An Engaging Bureaucracy

June 21st, 2013

It’s been a while since I’ve been able to write anything more interesting than the CDs I like, but I’ve recently managed to extricate myself from the turmoil of NHS reorganisation via the medium of redundancy. It also means I’ve got a fair amount of time on my hands to write things.

The recent widespread news coverage of the latest horror  story to hit the Care Quality Commission (CQC) focussed me to try and sum up what I’ve learnt from the last few years of NHS reform, and even further back over ten years working in patient engagement. The problems being experienced by the CQC are not surprising, in many ways  they are illustrative of problems that  the entire health and social care system has being storing up for many years. I don’t believe it is a failing of individuals, I can see that those directly affected by the decisions of the CQC have a right to expect some justice but the wider problems are  more endemic.

It is obvious that the system of  regulation we have  created  does not have the capacity to do the job that is needed. I say obvious because it seems to be publically failing on a fairly regular basis. Having said that, sizeable sums of public money are supporting this system of regulation and the  public have  a realistic expectation of a return on that money.

I believe the system of regulation is failing in the UK because it has been designed to fail, it is a system that has been created by a bureaucracy to police itself. The failure of design and delivery stems from one common point, a  lack of appreciation of what quality actually means.

The delivery of health and social care in the UK has historically been delivered via a bureaucracy, patients do not choose to take their health needs elsewhere  thus the subjective element of quality analysis has been consistently removed from planning processes. This post isn’t advocating an imposition of market dynamics on health care, it merely points out that, sometimes, the way markets are constructed gives an added level of feedback that is crucial in understanding quality.

The subjective element of quality  is the  part  that all of our systems of regulation fail to appreciate. The resource constraints on the CQC forces it to focus on inspection through objective analysis  of  data  without testing it against real patient experience. This is understandable, there  is a beautiful binary aspect to the delivery of healthcare (people lived or died) that makes a lot of this quite easy to do on a large scale with limited resources, but it doesn’t draw a very good picture of quality.

It’s simplistic philosophy but Zen and the Art of Motorcycle Maintenance gives a good overview of the competing elements of quality, though Pirsig’s fascination with calling them “romantic” and “classical” probably won’t find a comfortable home in NHS redesign. I prefer objective quality and subjective quality.

To fully understand the quality of services delivered, in the absence of  people withdrawing their custom, there needs to be a wholesale change in the culture of how health and social care services are delivered.

I’m not advocating a change in structures, structures are easy to change (though the last two years might not substantiate that). Our bureaucracy needs to fully understand that  it will only truly appreciate quality if it can better develop transparency and engagement.

Engagement has been a consistent mantra in public services for many years but has never been properly developed. There are a number of reasons for this, here are a few of them:-

Engaging with people is a slow process, you need to build trust for relationships to work, quite often that makes it look like staff that are very good at engaging are actually just sitting about chatting. The public sector has never been comfortable with staff that can’t maintain the illusion of frenetic (if useless) activity. Because it is slow it is expensive, because it is slow and expensive we often look for short cuts. Those short cuts  lead organisations to institutionalise the very people we need to engage with. Simplistically this means organising meetings that reflect the bureaucratic nature of the organisation itself.

This means we create forums that reduce the potential for staff to be uncomfortable, it reduces  the public willingness to challenge and completely removes any notion of obvious transparency.

One of the worst examples of the institutionalisation of engagement can be seen in the adoption of the notion of the critical friend. This assumes that people in a position to challenge public sector delivery should adopt a position sympathetic to the organisation whilst  providing constructive criticism. This notion fails on two levels, it fails to understand the nature of the power relationship between the individual and organisations and it fails to appreciate what we all think about critical friends, we find them annoying.

This theory seems to stem from the idea that  organisations will not listen to robust challenge but need to know that the issues being raised come from a foundation of sympathy. This is ridiculous, it indicates that public sector management needs to grow up and talk to people like adults. This is a disparity in power between the individual and the organisation, often that disparity will manifest itself in anger and frustration, the organisation needs to both appreciate and accommodate this.

Public services need to open themselves up to challenge in all its forms, this won’t be pleasant but is the only way that they can begin to appreciate  the  subjective element of quality. They need to do this by meeting people where they meet in the community structures that already exist.

Those with responsibility for regulation, should understand that everything they need to know about how services are delivered  is in the communities that they are being delivered to. They have to find a way to get into those communities without subcontracting engagement out.

We are at  a point where the new organisations that have responsibility for health and social care have an opportunity to do things differently. Unfortunately the time to do this is running out and all the signs are that the new is merely replicating the old.


Posted in Politics | Comments (1)

One Response to “An Engaging Bureaucracy”

  1. Daz Wright » Blog Archive » Social Network Says:

    […] been thinking for the last week or so that I should write something to follow on from my post about how bureaucracy finds it difficult to engage with people  and other organisations. I was thinking about writing something about social networks. I was wary because even mentioning […]

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