Dyslexic management can’t read signs of failure

THE REAL British disease is the unerring talent for putting together entities that are less than the sum of their parts.

THE REAL British disease is the unerring talent for putting together entities that are less than the sum of their parts. The comical inability to think in systems terms – call it management dyslexia – was on dazzling display last week, all over the front and back pages.

First up, the England football team. Management is supposed to amplify effort by providing a creative framework for individual expression that benefits the team. But defeat against Croatia was the reverse, the culmination of un management that over several matches has diminished team effort and turned good players into turnips.

It was the opposite of management that left players individually and collectively bereft. At least the England rugby players, in the World Cup, took the initiative to create their own playing system that, although limited, suited the available talent and took them against the odds to the very brink of triumph.

England’s Premiership is the wealthiest football league in the world. Its consistent failure to generate a satisfactory national team is deeply rooted and reflected in other systemic shortcomings. Only one of the top teams, Man chester United, has a British manager the starting line-up of the Premiership leader, Arsenal, contains just one, sometimes no, English player. Oh, and the new pounds 800m Wembley stadium can’t even produce a decent surface to play on. From grass upwards, English football is a system for growing anti-synergies.

Second up, a performance by HM Revenue & Customs that makes it hard to know where to begin – with the IT outsourcing that makes it an expensive extra to separate bank details from other personal data, to senior management’s decision to dispense with encryption to Gordon Brown’s repeated use of the ‘one bad apple’ excuse: the leak was the result of one individual’s failure to carry out procedures – at the dispatch box.

The spectacle of a general blaming his troops is always distasteful, but in this case is also bankrupt. The HMRC leak is primarily the result not of human error, but poor or non-existent systems design which failed in at least three respects: not segregating sensitive from insensitive information, allowing the two to be sent out together, and omitting to encrypt it. If any of those steps had been followed, the further error, of leaving a junior to decide to put it in the post, would have been harmless. This is called fail-safeing – part of any good systems design.

And by the way, don’t bother with a witch-hunt or a full-scale investigation to find out what went wrong: with the help of readers and the junior HMRC official, this column offers to find the root cause in a day, using a basic problem-solving technique called the ‘five whys’ (asking ‘why’ five times over) – and apply the answers to prevent the problem happening again. The five whys are at the heart of continuous improvement which, in turn, is the motor of systemic performance enhancement.

Last week’s third outbreak of British anti-synergy syndrome centred on Norfolk and Norwich Hospital. On Wednesday, the hospital went into ‘major incident’ alert because it was chocker. At one stage, 10 ambulances (nearly half Norfolk’s total) were immobilised waiting to unload their patients.

So the hospital’s too small, right? Well, hang on a minute. Why was the hospital full? Because of high demand, coupled with high bed-occupancy rates. Why are bed rates so high? Partly because the hospital is ‘efficient’, operating at occupancy rates of more than 90 per cent. But also because 60 beds are occupied by patients who have finished treatment but can’t be discharged. Why can’t they be discharged? Because, for financial reasons, the Norfolk Primary Care Trust is busy closing down the community hospitals that would traditionally have taken recovering patients, and social care, as almost everywhere in the country, is utterly inadequate to cope.

And why is demand so high? An epidemic or major accident? Nope. The extra demand comes from within. It is largely generated by NHS Direct which, terrified of making mistakes, routinely directs callers to A&E or their GP – but since GPs are no longer available out of hours, as a result of the government-imposed contracts, that means A&E.

In other words, the Norfolk NHS crisis, like that of HMRC and team England, was self-generated, the result of complete and continuing system-blindness. ‘Problems in organisations,’ points out Russell Ackoff, one of the first and best systems thinkers, ‘are almost always the product of interactions of parts, never the action of a single part.’ Treating a single part destabilises the whole and demands more fruitless management intervention management becomes a consumer of energy, rather than a creator.

Unfortunately, that’s the hallmark of 21st century UK management. As last week demonstrated, it still shows no sign of recognising it.

The Observer, 25 November 2007

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