Thursday, 14 February 2013

Asking the little boy's question

The little boy in the Emperor's New Clothes, the Hans Christian Anderson story, was the best kind of consultant - outside the structures of imperial management enough to be able to see the truth.  When I wrote my book The Tyranny of Numbers, more than a decade ago now, I suggested we use the little boy's question - actually it was a statement, not a question - as the antidote to fatuous or dubious data and the tickbox systems that spread from it, especially in the public sector.

I was reminded of that this morning by the NHS blogger Roy Lilley, who describes how hospital managers have turned David Cameron's narrow objective of speaking to patients every hour into a particularly meaningless process, quoting a nursing sister:

"Since Cameron decided every patient has to be spoken to every hour (like we don't) the managers have gone barmy. I'm usually responsible for eight patients in a bay. I have to tick and sign a box that I have spoken to each one of them every hour. That's 64 ticks I MUST sign for. Managers are terrified that the CQC will turn up and want us to prove we're doing it. I work six days a week, so I tick nearly 400 boxes a week." 

Here in a nutshell is what has gone wrong with public services over the past decade and a half.  There is so little understanding about how irrelevant this kind of process is.  Anyone who travelled in the USA in the 1980s will remember all those boasts in diners that you will be 'served within one minute' - which meant in practice that you got bunged an iced water while you waited.  And how targets for answering the phone within three rings just then gets you put on hold elsewhere in the system.

Not only is it ineffective, it is hugely expensive - and dangerous too, because there are more important things that nurses need to do to tick boxes.

Roy is kinder to the importance of data than I am.  The problem with data, as far as I'm concerned, is that it is collected for the good of managers not patients.  Hence the IT system brought in at A&E at King's College Hospital some years ago now, which forced nurses to go through 22 pages of questions before they could actually deal with each patient in front of them.

Which brings us to the little boy again, because for every fatuous piece of data, there is a devastating question which needs to be asked.  Yes, the school is top of the league tables, but does it educate?  Yes, the processes have been complied with in the production of this meatball, but will be do you any good to eat it?  And in this case: yes, we speak to the patients once an hour, but are we treating them humanely?

The challenge is to find the combination of leadership and the human scale that genuinely makes these things happen, and knows when it doesn't, without needing to pay a cadre of expensive auditors to crawl all over every objective and approved process (what does it cost? More of that later).

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alhire said...
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