The Mint:
Good morning, John, and thanks very much for giving up some time to talk to The Mint about social care reform.
John Seddon:
Good morning. And you’re welcome.
The Mint:
Well I thought, John, I’d start by asking you to just give an idea to people listening, how you got involved in the social care area, and what you do in it.
John Seddon:
Okay well, Vanguard, the company that I run, works in all kinds of service organisations. I think we got involved in social care, I guess, approximately 20, 22 years ago, something like that [crosstalk 00:00:39] I work with local authorities. And all of our work is concerned with helping leaders understand the advantages of changing the way they think about the design and management of work away from a command and control design and into a systems design. And we’ve been doing that in healthcare systems.
The Mint:
Right. So you work with people who are providing services, and social care, obviously, is a service and moving around from command and control to a systems perspective, what’s the difference between command and control and a systems perspective?
John Seddon:
Well, the simplest distinction is command and control thinkers focus on managing costs. And a systems design is focused on managing value. When you manage costs, your costs always go up. When you learn to manage value, your costs fall out.
The Mint:
If you were going to talk to someone who knew nothing about service or whatever, can you give a sort of very concrete example of what [inaudible 00:01:37]?
John Seddon:
Well, yeah. Well take social care. You would imagine wouldn’t you, if your life fell off the rails and you put your hand up, say “I need help,” that someone will pop along and help you. Well, that doesn’t happen. You can have a number of people popping along because all of these people are looking at you through their own specialist lens. And their specialist lens is governed by their budget. Their budget tells them what they can spend money on and therefore, what they can’t spend money on.
So, here’s a cost measure limiting the conversation they can have with you. They might set thresholds that you’ve got to be seriously in trouble before they release some of their money. They want to protect their money. Equally, they might decide that you need a service. And so they might commission a service from a provider because the government believes in the market. And if you’re going to go to the market for a price, then you have to standardise that service. But otherwise, people can’t put a price on it so, another cost focus. But standardised services don’t deal with the variety of people’s demands. So, we pay money to do things that are not effective for them.
The Mint:
Okay so, give me an example of a particular scenario of someone in need of care, who ends up getting an inappropriate service then.
John Seddon:
Well, a simple one is someone who needs social contact, but we don’t do that, but we do Meals on Wheels so we’ll send you a meal.
The Mint:
So almost sort of social contacts, you can’t define it, commodify it, determine it, et cetera, you can’t commission it, but you can commission someone to provide a meal.
John Seddon:
Yeah. Or you might have someone there helping you with your personal care, getting up in the morning, things like that, but they can’t take the bin out.
The Mint:
Cause that’s not the service that’s been specified. And-
John Seddon:
Yeah, that’s right.
The Mint:
So that’s a sort of command and control cost basis. If it was a systems approach, how would it work?
John Seddon:
Oh, well it’s entirely different. I should say first of all, what’s important Henry is that the leaders of these services go through the whole exercise of studying how ineffective their design is and how it’s the system conditions. So for example, the budget and commissioning and activity management, that kind of thing that are inhibiting our ability to understand what matters to people and therefore design services that work.
So when you’ve gone through that, you cross a Rubicon and you say, okay, well why don’t we consider designing a service that works, that starts in a different way.
And this has happened a lot around the UK and in other countries, it now starts with everybody who puts their hand up for help gets visited immediately. Not no qualifications, no form filling, no decide who’s going to be sent. Someone will come. And that someone will understand you, what’s happened to you, the context in which this has happened to you, and they will help you define what for you is a good life. Then they will help you take responsibility for achieving that. And then they will look to any help that you can get from your family, your friends, your community, from the voluntary sector, or indeed from state provision, which is designed specifically to help you achieve the aims that you’ve set out.
The Mint:
So it’s a bit like in other situations you have a sort of account manager or something like that. You have the relationship with, and they understand you and then they help you find the way through the system. And so would there then be a menu of things that you could provide? So in a way, there would still be a commissioning and they might have a budget would they, [inaudible 00:05:25]
John Seddon:
The menu is invented every time because you’re dealing with a particular person with particular needs. It’s not like that- we think about a menu. We think about how do we help this person achieve their ambition. The important thing about this is that the more you work this way, the more people get back on the rails quickly. That means you can help more people more effectively with the same budget, if you want to put it that way, but now-
The Mint:
Being effective in helping them. So you’re actually being effective in helping them. So rather ineffective and continuously problems recurring. And-
John Seddon:
That’s right. And so you increased your capacity by doing that.
