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    Yorkshire Socialist Health Association

    Command and Control Management:

    The Deadly Embodiment of Neo-Liberalism at work in the Public Sector

    John and Joe Carlisle, Mad Management[1]

    Although the Command and Control style of management is a fairly modern phenomenon, like all ideas, its roots go much further back, to a very dominant model of how to discipline and organise institutions. The philosopher Michael Foucault famously uses 18th Century Utilitarian philosopher Jeremy Bentham’s panopticon as a model for how a modern disciplinary society seeks to at all times to survey, or at least give the possibility of surveillance, its populace. The panopticon is a surveillance structure originally designed by Bentham for prisons but reproducible in any environment. The centre is occupied by a watchman who cannot be seen but who is surrounded in the round by the cells or workplaces of those he surveys. Each in their own compartmentalized sections the watchman, or manager, can see everything the prisoners do. As Foucault describes ‘[t]hey are like so many cages, so many small theatres, in which each actor is alone, perfectly individualized and constantly visible.’[2]

    Foucault rightly saw ‘panopticism’ as a paradigm through which individuals could be measured, assessed, marked and surveilled; it was not simply a design for a prison but a “how to” command and control for a whole variety of institutions from schools, hospitals and factories. It is worth quoting Foucault again, this time at length, as he describes the consequences of such a model:

    He is seen, but he does not see; he is the object of information, never a subject in communication… if they are workers, there are no disorders, no theft, no coalitions, none of those distractions that slow down the rate of work, make it less perfect or cause accidents. The crowd, a compact mass, a locus of multiple exchanges, individualities merging together, a collective effect, is abolished and replaced by a collection of separated individualities. From the point of view of the guardian, it is replaced by a multiplicity that can be numbered and supervised. 

    This top down model of designing the workplace was explicitly compatible with industrialization where work was broken down into small repetitive actions that can easily be measured and codified. What is harder to understand is why the model was placed upon all forms of work. Why do so many managers insist upon forcing this model onto industries, such as service, which it does not fit, and more tragically, why use it as the model for management in public services?

    It is now common for most people who work now to have a sense of being monitored. Whether through the ubiquitous CCTV camera, which now often can record audio, to electronic clock ins,’ recordings of all phone calls made in a call centres or on workphones, targets to be hit, milometers which time how long a delivery takes to go from A to B, to IPad’s whose programs must followed to the letter. What this produces is an abundance of data, a mountain of information which can be turned into charts, graphs, and reports. This gives the manager a great sense of control; to him nothing is hidden.

    Except of course a lot is hidden. Data by its very nature hides vast amounts of knowledge. The time it takes to get from A to B does not reveal that the final stage may add 20 mins because there is nowhere to park the lorry. The failure to reach the target may simply reveal the arbitrary nature of the target. In data the whole complexity of the human world is erased, flattened out into a spreadsheet, and the manager ends up mistaking the map for the terrain.

    Not only does it give the illusion of knowledge but command and control management style doesn’t work.  It makes waste rather than reducing it. This article will argue that it is an empirical fact that these modes of supervision fail to achieve what they claim to. Systems thinking is a far more effective way of improving organizations, and ironically, it has the data to back it up.

     Systems Thinking

     In 2003 Professor John Seddon published Freedom from Command and Control. [3] It caused quite a stir, demolishing most of the principles upon which the government had based its efficiency drive – which later morphed into wholly inappropriate and damaging austerity policies. It refuted the top down principle of leadership that is implicit in the New Public Management (NPM), which is a promoter of what Seddon calls ‘the management factory’: ‘The management factory manages inventories, scheduling, planning, reporting and so on. It sets the budgets and targets. It is a place that works with information that is abstracted from work. Because of that it can have a phenomenally negative impact on the sustainability of the enterprise.”

    The case studies gave irrefutable evidence of the damage caused by this neo-liberal mechanism in the public sector. Seddon’s solution was systems thinking as expanded in his next book, Systems Thinking in the Public Sector.[4] Here example after example illustrated the waste caused by NPM, especially as advocated by the likes of Barber (targets etc.) and Varney (shared services – see appendix)

    The research and analysis conducted by Professor John Seddon, which has looked at reasons for diseconomies of scale specifically in service organisations, fundamentally challenges the ‘Command and Control’ logics that underpin much of the public sector. Instead case study after case study confirms that concepts such as ‘designing against demand’, ‘removing failure demand’ deliver outstanding success  , while the typical drive to standardisation and specialisation of function results in inappropriate services being delivered, resulting in turn in escalating monitoring, management and correction costs.

