis could mean:

• Increased demand, like at a council's Welfare Benefits service I spoke with earlier on in this crisis, who had in two weeks received as many claims as they had in the previous two months.
• Fewer people to do the work, because of increased sickness, self-isolation, caring responsibilities, etc.
• Simply being unable to do the work, because it's unsafe or impractical.  I spoke with a council's Food Safety Team, who've been unable to do any of their scheduled inspections. 
• The exceptional priorities this crisis has requires of all of us, with people taking on different roles, or being moved to where they are most needed.  That same Food Safety team were speaking about the possibility of them doing coronavirus contact tracing, as they're already skilled in doing this for other diseases like salmonella.

During the conversation, Andy Brogan (founding partner of Easier Inc) shared what I thought was some really helpful advice about backlogs, in both business and human terms.  I thought others might benefit from this advice, and I was keen to know more, so Andy and I got together for a (remote) chat where I asked a few questions. Here's how it went.

Q1: If you’re a team with a backlog, how might you start to tackle it?

The first thing is to consider how we frame the problem.  It's easy to think of them as backlogs of activities or things to be done.  In healthcare and public services, we may see queues of referrals, assessments, appointments, and wonder "How will we ever get through these?"

So I'd suggest we start framing our backlogs as backlogs of people to help, not backlogs of things to do.  This has a few benefits:

1. In our backlogs there may be multiple items relating to the same individuals, families, households, or communities.  By framing the backlog as 'people to help' rather than separate activities, we can collapse out activities in to something much more effective.  This strips out the noise and duplication and gets what matters done much faster.  I saw this an an insurance firm a few years back.  Their backlog was around 10,000 items, but through a household centred lens it was really about 1,500 households.  Understanding this totally re-framed the operational response. We created small multi-skilled teams that had case ownership rather than task ownership, and saw the queue evaporate within a few weeks. 
2. Taking this human-shaped lens gives us the opportunity to focus on doing only what matters now, post-crisis. The things that were wanted and needed pre-crisis may look very different by the time we get back to work, so doing the activities that are sat in in our queues may not be doing what matters now
3. Another opportunity – especially in public services – is to recognise our relationship with people, families, households and communities may have changed.  Their capabilities, expectations, and openness or desire to embrace different methods of engagement may have changed. They may be more willing to use technologies like Zoom or social media.  The pride in our key workers and the spirit of responsible citizenship and reciprocity between people and public services that this crisis has encouraged may mean there are greater opportunities to support people to self-help, to help each other, to volunteer, to hold group consultations and so on.  We can capitalise on the experience we have all been going through without abusing it, and we can all emerge a little bit different, a little bit more capable and perhaps even a little bit kinder than before.

Q2: What information might be helpful for people to know while working on a backlog?

I might start by asking “who is in my queue?” instead of “how much is in my queue?”

I’d think about where it makes sense to look at the queues as individuals, and where it makes sense to look at them as ‘hotspots’.  By this I mean groups of people who share characteristics that may be important to how we can help them.  For example:

• people who are related or live together (where a household shaped response could be an opportunity);
• people who live in the same area or access the same community centres, e.g. schools, GP practices, sports clubs, etc (where providing or supporting a local response could help;
• people who have the same needs and requests as each other (where supporting them as a group of providing peer support could help)
• people who are likely to be capable of self-help (where written information, a conversation, or group session could set them free).

There might also be a simple basis on which to prioritise who to focus on first, for example who is likely to experience harm if we don’t help them within the next days or weeks?

Q3: What are some practical things a team working on a backlog could be doing – say on a daily or weekly basis?

There are a few things that I think are really important for teams to do.