The Mint:
So this sounds a bit like common sense in a way. So why don’t people listen to this, or why- you explained to me, obviously I’m not technical. I don’t work in social care, but it makes just total obvious common sense. So why is it ignored?
John Seddon:
Yes. Well I think first of all, the narrative in Whitehall, all the power is held in Whitehall, the narrative in Whitehall is as we are getting older, living longer, demand is rising. So therefore who’s going to pay. Now the fact of the matter is when you go and study demand, as we help leaders do, is quite extraordinary. You learn that demand is actually stable.
What is growing enormously is what I call failure demand. So if we don’t help people, they come back. This is one of the things that leaders see when they study their systems. They see the life story of somebody for the last say, 20 years. Of all of the interactions they’ve had that have been effective or ineffective. And so, that is if you like the ‘truth’, but Whitehall doesn’t work on knowledge, it doesn’t work on data, doesn’t work on truth. They work on narrative.
And if you’re a politician, what would you prefer to say? Would you prefer to say, well, we’re living longer, demand is rising, so who’s going to pay? Or would you like to say, ah, what I’ve learned is that the way we’ve designed and manage care services historically is fundamentally flawed. We waste about half of the money that we invest in these services. And so we better change them. Well politicians don’t like saying they’ve got things wrong.
The Mint:
But even at the moment, the current government is trying very hard to say they haven’t been governing for the last 10 years. And they’re totally new and different. That’s the Johnson brilliant political trick if you like, is to pretend that the conservatives haven’t been in charge for 10 years, and now he’s in charge and everything’s new. So is there any possibility from that narrative that he can take, then he can admit that over the last 10 whatever years that the approach has been wrong. And that it is possible-
John Seddon:
Well, we’re not seeing it in all the documents being produced. Do remember that Boris did promise to fix it quickly and he hasn’t.
The Mint:
Didn’t he about two years ago?
John Seddon:
Apparently. And that now we’re told that the announcements will come in the spring as to what they’re going to do. But when you read the papers, as I do of what’s being talked about, I don’t see anybody talking about the fundamental need to change the system and specifically regulation that sits over it.
The Mint:
What regulation is that?
John Seddon:
Well if you run a care service, then the regulators are going to turn up and see that you comply with all of the edicts from central government. You should be using commissioning. You should be using the market. You should be managing activity. You should be meeting your target times for assessing, but you should have good control of your budgets. And also this is what makes for your reputation.
Let me just give [inaudible 00:09:32] how powerful this is. I was working in a place in the Midlands. This is a long time ago now, this would’ve been in the days of the audit commission. You remember them. We’re working for a county council on adult social care. We helped them study it. So the leaders understood it was suboptimal. We helped them redesign it. So they got a fantastically better service. And then we had heard that the audit commission was coming to do their audit of the county council and their performance in social care is a major contributor to their audit result. They had historically been a four star council, therefore super good. And the chief executive insisted that the design in the care service had to go back to the one that the audit commission would be familiar with, otherwise they might not get there four stars.
The Mint:
So everything that they’ve learned, they put aside to try and replicate what was expected.
John Seddon:
Yes. Because reputation is more important than performance. And you don’t want to argue with the regulator.
The Mint:
So the regulator doesn’t actually look at performance, they look at whether you are meeting what they expect to see in terms of how you’re managing it.
John Seddon:
That’s correct. I remember saying to Steve Bunridge, who was the chief executive of the audit commission around that time, I remember saying to him you are a civil servant. Well, don’t you think you have a duty if someone points out that things are flawed and there’s a better way to do things that you should take an interest. And he simply said to me, I just don’t agree with you, John.
The Mint:
Did he give the basis on what you disagreed with your analysis?
John Seddon:
No. No. Did he show any curiosity to come and see things in practise that were better? No.