    This, however, requires a change of thinking about how organisations work best in this the 21st century. Over a hundred years ago the workforce was only one generation removed from an industrial culture. Their understanding of industrial production and its organisation was very limited. Consequently even the best designers of organisations, e.g. Henry Ford, the Quakers, Cadburys, Rowntree’s and Clarks, were at best paternal, and at worst, reductionist pragmatists, i.e. treating workers as intelligent tools. However, even the latter did not mean not trusting them or attempting to look after them. After all, Henry Ford doubled the wages of his workforce overnight and refused to allow women to labour after 5pm so they could look after their families. He was also sued by his major shareholder for doubling his workers’ wages at the expense of dividends. The shareholder won.

    Today, we have a workforce that is literate and numerate and is at home with modern organisations, BUT are managed as those of 100 years ago. Why is this? The reason is the Command and Control style is more comfortable for those leaders whose upbringing (conditioning) and training at Business Schools has brainwashed them into feeling that being in charge means taking control. As they cannot be everywhere they therefore use measuring as a proxy for their physical presence. This usually translates into columns of comparative data or run charts, tick boxes compliance, and often targets to be reached as evidence of success of failure.

    So, who is the guardian in the panopticon? It is HR. In many public sector organisations HR has seized this opportunity to become the enforcer of compliance for the board. Rejoicing in their power they have abandoned their traditional role of looking after the workforce and now “guard” it.

    Politicians are entranced by these governance measures. They can conceive of nothing more confidence boosting than setting targets for, e.g. hospital waits, housing allocations, repairs completed. Their mental model is captured in the Table 1, below, in the left hand column. It is informed by their neo-liberal mindset, something they have imbibed from exposure to the right wing press; the fascination with material success, for example Peter Mandelson, playmaker of the Labour party said twenty years ago that he was “intensely relaxed about people getting filthy rich as long as they pay their taxes”; privatisation continues even though it is clearly an utter failure; and cost-cutting  and targets are the first knee jerk reactions to perceived public sector overspend.

    But there is another way. It comes in the form of a System of Profound Knowledge, first propounded by the great management philosopher, Dr W. Edwards Deming, whose principles are best presented in the work of Professor John Seddon, head of Vanguard.

    The Seddon Vanguard model, constructed from his research into effective organisations is the right hand column (Table 1).

    Table 1. The two conflicting models of management

    The question is why, in particular do UK politicians favour the Command and Control model? Our theory is that it is the “control” element that matters most – and, which has caused the most waste, and managers and politicians in particular are comforted by the illusion of control even when it clearly causes so much damage to people and resources as the examples below illustrate. [5]

    • Western Australia’s Department of Treasury and Finance Shared Service Centre promised savings of $56 million, but incurred costs of $401 million.
    • A National Audit Office report said that the UK Research Councils project was due to be completed by

    December 2009 at a cost of £79 million. But, in reality, it was not completed until March 2011, at a cost of £130 million.

    • The Department for Transport’s Shared Services, initially forecast to save £57m, is now estimated to cost the taxpayer £170m, a failure in management that the House of Commons Public Accounts Committee described as a display of ‘stupendous incompetence’

    Covid-19 has made the flaws are even more obvious. That greatest of all control freakery, the centralising state, has been shown for disaster that it is. The Health Secretary has kept control of all the testing and tracing administered from the centre, and it is failing at every level. The report from the Independent SAGE, a group of 12 leading scientists headed by former UK Government chief scientific advisor, David King, said the governments test, track and trace system is not “fit for purpose”.

    The government’s current approach to this system, including the contact-tracing app, is “severely constrained by lack of coordination, lack of trust, lack of evidence of utility and centralisation”, it adds. “The effective operation of this subsystem is also complicated by the apparent failure of the app that was designed to facilitate identification of contacts of those who have Covid-19” (Digital Health, June 16, 2020). We are talking here about thousands of British lives and further damage to a reeling economy.

