Fifteen years ago I was invited by the Cabinet Secretary, to discuss ‘why won’t the front line do as it is told’ with a group of senior civil servants, reflecting the irritation of policy makers with service deliverers. I was asked to cover health, education and the police. This was easier than anticipated as the problems of getting policy delivered transcended organisational differences. Government legitimately sets direction where large sums of public money are involved but policy implementation often fails to deliver the desired political outcomes. It leads to frustration, with politicians blaming the civil service for their failure to deliver and the front line for being resistant to change; civil servants criticising politicians for poorly thought out ideas; managers believing neither has any idea about the reality of change in large, public-facing delivery organisation; and front-line staff being convinced it is all about money.
Delivering desired and sustained change in any large organisation is complex, time-consuming and difficult. Public organisations do not have a clear bottom line. They deliver a mix of services with ambiguous and often conflicting objectives and are staffed by experts who have been trained and socialised to behave in certain ways. Staff have multiple loyalties: to the public they serve, their profession, the organisation they work for and the community. Loyalty to Government is very low down the hierarchy. Policy makers deliver nothing. At their best they create policy which is transformational. At their worse they tinker with subcomponents of complex adaptive systems without fully appreciating the complexity and interrelationships. This results in policy that delivers very little or can even cause harm.
An example is the Health and Social Care Act in England (aka the Lansley reforms). The policy objectives of getting decisions made closer to patients, reducing costs and freeing up the service to be more innovative and flexible to meet the needs of an ageing population were laudable. Delivery required different approaches to the delivery of clinical care that could only happen with the commitment of clinicians. However, the only lever seen to deliver rapid change was organisational restructuring which took time and energy from the people needed to deliver the necessary changes to patient care. It became so complex that no one could fully predict the exact impact of any single component and led to the people working in the NHS being unclear about the purpose. Conspiracy theories of ‘wholesale privatisation’ abounded. The general opposition was dealt with by asking a group of stakeholders to suggest improvements in a piecemeal way. Individual components were changed or deleted without any understanding of how these would impact on the whole. The spectre of large numbers of redundancies and their associated costs led to further fudges. The outcome has been the antithesis of the political desire; fragmentation, loss of grip, local inertia and more central monitoring and regulation.
Reorganisation is a beloved policy tool as it looks activist and gives the appearance of grip. The NHS has been subject to a minimum of twenty reorganisations since 1974. The evidence that this improves the things citizens and staff want is sadly lacking. Public services are complex and are delivered on a day by day basis by professional staff, the majority of whom (whether teachers, nurses, doctors or police officers) are disengaged from political and managerial processes and just get on with their day job.
Change can be delivered but it needs a clear and understood purpose that is shared and resonates with the people who are required to behave in different ways. This can be difficult as policy makers are often unclear about exactly what difference they want to make and may have simultaneous, conflicting desires. Every civil servant has a story of a political discussion where two opposing objectives are desired. Framing clear and unambiguous outcomes in an increasingly complex world is hard. It takes time, discussion and debate. And, for the most complex issues it takes time beyond the normal electoral cycle of four or five years and may require a plural, cross-party approach and negotiation. This means that really wicked problems that only Government can sort, such as social care reform do not get tackled.
Simultaneously policy makers have become more interested in the means and mechanisms of delivery which, superficially, appear easier and quicker to prescribe and monitor. Thus policy focuses on the type of school, its governance and structure rather than what is desired – great teachers who drive and stimulate better educational standards in pupils leading to higher standards in school leavers. The purpose for change is expressed as criticism rather than the need to deal with new challenges and appears hostile or ill-informed to the front line. Effective change engages the front line in identifying how to deliver what is needed but practitioners are involved late if at all. The actions prescribed are never owned by the people who need to deliver, and thus fail.
Few politicians have ever worked in large complex organisations. There is an assumption that failure to change is due to weak management, intransigence or political opposition. The increasing managerialism often comes with a lack of respect for experts and a failure to recognise that some apparently simple things are complex in reality. For example, it is sensible to require every orthopaedic surgeon to use the hip prosthesis proven to be safest and cheapest in scientific studies. It is clearly nonsense for over ten types of prosthesis with a threefold variation in cost to be routinely used. But moving to implementation is not simple. Surgeons need experience and training in using the prosthesis as it can feel different in practice. Operations are likely to take longer initially and there will be more complications. Theatre staff may need retraining and new instruments may be needed. All without reducing productivity and affecting waiting lists. It can be done but just exhorting the system to do it without understanding the challenge will not deliver at pace as small changes must be made and sustained by many people.
Poorly designed incentives can act as a block to change. Incentives result in individuals behaving in the way that is most favourable to them and their organisation, not in the desired way. This is seen in every public and private organisation. It leads to the current wave of academic fraud as individuals and institutions are rewarded for publication; to teachers sharing exam papers as exam success is used to judge performance. In the NHS it leads to patients being kept in ambulances when A&E is busy so that the hospital’s target of 4 hours is not breached, despite the negative impact on the ambulance service’s own targets and on patients. Properly designed incentives would reduce gaming of the system but are usually developed centrally without involvement from the frontline staff who understand the perverse impact of a poorly designed measure.
Finally, change requires time. For every month spent in developing a policy three or more months are needed for delivery. Yet all too often the time available is exactly the converse. Organisations are given an unrealistic timescale which leads to poor decisions and corners being cut. There is rarely proper piloting, adequate time, or double-running to ensure success before previously used mechanisms are discarded. Mrs Thatcher famously remarked that the war was won in less time than it took to change the NHS. A clear example of how rapidly people can respond to a clear, unambiguous and supported policy. Perhaps policy makers should use the observation to question the policy rather than blame the deliverers!
This article first appeared in the welsh agenda in Winter 2017.
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