The ‘Approved Version’… and its consequences

How reporting and evaluation become a poisonous substitute for understood practice

A guest blog by John Higgins, November 2020

I recently had a DVT (Deep Vein Thrombosis) which threw me into a lived experience of hands-on health care. Chatting with the nurse practitioner in the anti-coagulation clinic, as she sorted out my treatment regime, I talked about my work on organisational silence and how the biggest finding was senior people’s habit of over-estimating how much they knew about what was going on in the workplace.

This spoke to her – her previous senior boss had known nothing of the work of her department (and had no first-hand experience of any form of health care) and when talked to by clinicians showed not a glimmer of interest or understanding. The current one was better; they similarly had no direct experience to draw on but were at least open to hearing about what mattered to the people who worked with DVTs and related matters.

My experience of working in and around the health care system over the last twenty years or so, shows that many people seeking to deliver front line care find themselves subjects of a top-heavy regime of seemingly ceaseless (and purposeless in terms of day-to-day impact) organisational reporting. Each organisation generates its own raft of pro-forma templates, to go alongside the corporate wide ones, full of pull-down menus to ensure consistency of response from across geography or departments, and a tight deadline for their completion. This is what one recent author, Jerry Muller, incisively declared to be “the tyranny of metrics” – and, as with any tyranny, it requires committed apparatchiks to operationalise them through their oversight and imposition of process.

There is a clear sense that the world of work has slipped out of kilter, with the balance between the time available for activity and the time required to report on activity – two different facets with very different social utility – skewed unhelpfully in favour of the latter.

In brute economic terms, there is an opportunity cost here, with time spent on marshalling and submitting data being time that cannot be used to do the work, a crucial issue when it comes to clinical workload. Despite this being obvious to everyone implicated in serving this regime of control, the ever-present army of efficiency experts, mapping out the world with stop watches, occupancy data, and the neo-Taylorism of “Lean” techniques, ignore this completely. There would appear to be an assumption that measurement is a cost-free activity – or one whose benefits are so legion that no cost is too much.

This leads to what lies at the root of all this. Anyone who has spent time in organizational life knows that this form of data creation generates a wholly fictionalised picture of the world, one that derives not from the actual experience of people doing useful work, but from the centrally mandated narrative of fixed goals, measurable impact against arbitrary units of activity and delivery of notional budgets (in another context, one captain of industry referred to organisational budgets as ‘the biggest lie of all’). This fictionalised reported world, with its capacity for delivering impressive looking control through regimes of hyperactive data flows, from the periphery to the centre and back again, becomes the lodestone that justifies the existence of a centre in the first place.

I am always struck by how quickly people return to the simulacrum of control, despite well-known stories such as that of Alan Mulally. When he became Chief Executive of the Ford Motor Company in 2006, during one of its periodic bouts of financial crisis he was presented with RAG (Red, Amber, Green) reports from across the business which were uniformly green, despite the company haemorrhaging billions of dollars at the time. Equally, he became aware that his business units were presenting the data differently depending on the audience – but always seeking to reassure the reader that all was proceeding well, to plan and budget. Mulally’s intervention was to make it okay for people to be honest about what was really going on, rather than play the reporting game of saying everything was on target. He wanted reporting to be in the service of the primary task of the company, not sustaining the managerial reporting game.

In my experience, a second consequence of overbearing regimes of scrutiny and oversight is to set organisational units in competition with one another, playing the reporting game. If Unit A reports a return that supposedly provides reassurance in terms of activity, Unit B will want to ensure that what they offer up is at least equal to – if not greater than – the summary provided by the other. This adds yet another layer of distortion: it’s not merely that the data is a representation of – but not a true reflection of – reality, it’s that the data creation/collection process incentivises people to exaggerate, or downplay, elements that make up that representation.

At the centre of this sits “the leader” and their leadership bureaucracy, immersed in whirls of red, amber and green and bowed beneath a ceaseless cascade of numbers, reassuring themselves that their elevated position is justified on the basis of their rich understanding of what’s going on.  Their personal and positional power comes from their capacity to declare what needs to be done in light of what they see amidst the maelstrom of fictionalised and exaggerated data. It’s a corporate version of visiting a palmist on Blackpool seafront…

At some point the disconnect between the fantasy of approved reporting procedures and lived practice comes out, but often the people at the most senior levels are the ones who are the last to know (and are the least incentivised to notice the game being played). In my research with Megan Reitz we talked to bankers in place before the 2008 crash, who reported that it was only the people who lived in the executive suite, far away from the messy reality of the trading floors, who believed that the good times were built on anything but sand. Within healthcare, any Chief Executive worth their salt knows that you only announce any budget over-runs at the end of the financial year, at the same time as everyone else. One now ex-CEO, who had had enough of that game, signed his professional suicide note by insisting on posting a deficit budget at the start of the year. He was moved out, the turnaround heroes parachuted in, new outcomes promised… and at the end of the year everything turned out just as the original CEO had predicted from the outset.

