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Why 'doing things better' makes them much, much worse

Thu, 20th Oct 2011

 Meet 90-year-old Tom. Like many who get that far, Tom is beginning to show his age. He doesn’t see or hear too well, and he’s not very dextrous, which makes dressing difficult. But he’s vigorous, independent, full of spirit, and lives for his daily visits to his wife of 70 years, Iris, who went into a home last year with advanced dementia.

 One day Tom is admitted to hospital with a suspected stroke. Actually it wasn't a stroke (but better be on the safe side…). In hospital, Tom is distressed and confused. He can’t see Iris. He’s moved several times, is seen by many different people and can’t make out what busy doctors are telling him. He has difficulty with his clothes. He’s not sure where the loo is but is not very good with the bedpan, spilling some urine and slipping on it and falling. He’s quickly labelled 'vulnerable'. ‘at risk’ and ‘unsafe for discharge’.
 
Eventually he does get home. But a few weeks later he is readmitted after a fall because an out-of-hours doctor sees the reference to stroke (better be on the safe side… ).
 
In most circumstances, Tom’s independence would have ended there. The ‘problem’ (the system's, not his) would have been resolved with a move into residential care. There, living the life the system prescribed for him, not his own, he would indeed have been depressed and confused. Thus do people become the label the system pins on them. 
 
Fortunately, however, Tom lives in Somerset, where a small integrated team has been piloting a very different approach to the commoditised world of care. Tom is one of the team’s service users, and his carers knew that he wasn’t, at all, a lonely and confused old man who couldn’t cope – he just looked like that because he was out of his normal context.
 
Having taken the time to understand Tom’s context, the care team discovered that putting his life back in balance, under his own control, was astonishingly simple. 
 
He didn’t need a local authority ‘package of care’ for dressing or meals, still less a place in a care home. What he did need was clothes that fastened with velcro rather than the buttons he fumbled with. Yes, he had fallen, but that was due to poor lighting and inability to locate his glasses rather than failing balance. Solution: automatic lighting switches. As for eating, Tom’s issues – he had alarmed carers on their first visit by trying to prise bread from a toaster with a breadknife – were met by modest changes to his shopping habits: like buying rectangular bread.
 
Analysing what happened to other care users, the Somerset team found that Tom's case set a depressingly standard pattern (minus the happy ending). Like Tom, most people presented with non-medical isses but, once through the NHS gateway, were rapidly medicalised. They became patients. To find a package of care they could be fitted to, they were assessed and passed on to different agencies, departments and teams literally dozens of times – in one case 35 times in 18 months. 
 
Paradoxically, things were being made worse by each agency's attempts to meet financial pressures by ‘trying to do things better’. In practice, this meant increasingly standardised processes and packages, spending less time in interviews, and rationing the time of experts.
 
Unfortunately, you can’t improve the system as a whole by optimising the individual parts. As Deming patiently explained, 'If the various components of an organisation are all optimised, the organisation will not be. If the whole is optimised, the components will not be'.
 
In care, the cost of optimising the components was to make the system more fragmented, more impersonal and more prone to error – which is exactly how users experience it. ‘We’re great at assessment,’ notes Fiona Catcher of the Somerset care team. ‘But understanding… ’
 
In services as in manufacturing, the counterpart of increasing speed and standardisation is overspecification (better be on the safe side…). It's a false economy. In care, repeated too-heavy solutions (hospitalisation, ‘at risk’ labels) further unbalance lives so that people rarely regain their previous independence. Horribly, it's the reverse: once in the system they are on a ‘clear glide-path into residential care’. Adds Catcher ruefully: ‘It’s really perverse, isn’t it, that when the system swings into action to help, it gives you a leg up into greater dependency, greater need and of course at much greater cost to the public purse.’
 
Instead of operating on the old ‘assess-treat-refer’ process, Somerset now offers an ‘understanding and rebalancing’ service. Its mantra is ‘light touch, right touch’ and its aim to help people solve their own problems, maintain them in their own context, and manage their own lives. The most important qualification for this work, it has found, is an ability to listen. ‘Listening and understanding isn’t a profession,’ notes Catcher. To carry out the new value work, ‘what we really need is staff who can give people a right good listening-to.’
 
Understanding takes time upfront. But this is a small price to pay for a move from ‘doing things better’ to ‘doing better things’ that takes service and its cost into a dimension that is incomprensible to those stuck in the old model. As in Tom’s case, the material costs of rebalancing are laughably small, while the savings elsewhere in the system are uncountable. For 93 people discharged from the Somerset service, there were 12 prevented hospital admissions, 25 reduced stays, six prevented admissions to long-term care homes and 29 reduced packages of care, let alone numberless assessments, appointments and other transactions that didn't need to happen. And how do you compute the positive benefit? ‘Think of the effect on Tom’s life,’ reflects Catcher. ‘And think also of the effect on the social care budget’.
 
Somerset began by thinking it was redesigning an adult re-enabling and rehab service. Now it believes it’s doing something much bigger, recasting the entire interface between communities and services, with implications that at this stage can only be guessed at.
 
‘What we’ve done in administration in the public sector over the last 15-20 years is turn public agencies into deliverers of transactionalised services,’ reflects Richard Davis of Vanguard, the consultancy that helped Somerset's care team. ‘When we do that the issues that come to the fore are standardisation and efficiency, and the more we standardise the less we understand what matters to people and the more we miss the plot. One of the things that’s beginning to interest us is a move from looking at services as commodities, as they’ve become, to relationships, which is what they used to be. In many services, certainly the police and health, a lot of things go wrong because we don’t know people and have no relationship with them. It sounds terribly expensive until you understand the harm that’s being done because we don’t understand and the cost that’s being incurred as a result of doing the wrong things’.  

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