    Dr W Edwards Deming summed it up perfectly: “Most people imagine that the present style of management has always existed and is a fixture. Actually, it is a modern invention – a prison created by the way in which people interact.”  He then asked the question:

     How do we achieve quality? Which of the following is the answer? Automation, new machinery, more computers, gadgets, hard work, best efforts, merit system with annual appraisal, make everybody accountable, management by objectives, management by results, rank people, rank teams, divisions, etc., reward the top performers, punish low performers, more statistical quality control, more inspection, establish an office of quality, appoint someone to be in charge of quality, incentive pay, work standards, zero defects, meet specifications, and motivate people.”[6]

    Answer: None of the above. (Will someone please tell our politicians.)

    All of the ideas above for achieving quality try to shift the responsibility from management. Quality is the responsibility of management. It cannot be delegated. What is needed is profound knowledge. A transformation of management is required, and to do that a transformation of thinking is required – actually the neo-liberal paradigm is so entrenched that that nothing less than metanoia (a total change of heart and mind) is needed.

    When this transformation happens almost miraculous levels of performance occur. For example, when left to the medical staff only, the level of delayed bed days fell from over 12,000 per month to under 6000 in a year (2017/2018) – an over 50% reduction! Much less command and control leads to much more economic and effective activity. It is time all the politicians learned to trust their public servants much more, and abandon the illusion of control foisted on them by neo-liberal ideologists from Labour and Conservatives. It is a political thing, not a party thing. The whole system of government must be overhauled.


    References

    [1] https://jcashbyblog.wordpress.com

    [2]Michel Foucault, Discipline and Punish, trans. A. Sheridan (Vintage books, New York, 1995) p. 200

    [3] Seddon 2003 ‘Freedom from Command and Control’ Vanguard Education

    [4] Seddon 2008 ‘Systems thinking in the Public Sector’ Triarchy: Axminster

    [5] John Seddon 2012 submission to the Local Government and Regeneration Committee – Public Sector reform and Local Government. 2012

    [6] Deming, W.E. (1993) Out of the Crisis, MIT: Cambridge

     

    4 Comments

    Former Health Secretary, Jeremy Hunt, probably Britain’s worst leader since General Percival surrendered an army of over 80,000 soldiers to 36,000 Japanese soldiers at Singapore in 1942. It was the worst ever British defeat and led directly to the dreadful Japanese concentration camps. Hunt was in charge of over a million highly committed NHS professionals with oversight of Social Care, looking after nearly a million people. He surrendered these to a succession of debilitating neo-liberal reorganisations, privatisations and defunding regimes. Like Percival he could have fought for his people, but chose not to, and England is paying a high price.

    Percival’s reward was the pension of a Major General. Some think Hunt’s reward may be selected as the next Prime Minister. Think again.

    Apart from his duplicity with data, his bullying of Junior Doctors, and his hypocrisy in praising the NHS and shrinking nurse’s pay, there is the question of his ability to manage. Managerial incompetence is a common trait in this Conservative government, as exemplified by Grayling, Hancock, the Prime Minister, Priti Patel and others in the Cabinet.

    Hunt the manager.

    In every good organisation there are key performance indicators whose sole function is to help the executive steer the organisation most effectively. In British Rail one was trains on time. The purpose was to keep the passengers safe and satisfied, as the most important need was reliability, not speed, as the politicians keep getting wrong.

    A key indicator in Social Care was the performance of transferring patients from the hospitals back into their homes and care homes. The indicator was called Delayed Transfer of Care (DToC), which meant that something was preventing the patient from being discharged when they were better. It was measured by the month. It was a very important indicator, for two main reasons:

    • Cost: Each time the transfer from the hospital failed on average it causes up to 31 bed delays, i.e. unavailability. The cost of this is about £400/day, compared with £90/day in a home. So each DToC generates a net loss to the NHS of at least £300×31, i.e. about £9,000. At the time of Hunt’s appointment these Social Care DToCs were averaging 1050/month – a net loss of £9.5 million per month and steady.
    • Care: Patients who are well enough to go back get more ill if they stay in hospital, especially if they are elderly, thus occupying beds for much longer. They also require extra attention from busy nursing staff who are not always used to dealing with the elderly. There is also an increased risk of readmissions.

