My mission to slay tickbox to save the NHS

The tickbox phenomenon, which I have been writing about for most of this year, seems finally to have reached its apotheosis with the appointment of the queen of tickbox, Dido Harding, to run the government’s test and trace service.

Now I have never met her, I’m afraid – I’m sure she is delightful -  but as a former chief executive of one of the most useless phone companies known to mankind, she personifies tickbox: the fantasy, shared mainly by the richest and most powerful people in the world, that data and algorithms can describe the world accurately.

Because of this mistaken idea – that we can hand over human decisions to machines, programmed by our philosopher-kings – explains why, at the heart of so many centralised and technocratic organisations, you have this remarkably widespread fantasy that the data and the ticked boxes that pour in from the front lines represent exactly what they purport to.

That is a working definition of tickbox – the gap between official rhetoric and numbers and the reality.

If you want to know why our test and trace system has failed to work, it is this – over-centralised privatised outsource contractors, whose only skill is providing the ticked box figures that ministers crave, have been put in charge of an enterprise that simple must be made to work and they just can’t do it.

Other examples of tickbox may vary. You might for example find tickbox demanding impossible information, impossible in the real world. As it did via Home Office computer system to Anthony Bryan, caught in a kafka-esque world, managed by immigration software and deaf algorithms. The Windrush generation former painter and decorator (whose story was recently dramatised) provided huge amounts of evidence to the Home Office, as they prepared to deport him from the UK, which the system studiously ignored.

Second, tickbox works because the centre really wants to wash their hands by automating decisions, for example over the cladding used on Grenfell Tower and other blocks.

Third, it tries to automate tough decisions to insulate the handful of people in charge, as it did with the recent exams fiasco – damaging lives which failed to fit into its neat formulae.

That is why I have helped start a petition to lift the tickbox curse from one of the most centralised organisations in the UK, the NHS – where so many resources get eaten up ticking boxes which don’t really relate to reality, for all those three reasons (and others too). All of them because the centre believes they can control everything on the front line, and has faith that the numbers they receive from there are real.

I don’t mean checklists here: they provide a means to save lives – as long as they are controlled by individual surgeons and their teams. Tickbox seems to provide an answer to the problem of accountability in huge, centralised organisations. Sir Keith Joseph, once Health Secretary, used to complain that he had struggled his whole life to get his hands on the levers of power, only to find they weren’t attached to anything.

But tickbox and the automation of accountability only works if the flow of information is at all accurate, and tickbox information rarely is – because of Goodhart’s Law (any numbers used to control people will always be inaccurate).

When the chips were down to fight covid, NHS managers lifted the tickbox yoke because – as they told staff in one north east trust – because “we are all grown-ups”.

Of course that was right, but they were before and they still are. It is time to lift that tickbox burden and restore the trust in the UK between top and bottom, so that – once more – the only thing that matters is what individual patients need…

So go on, please sign!

This post first appeared on the New Weather blog.

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How to untickbox the NHS

GO on! Sign our petition!

It is a strange divide in society. Some people furrowed their brows when I told them I was publishing a book called Tickbox, and really seemed to struggle to understand what I was on about – while some people grasped it immediately. Among those who got it, I couldn’t help noticing that many of them worked in the NHS.

It maybe that the NHS is not the most boneheaded user of tickboxes but – as a huge over-centralised operation, managing people looking after people’s very individual needs, somehow the gap between appearance and reality (which is for me the heart of tickbox) – the NHS has seemed to involve more tickbox-inspired sclerosis than most.

Yet, what did they do when the NHS was absolutely the front line? They rolled it back, the whole amalgam of online tickboxes, KPIs, targets and centralised controls that NHS managers rely on to monitor performance.

“Decisions that used to take months or even years because of endless, pointless form-filling and meetings are now made in less time than it takes to boil a kettle.” This is the new NHS under COVID-19 according to Dr Max Pemberton. One doctor we know was told by managers that sudden freedom was because NHS staff are “adults” and can be trusted to make the right decisions on the spot.

And of course that was right. They were adults yet they still are as the whole tickbox thing wafts back across the NHS. That is why we started our Radix petition to stop it in its tracks.

And what their managers want is often to make the best impact on the company hierarchy. Which in the NHS means saving money – or appearing to. Then the argument shifts, almost imperceptibly, away from ‘Is this the best thing for this patient?’ – to ‘Are we meeting our KPIs?’

It provides a fake, simplified and mechanistic view of what is undoubtedly a complex system – but complex in a different way. Anyone who thinks differently looks as if they are missing the point, but it is actually the system that misses the point.

My Tickbox book argued that this is part of what might be described as the simplification – not to say vulgarisation – of the official mind. And it is already having serious consequences. We have already witnessed during the current crisis how inaccurate the figures will be for Covid-19 deaths or tests or people affected – and how officials intervene in the definitions (for example on safe protective equipment) the whole time.

I am also hoping the NHS increasingly understands that tickboxing may simply achieve the opposite of what was intended. It can be a real hindrance, not the great time saver it purports to be. Mere tickboxing enables a lack of accountability.

All the systemic failures enabled by tickbox – from Mid Staffs Hospital onwards – have to be measured against the extreme pressure on services brought about by the austerity policies of successive governments, which is why NHS managers are trying to tickbox compassion into the mix, fearful perhaps that the real thing is unaffordable.

That is what happens in large centralised organisations when tickbox takes control.

Part of the costs fall directly on NHS staff. “The Berkeley University psychologist Christina Maslach defined ‘burn-out’ as a combination of three feelings: ‘emotional exhaustion, depersonalisation (a cynical, instrumental attitude toward others), and a sense of personal ineffectiveness’, wrote Atul Gawande, the doctor and author of The Checklist Manifesto. These were his conclusions:

“Many fear that the advance of technology will replace us all with robots. Yet in fields like healthcare, the more imminent prospect is that it will make us all behave like robots. And the people we serve need something more than either robots or robot-like people can provide. They need human enterprises that can adapt to change.”

I am quite hopeful here because of Health Secretary Matt Hancock’s campaign against bureaucracy. He can see ow much it gets in the way. There are some self-help ideas we might encourage as a stopgap in the NHS. We could, for example, learn from the Dutch health service and their schrapsessies.

That is the name the new movement in the healthcare sector in the Netherlands has given to the ‘scrap sessions’ they hold at work to identify regulations, targets, tickbox rules it would be possible to get rid of completely. The idea emerged in 2018 from the Dutch thinktank (Ont) Regel de Zorg, but the movement now has a head of steam behind it, and the backing of ministers.

It is high time we spread it more enthusiastically over here. Hence our petition to demand the government to permanently remove their tickbox regulations on the NHS, partly to thank staff, partly to recognise their adulthood and partly to save money – which should be reinvested in the frontline.

We hope in the end that covid-19 could mark the moment we stop infantalising NHS staff, and also the moment we lift the threat of tickbox over all public service staff.

Because, decentralising the management of the NHS is the key to its survival and the most urgent element here is to stop the centre from their disastrous habit of micromanagement. So please sign the petition and pass it on if you feel as strongly as we do about this.