1. Make the backlog visible at the team level.  Avoid running lots of little backlogs everywhere which end up hiding or compartmentalising the issue, and creates extra pressure on people to reduces their queues, which may not be the same as doing what matters. 
2. Have a clear priority rule for who gets helped and in what order.  Without this it's really hard not to get drawn into fire-fighting the 'hotline' requests which quickly pulls effort out of shape. 
3. Have clear definitions of what good looks like, both for the people your work exists to help, and with progress through the backlog.  For example, how would you want the people you are trying to help feel as a result of your help? When would you have helped 'enough'?  What would you want to be true as a team at the end of each day, week, month, etc?  What would you see if you were making good progress together?  Framing these things can help quickly reduce tensions, make sense of progress, and agree decisions about whether, when, and how to adjust.
4. Have regular check-ins, favouring frequent and quick so visibility and collective responsibility are maintained.
5. Have meaningful 'in the work' support, where someone is paying attention to what's happening and why, what's being learned, what may need adjustment, and where judgement calls need to be made or supported.  

This last element can really grease the wheels of progress and provides a great opportunity for rapid and dynamic learning and adaptation, as well as a sense of ‘being in it together'.

Q4: What challenges to you think a team might face?

Every context will reveal its own challenges.  A key one for management and leadership is to recognise that the old measures may not be helpful in the new world. Continuing, for example, to monitor things like waiting times for specific activities doesn’t really make sense in a human shaped – rather than activity shaped – world.  This will also drive behaviour back in the direction of ‘getting things done’ over ‘getting people helped’.

In some contexts a predictable and important tension can also be around where service scope should start and end. As we take a person-shaped lens we may see that what would really help people is something quite different to what we might normally offer.  Or it might be something that is beyond our normal scope of expertise. In such circumstances it really helps to have clarity and peer support:

• Clarity: do we have a shared collective understanding of when we have done ‘enough’? Can we afford for our customer to define this for us? Can we afford for them not to?
• Peer support:  is it easy for us to get help with decisions that may be at the boundary of what’s clear and certain? Have we baked this into 'the work', which will enable us to keep working effectively and at pace.  Or is it remote, hard to access, or hidden behind committees, email queues, etc – which will leave us juggling activity rather than getting people helped.

Q5: Can you give any examples of when you’ve helped people with their backlogs?

In pre-crisis times this was a common issue.  I’ve helped quite a few organisations and teams – public and private sector – with backlogs.  One of my favourite stories is about what happened after I’d left a pensions firm I’d worked with. They had a predictable problem every year during what they called 'pension season'. A flood of requests to top up pensions before a tax deadline would hit the firm and send queues into meltdown. It would take them a full quarter to recover their position.

When I worked with them we realised a more human-centric response to their work in general – not just for pension season – would mean using multi-disciplinary teams who had case ownership, much like the earlier example I mentioned. This naturally led teams to do a degree of cross-skilling. People in the teams spotted that simple tasks they could each do separately but not all do together, could be easily trained in and would create more resilience. 

When I checked back with that client 18 months after working with them I asked ,"How was pension season this year?" to which they replied "You mean pension week?"  The teams had cross-skilled so that each team member now had the specific skills required to do pension top-ups. This took the operational capacity to handle ‘pension season’ from being a few skilled people to a system wide capability. Pension season now hardly registered as a blip on their radar.

Q6: What opportunities might this give us to improve how we work once this crisis is over?

I think the big opportunity here is not just backlog busting nor even ‘just' better, more effective, more timely or more efficient service. All of these things are possible and valuable but the huge win is what it does to the workplace. 

Imagine a workplace where you:

• Have real collective ownership of the work that exists to be done
• Work together to stay on top of it
• Are supported to grow your skills in response to the opportunities you identify for adding more value
• Have a voice in what’s happening and how that’s affecting you as individuals and your shared mission as a team
• Have a greater and much more systematically supported connection to the purpose and value of your work because you are dealing in humans and families and communities, not in widgets, referrals, tasks and activities.

In a pretty profound sense, I think that what can seem like a fairly prosaic task – "tackling a backlog" – could in fact be a perfect opportunity to truly re-humanise work.  Don’t you?

Want to know more?

If you’d like to see more stuff like this, have a chance to chat with Andy, myself, or other like-minded folks, then check out Next Stage Radicals.  

We’re an open learning community made up of people with a passion to make work work better. There’s more on the website, or follow us on Twitter, or feel free to get in touch with Andy or I if you’d like to know more.  