The Mint:
So presumably you have a business providing services. Some people are listening to you. Who are listening to you?
John Seddon:
Leaders and care services. In Wales for example, smaller country, they talk to each other. About a third of the care services in Wales follow our method and the Wales assembly government have changed the policy regarding care services in Wales as a result of that work. This is a really simple thing in Wales. The requirement is no longer to fill in lot of forms. The fundamental requirement in policy is if someone’s life falls off the rails, your priority is to go in and understand what matters to them. Now that might sound small, but it’s quite profound. But also a lot in Denmark, a lot in Sweden. In Sweden, the problem they wanted to solve is how to provide continuity in a relationship. Cause that’s so important in a care service. You don’t want different people turning up all the time. You want continuity, but you’ve also got to design a service that is thermostatic because-
The Mint:
Thermostatic? What does that mean?
John Seddon:
Well, you might need 20 minutes today, but 40 minutes tomorrow-
The Mint:
So it goes up and down depending on what you need.
John Seddon:
That’s right. That’s right. So now how do you tackle that problem? And for us, it’s just a statistical problem of working out the predictability of demand and consumption and therefore working out how to organise the helping resources, such that pretty much all of the time, or certainly most of the time you’re going to get the same person turning up.
The Mint:
Okay. And so there’s a solution to that is there?
John Seddon:
Yes. The first time we worked it out was in Sundsvall in Northern Sweden.
The Mint:
And it’s a scheduling problem. Is it basically?
John Seddon:
Yeah. Yeah. That’s right. Yeah. If you can understand the predictability of demand and the types of demand, and therefore what resource you need and therefore what capacity, you can start to work towards optimising continuity.
The Mint:
So you model it and you develop the systems to do that.
John Seddon:
Yeah. Yeah. Well, you don’t model it. You take the actual data. You can do the same with any repairs organisation. This is understanding the predictability of repairs. And then the time it takes to do them, what trades you need to do them. I describe in my latest book how you do that with housing repairs, and the consequence with housing repairs is you’re able to deliver a repair to a tenant on the day and at the time they want it. That’s quite a remarkable thing. And doing that your costs fall.
The Mint:
Say I say, well I am a Whitehall bureaucrat in part of my life. So I am concerned that, well if you give people everything they want, well they could demand endlessly. It’s going to cost arm and a leg.
John Seddon:
Well done, Henry. That’s exactly what they think. [Crosstalk 00:14:31] Well so this is all about changes. If you go into them and say, the thing you’ve got to do is give people everything they want. They’ll go, you must be mad. So the first step is understanding by not giving them what they want, what it’s costing you.
The Mint:
When you sort of demonstrate that gets people thinking.
John Seddon:
Yes. And I don’t demonstrate it. This is very important from an intervention point of view, I help them study it and then they can’t deny it.
The Mint:
Right, so you help them find the information that shows what’s happening
John Seddon:
And they must do it. I’m a psychologist, so this is a normative change. If I tell them it’s a rational approach and they argue with it because it hits their mental model, they don’t like that. If I make them study it, they can’t argue with it. They realise that what they’re currently doing in care services, for example, they realise they’re wasting about half of their money. They’re buying things for people that don’t help people, that these people coming back with the same issues, that these people are also hitting half a dozen other services, we are not helping them.
The Mint:
And so in Wales, has the message got totally across. You said a third of Welsh-
John Seddon:
Currently, yeah.
The Mint:
And could it go further, do you think? Or what’s the-
John Seddon:
Of course. Yeah. And I expect it will, simply because they talk to each other and it’s a smaller community. Well in fact there’s a whole lobbying exercise going on amongst the people who work this way from both the public sector and the voluntary sector, they are lobbying the minister for social care to rethink a lot of the things that are coming out of what do they call it now? The Senate, isn’t it? They call it something like that. What used to call it the Welsh semi government. And I they get listened to, when Mark Grapefruit, He was previously the minister of social care and the policy changed under his watch.
The Mint:
Right. Well, that’s good. That’s really good. So can you sort of show also in terms of the data, that the places where they’ve implemented this approach of immediately supporting people, providing what they need, works in terms both financially in terms of outcomes?