Reporting and evaluation can play a useful role, when they are useful servants instead of masters. Within the myriad of professional, clinical disciplines of the NHS there are important standards to be paid attention to – all with a direct impact on clinical practice. If these clinically approved disciplines become dysfunctional, it soon shows up in terms of clinical outcomes. The potential for gaming the system is limited. Within the worlds of organisational leadership and management, no such tight feedback loop exists, causal connection is largely impossible to prove. Instead what gets deployed are all that is fashionable from the world of management studies which reflect the following:

‘The business school… has tended to become somewhere that produces knowledge for management rather that knowledge about management… It is knowledge… that relies on flattering those in power’ (Parker 2018, pp36-7)

Reporting and evaluation are an essential part of this self-serving discourse, where its purpose is not about making an organisation better managed, but about sustaining the importance of the managerial cadre and way of knowing the world. An example of this comes from a conversation with someone who has been performing their organizational role for some years. They reported glumly how their annual appraisal was experienced as no more than a cataloguing of all the reasons as to why they couldn’t do the job that they were already doing. Many of us also know people working on tasks outside of their defined area of responsibility – often at a level above their pay grade – but, in the corporate pecking order, would not be considered for promotion. It leads one to a simple conclusion: like the regimes already discussed here, the evaluation and selection game has become completely detached from the reality of the job.

The late Professor Hopwood of the Said Business School in Oxford spoke to this in a letter in 2009, how the NHS was becoming befuddled by a parallel universe of KPIs and managerially approved metrics which bore no relation to the lived experience of staff and patients. His critique has had little effect; press reports and emails sent to me tell the story of external advisers continuing to be brought in, who are as invested as ever in their own relevance and brilliance while denigrating local intelligence. Stories abound of NHS staff working diligently over recent years to try and integrate systems of care and how they’ve seen senior leaders up and down the country sticking with the learned habit of ignoring them and bringing in the usual caste of management consultancies. Because this has become the approved way for leaders to respond and they could see no other way of working on the issue. I’m reminded of Keynes’ observations from the 1930s, how it was perfectly acceptable for bankers to fail so long as they stuck with the approved approaches that passed as common sense at the time. To try and do something different would be the height of folly. So it is that the ever-present consultancy firm McKinsey gets a £560,000 contract to develop the “vision, purpose and narrative” for the new test and trace body.

In the fairground attraction of distorting mirrors in which we find ourselves in corporate life, leaders take the twisted images that they see in their management reports to be THE true reflections of reality, while also accepting uncritically assertions by external consultancy firms that they are experts in the field of health management.

Charlie Chaplin (The Circus, 1928) pursued in a Hall of Mirrors. Ordinarily, these arrays of mirrors generate recursion and distortion, so one doesn’t see an accurate reflection of reality and it is impossible to orient properly.

Meanwhile it becomes impossible to raise the possibility of an alternative truth, that perhaps true expertise in health management lies in the lived experience of those who do the work and who doubtless have boundless ideas as to how things could be improved. As one of the few genuine thinkers in the field of management, Reg Revans underpinned his work with the understanding that if you want to know how to do a job better, go and talk to the people who currently do it.

His informing belief comes from valuing the wisdom of ordinary people, which means that valuing people is at the heart of good management, and assumes that all that is important cannot be codified according to some decontextualised template (for more on this do have a look at the work of Ken Kamoche & Kevin Maguire). It was a troubling, but unsurprising, discovery in a recent interview when I came across someone who had left the NHS to join a well-known retail distribution firm (not famed in the public eye for their human qualities). They had been impressed by how connected the senior management were in this new setting to the day-to-day work of the staff. Back in the NHS they had had no idea of what senior management was for or how it contributed to the work of their unit. All management contributed was endless reporting overhead.

Meanwhile in another conversation a senior health leader came back from a sabbatical, struck by how much better a profit driven, heavy manufacturing firm was at valuing its people than their Trust. As with the recently published investigation into safeguarding and child abuse in the Church of England, it would appear that organisations with compelling moral purposes are prone to overlooking their own actual moral practices – and I would argue that the valuing or not of people in the workplace is a moral choice, a framing the business school world and its acolytes are ill-equipped to engage with.

My sense is that the practices and principles of management and leadership in the NHS have been transplanted in as if context and history didn’t matter. There has been little attention to working with the NHS world as it is, instead it has been flooded with managerial nostrum after nostrum, which have mostly become about justifying management and the managerial industry. A healthy next step would be to stop this addiction to an alien managerial discourse that simply doesn’t work and instead starts by working with the abilities that already exist within the NHS world – many of the core skills of management are bread and butter in clinical settings, such as being curious, listening well, speaking in a way that others can hear, working with hard and soft data, engaging with the world as it is rather than as you would like it to be. Such an approach, which built on what already exists rather than what various snake oil salesmen want there to be, might at least have the potential of being fit for purpose in a system predicated on the delivery of universal health care, rather than one based upon finding profitable niche markets and outsourcing costs onto unsuspecting suckers.

John Higgins is a researcher and author. His latest book ‘Speak-up! Say what needs to be said and hear what needs to be heard’, co-authored with Megan Reitz, was shortlisted for CMI management book of the year 2020. His next book, entitled Leadership unravelled: The faulty thinking behind modern management will be co-authored with Mark Cole of the NHS London Leadership & Lifelong Learning team and published by Routledge in 2021. John and Megan have an article in BMJ Leader on the subject of: ‘Speaking truth to power: Why leaders can’t hear what they need to hear

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