How traditional funding would ruin something good

I've been doing some work looking at how we support people who experience domestic violence or abuse, and how we might improve that support.  

During this work, I've gotten to know a fantastic local place that helps women who've broken free of domestic abuse to stay free.  Don't take my word for how great it is – here's what some of the women I spoke with there said about it:

• "Of all the services I've dealt with, this is the only one that works."
• "You are actually helped and understood.  They treat you as a person as a whole."
• "It's welcoming, and you are listened to.  It's like a family working together."
• "When you experience domestic abuse and leave the relationship, you don't know what you don't know.  They take you through it one step at a time.  They help with all the applications."
• "You get peer-to-peer support.  It's compassionate, and survivor led."
• "It's informal.  There's lots to be said for a cup of tea and a chat."
• "They pull out every stop for the children.  They helped get my child diagnosed for ADHD."

They don't turn people away because of thresholds.  No one completes an assessment form.  They don't work to targets, KPIs, or other metrics.  They build relationships with people, understand what really matters to them, and support them in achieving what matters.  The support is 'bespoke-by-default', responding to each person as an individual.  They have a network of friends and volunteers on hand with all sorts of skills – a handyperson, locksmith, experts on the law, housing, immigration, benefits, etc.  The support isn't time limited, and some of the women have been coming for years.  Many turn their experiences in to 'gifts' they can support their peers with, or have become volunteers themselves.

They've created a safe, welcoming, compassionate, and supportive atmosphere.  There's a real sense of community among the women – at times I struggled to work out who were volunteers or paid workers, and who weren't.   

And it works!  In five years none of the women they've supported have returned to the abusive relationship. 

How might traditional funding ruin it?

In my naivety, I asked one of the people who runs it "Do you get any funding – from the council or health or anyone else?"  The answer was a resounding "No".  The place is funded unconditionally by a charitable organisation, through local donations, and through the work of its friends and volunteers.  

I started to speculate on how this place might be ruined if they were commissioned or funded in the traditional and prevailing way.

• Traditional commissioning starts from an assumption that competitive markets work for public services, giving greater choice and efficiency.  To understand why this assumption is so flawed, read this book chapter from Kathy Evans, Chief Executive of Children England.  
• This means, in practice, the focus is on price.  To compete and compare on price, the service needs to be specified.
• Specification means a standardised service response.  This is where things really start to go wrong.  People are people shaped – they don't fit in to neat little boxes.  A standardised response cannot cope with the huge variety of people's need.  As Mark Smith writes in his blog, "[Standardisation] takes away an opportunity to apply judgement and nuance, borne from experience and an appraisal of what matters to whomever needs help"
• Once you standardise you have functional specialisms or silos.  Each service or provider is commissioned to only do specific things, and therefore won't do others.  The people who come to that service are looked at and labelled through the lens of whatever that service is commissioned to do.  Then they're referred or 'sign-posted' to the next service, who repeats the process again. 
• When providers are commissioned only to do certain things, they introduce thresholds or assessment criteria – essentially gate-keeping.  The thinking here is there's only a scarce resource available, so you need to ration what you do.  
• But, when people get turned away (or referred, or sign-posted), it means they either present elsewhere in the system, or come back later when their needs are higher.  Thresholds can be a false economy, as when people get worse they are more expensive to support.  
• Instead of building trust and relationships with their partners, commissioners and funders are typically interested in accountability (which is a nicer way of saying management by fear).  It means providers becomes concerned with external approval, which undermines intrinsic motivation and responsible practice.   
• To hold providers to account, commissioners use monitoring and performance management.  They ask for detailed information about how workers are spending their time, what activities they're doing, or if they are working to the standard.  A damaging example is 'time and task' commissioning in homecare services.  
• Another way to hold people to account is by setting numerical targets.  I've written about the problems with targets in a previous post.  They change the focus from doing the right thing to making the numbers look good, even if that means doing the wrong thing.  
• The undesirable effects of targets can be made even worse by payment by results.  They are a way to financially reward providers for producing data about targets, and not for helping the people they exist to help.  