John Seddon:
Oh, yes. Yes. It costs less to help people properly. You help more people more effectively, fewer people going into hospital, fewer people placing demands on other services. And actually, here’s something that might interest you. Have you heard of Buurtzorg?
The Mint:
Yes. I think that’s a sort of model from the Netherlands, was it?
John Seddon:
That’s right. That’s right. And being pretty stupid, quite a lot of our leaders thought, oh that’s interesting. We’ll copy it. Let me say, first of all, the results in Buurtzorg are the same as the results from what we do. More effective help, less demand elsewhere, less failure demand. All good. But Tony Blair had this idea with choice based letters. Oh, look, the Dutch are doing choice. Let’s steal it and pilot it. And so we’ve done the same with Buurtzorg and social care. And people think these pilots are all about self-managed teams. And we need to put these self-managed teams out there as a little pilot exercise, see how they get along. And they don’t recognise they’ve got to change the system that sits around them, they think they’ve managed them in the same way.
And so the results of these pilots are pathetic, absolutely pathetic. So I did a podcast all about, you got to understand what happened to Jos de Blok. Jos de Blok is the man who invented Buurtzorg. It’s a normative of change. You see, he was working as a care worker in the Netherlands, and he grew up the hierarchy at the same time as this new public management stuff came in, which is all about cost. It’s all about outsourcing. All about commissioning, et cetera. And he could see it was wrong. And by the time he’d got to quite a senior position, he was arguing that this was wrong. Now he didn’t get listened to, he got ostracised. So he buggered off left. He left, he went to the Ukraine to work for a couple of years, right?
When he got back to the Netherlands, the government had realised that they had a crisis in social care. They said, here’s a pot of money. We want anybody to come up with any idea, we will fund ideas. We’re not going to run it from central government. And so Jos de Blok put forward his proposal, he got funded. It worked. And then it grew. But what people don’t realise is that the thing we have to go through as leaders in this country is the same normative experience that he went through. What’s wrong? We’ve got to understand why it doesn’t work in order to work out how to make it work.
The Mint:
Fascinating. So you’ve got a lot of proof of the solution in Wales.
John Seddon:
And in England and in Denmark and in Sweden and in Australia.
The Mint:
And social care reform is now on the agenda, isn’t it? And it’s in the media and so on. Are you getting coverage there? Is there interest, is there a TV pro documentary coming out that’s going to point out these things.
John Seddon:
No.
The Mint:
Why is that?
John Seddon:
Well I think it’s because when I listen to the radio, I’m a radio four news listener, and I get very angry when the presenters just don’t ask the right questions. They kind of share the narrative. And even if I write- one of my people sent the Buurtzorg podcast to Justin Webb because he was talking about the problems that he had with his mother going through the care system. And he replied, it’s fascinating. It’s a word he uses quite a lot, but he still and all of the others are unable to ask the right questions because they haven’t got that mental frame as it were. These are hard questions as well, it’s not just how much failure demand there is on the health and care system.
The Mint:
Yeah. I suppose you then have to define what failure demand was. There is a wellbeing economy Alliance publication recently about failure demand, which goes even larger that says, so often we are creating problems that then cost us huge amounts across the piece that this is a pervasive systemic problem. Do you think that’s right?
John Seddon:
Well I’m not familiar with that paper. Of all of the concepts I’ve developed, failure demand has got the fastest legs. And I often say it’s easily understood, but also easily misunderstood.
The Mint:
How is it misunderstood? How can it [crosstalk 00:21:52]?
John Seddon:
Well, conventional command and control thinkers get the idea that there’s this thing called failure demand, which I define as caused by a failure to do something or do something right for the customer. So it’s defined outside in, it’s a very strong operational definition. And they immediate assume that the causes are people not doing their jobs, or processes is not working right. And they’re wrong. It systemic. So in care services, for example, if you are focused on activity management, if you are focused on caseload management, if you’re focused on budgets, if you’re focused on specialisation, standardisation, commissioning, all of those things will create failure demand.