    The Department of Health details reasons for these delays, 40% of which are generated within Social Care. These are the major reasons, respectively: Awaiting Care Package at Home, Awaiting residential home placement or availability, and Awaiting nursing home placement or availability. As all these delays generate extra bed demands in Acute Care as well as, so to address these immediately would be a win/win, an act of intelligent leadership, especially for an opportunist like Hunt.

    Now, the bad news for Hunt: He has no organisational leadership qualities at all, especially when it comes to doing what is best for the organisation, i.e. the good of the users, the employees and the community. If he had he would have predicted a serious problem emerging in social care, and consequently a rise in the transfer of social care patients into acute care.

    Hunt became Secretary of State for Health in 2012. At that point Care DToCs were running at 1050/month, but trouble was on the horizon. Back in 2011 Nicholson, the CEO, set the NHS and Social Care the challenge of taking out £18 – £20 billion by 2014. Why? It was a classic act of hubris which of, course, the health system paid for. It was to be efficiency savings; but how? The care system was short-staffed, underfunded and, because of the privatisation, in negative productivity. Overworked and underpaid staff, the main source of innovation, were in no position to study ways of improvement. Morale was falling and the staff turnover was 27%.

     

    Hunt should have stopped it, but did not care, or have the nous – or else was confusing fewer staff per user as a sign of efficiency. Either way he should have kept his eye on the statistics. Social Care is a major driver of demand in the NHS. The better the care, the lower the rate of admissions into Acute Care: a very simple equation.

    By 2015 there were ominous signs. The rate of DToCs was beginning to rise in a statistically significant way. The trend was clear. The average was rising to 1250, a 19% increase. Any executive worth their salt would have instituted an instant investigation. Hunt did not. His NHS 10 Point Efficiency Plan mandated the “freeing up about 2000 to 3000 beds by ceasing DTOC delays in social care.” Just like that, like Napoleon instructing his troops to conquer Moscow – winter. There was no strategy, no plan that mapped out the route. Just an edict, and like Napoleon, thing got a lot worse.

    The average for the years 2016 to 2018 rose to 1900 DToCs, 80% greater than in 2012 – so much for “ceasing” DToC delays. It was not a plan but a target, and a silly one. This is worth unpacking. In five years Hunt oversaw an increase of about 900 DToCs from the Care sector alone. This is an increased loss of £8.1 million per month, or close to £100 million a year.

    Just how many staff in Social Care would that have paid for at £25,000 a year? The turnover would have stopped, the facilities enhanced (including private care) and morale and user satisfaction improved.

    These cold statistics disguise the misery of the people involved, nurses, carers, families and, most of all, the users, mainly the elderly. As Neil Kinnock said prophetically of the Tories if they got in:          I warn you not to fall ill, and I warn you not to grow old.”

    In summary, in the first three years of his appointment the total loss due to DToCs was £114 million a year. In 2015 Hunt sat on his hands, no doubt transfixed by Stevens’ unnecessary reorganisation along USA private care lines. Over the next three years the total loss would be £205 million per annum. The damage to the NHS and Social Care is incalculable. And remember we are only looking at 40% of all the DToCs, i.e. half a billion pounds a year. Much of that could have gone into PPE stock replenishment.

    A final irony: In Hunt’s 2016/17 NHS 10 Point Efficiency Plan the target mandated was to “reduce Delayed Days to 4000/day, which translates into 124,000 per month by September 2018”. This equates to 4000 Delayed Transfers of Care per month across the NHS and Social Care – a figure that is actually higher (worse) than they had been achieving regularly in 2010 – 2013! But what makes it even more damning is that it was, statistically, an unachievable demand. The average for 2016/17 was 4560 DToCs and the lower control limit was 4995, which meant that statistically there was less than a 1/1000 chance that it could be achieved. Setting unachievable targets is feature of Hunt’s tenure. Caroline Molloy details these in her withering assessment of Hunt in her article What did Hunt do to the NHS – and how has he got away with it? (Open Democracy, July 13, 2019).

    Matt Hancock now grasps the poisoned chalice Hunt has handed him. Luckily he is an optimist and probably sees it as a great opportunity. One day he may also be rewarded with the Chair of the Health and Social Care Select Committee like Hunt, for the utter failures, especially the disaster of his outsourcing of test and trace to private companies (0ver £10 billion), greatly exacerbating effects of the terrible Covid-19 pandemic in 2020.

    Dr John Carlisle

    Chair, Yorkshire SHA

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