Imagine what the place I visited might look like if it were commissioned in the traditional way?  What would it be like for the women who go there?  What would it be like for the staff and volunteers?  Would it be any more efficient?

Why do we fund and commission in this way?

As business writer Aaron Dignan puts it, "The way we work is broken.  It was invented 100 years ago on a factory floor for a world that no longer exists".  Commissioning is a symptom of these outdated ways of working, grounded in mass-production and 'Taylorism', which results in treating people as though they are parts in a production line.

In the 1980s, public services started to embrace what was subsequently called New Public Management.  This meant running public services as though they were private sector organisations, being more 'business-like', treating citizens as customers, and attempting to use competitive markets to reduce costs.   This led to policies like Compulsory Competitive Tendering (CCT), later replaced by Best Value, which are is still with us today.  

What are the alternatives?

There are many folks who know much more than me about how to improve funding and commissioning practices.

My go-to person for this is usually Toby Lowe.  He's an academic, who's previously been a provider of commissioned services, and has done loads of research in to this area with voluntary and public sector organisations. With his colleague Dawn Plimmer, he's put all of this into a brilliant report called Exploring the new world: Practical insights for funding, commissioning, and managing in complexity.  You can watch him speaking about it in this 13 minute video.

Andy Brogan, co-founder of Easier Inc, has recently written an accessible 'how' to report.  It gives lots of insight and helpful advice on how to put what he calls 'Commissioning 2.0' in to practice.

Jo Gibson from Vanguard has been doing some great work in this area too.  You can watch one of her students speaking about how they changed the way they commissioned homecare services in this 20 minute talk.  Jo is co-hosting a one-day commissioning event in London on 5 May 2020 which is worth checking out.

Over to you...

Do you work for a an organisation that provides commissioned or funded services?  How accurately  does what I've written here reflect your world?

Likewise, if you're at an organisation that commissions or funds services, are you still doing it in a traditional way, or have you started to look at some of the alternatives?

I'd love to read your thoughts in a comment below.  And please do feel free to share this with anyone who might be interested.  

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.

Finding the purpose of a service in four steps

In my last post and the one before I discussed the importance of purpose, and the perspective it should be considered from.  Here I'm going to share some tips I've learned to help others define a purpose of a service – set out in four steps. 

1. Gather people together from different parts of the service
A service is normally made up of teams and people performing different functions (a common aspect of a command and control design).  When you split a service like this, the people in each function tend to become like characters from Rashomon, with different views about what the service exists to do as a whole.  It's helpful to bring those views together, and start aligning them around a common purpose.

2. Ask them what the purpose is
I've adapted an activity Dan Pink does.  Ask everyone "what is the purpose of [this service]?" and  instruct them to write it on Post-It notes.  Stick the answers up, and read them out.  (In local government, I've often had answers like "to carry out our statutory duties to..."   They are used to taking an internal perspective rather than a customer one). Next, have a discussion and agree a working definition of purpose.

At this point I've made mistakes.  I've been impatient.  I've wanted them to nail the purpose too early on, and wasted time debating the issue and getting nowhere. 

3. Go and study demand
Instruct the team to observe customer demands on the service.  Listen to phone calls, observe face-to-face conversations, read emails, etc.  Write down each demand in the customer's own words.  Consider what matters to the customer at the point of making a demand.  If you speak with customers, ask them "what matters?"  In a future post I'll write more about studying demand.

4. Ask them again
This time, be clear that the purpose should be from the customer's point of view.  Reflect on what you've all learned about demand and what matters to the customer.  I've always found that by now the team come up with a definition of purpose that's at least very close to representing what the whole service exists to do for the customer.  It can be useful to have a discussion about how this differs from the first version of purpose, and why it's changed. 

 

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The definition of purpose is likely to keep evolving as you learn more about what matters to the customer.  That's good.  The important thing is to be crystal clear about purpose before starting to redesign the service – something to cover in a future post. 

What are your thoughts about these steps?  Would you use them?  How could you improve them?  Feel free to comment below, or share with someone who might be interested.