The Mint:
So it’s quite a big thing to take on board that, yes, it’s not people out there failing. It’s the people who are running, designing in charge of the system who are failing.
John Seddon:
That’s correct. it’s systemic. And therefore the responsibilities right at the top. Right. And we think about the care service review. The thing that I’ve noticed about Josh Macallister’s work is he doesn’t talk about regulation, which is the most important thing. It’s how we control the whole system.
The Mint:
Where do you think this blindness is coming from?
John Seddon:
I think to be fair, we don’t teach people to think like this. We teach them, you go to business school and you learn that organisations are all about finance.
The Mint:
And are the people from business school, the people who are running the systems, not many people I suppose, go to business school and then go to Whitehall. I mean, Whitehall’s more people brought up in the Whitehall system and treasury and so on.
John Seddon:
Lots of philosophers.
The Mint:
Lots of philosophers. Ah, well actually-
John Seddon:
And economists.
The Mint:
I tick of your boxes actually. Cause I studied philosophy and then I studied economics. But actually as a result of studying philosophy, it helped me understand all of the disastrous failings in the way economics is taught. Actually I would put my money on philosophy being better than economics, which-
John Seddon:
I Agree.
The Mint:
More like a brainwashing approach than actually [crosstalk 00:24:08]
John Seddon:
It makes you think in constructive ways. Whereas, as I’m sure you’re aware, economics wishes it had the ability to be a science, but clearly doesn’t.
The Mint:
So just to end on it, what can you give us in terms of a positive sort of hope moving forward that this thinking will spread further?
John Seddon:
Well because it doesn’t stop. You see the important thing is that once you’ve crossed the Rubicon you now can see the difference between the way you should think and the way you used to think. You never go back, which accounts for the growth of our work around the world, really. But also, it’s an inhibitor to growth because the way to get it is to engage and do these normative studying things. So it will always be slow because leaders of organisations don’t think they need to learn things.
The Mint:
No, no, no. They didn’t get to where they are today.
John Seddon:
But everyone who’s crossed the Rubicon carries on, which is also where our work comes from. For example, we work for a major UK bank, lots of leaders understand it, get it. if they say, for example, they’ve got a new chief executive comes in and reimposes all the old stupidity, these people leave, they go to other places, they see the same issues and they call us in and we help them.
The Mint:
Well, I wish you the best of luck then in spreading the message. And I will look out, I will become that more aware of the fact that the wrong questions are being asked in social media and the social care debate. And I also hope that someone asks the right questions.
John Seddon:
Well, have you read my most recent book? I don’t think I’ve got it here.
The Mint:
No, do tell us about it or yes, we can put information about it on the webpage, by the interview.
John Seddon:
Okay. Well I think there are two that are important. The latest one is called beyond command and control. And it’s all about service organisations. It’s all about normative change, lots of examples, practical things. The other one, which I think is relevant to this interview today is the Whitehall effect. I’ve got a copy of it here, you might recognise the artwork on the front there.
The Mint:
Oh yes, yes.
John Seddon:
I wrote this book because I’d spent maybe 14, 15 years with people in Westminster and I decided in 2014, I’m not going anymore. I’m fed up. I first talked about this care thing with Ivan Lewis and David bien in about 2003. That’s the first conversation, I had a series of conversations with people about the care service since. No one’s interested because of the narrative. I even had grant chaps visited a housing site where they were delivering services to tenants on the day at the time they wanted it, when he was housing minister, didn’t do anything about it. His next announcement was that people should do their own repairs, which is completely stupid idea, never happened. So I gave up talking to them and this book is everything that I’d said to them about what’s wrong with public sector reform. It’s my dear John book.
The Mint:
Well, that’s wonderful. Well I will now read it because yes, the latest reform in Whitehall is becoming agile. And we’ve got an interesting time where agility is being turned into an inflexible system. Be agile in exactly the same way with exactly the same processes.
John Seddon:
Yes. It is a total load of bollocks. I spend four chapters talking about it and agile in the beyond command control.
The Mint:
Well, I will share that with my colleagues who are so keen to converter us all to agile working. Thank you very much John.
John Seddon:
My pleasure, very nice to have met you Henry.