Who's Responsible?

A Common Denominator

Statistician W. Edwards Deming’s equation lays out the relationship:

When people and organizations focus primarily on quality, defined by the following;

quality tends to increase and costs fall over time.

However, when people and organizations focus primarily on costs, costs tend to rise and quality declines over time

Across the spectrum of public and private organisations there are a lot of ‘cracks’ as defined by very poor quality of provision.  Many will be able to identify examples of their own; Instances when quality of provision is ashamedly poor.  Only in times of crisis are the realities addressed.

The ‘cracks’ that lead to poor quality provision are the direct result of strict demarcation that severs any lateral channels of communication within an organisation.  Strictly vertical lines of communication designed to create maximum economic efficiency prevent one department from cooperating with another.  Hence, there is never any holistic consideration of what needs to be achieved when circumstances arise that ideally require the supporting services of several departments.  Listen carefully to the news headlines.  Retrospective reviews of every public care crisis to date concur in their findings.  Staff are overworked and function within a culture of demarcation; there is no communication between relevant service departments.  Hence an enforced abdication of responsibility emerges that allows for many cases to fall through the cracks and fester into crisis.

Strictly enforced demarcation solely to serve the mantra of economic efficiency is what currently drives healthcare delivery systems and councils’ social care systems alike.  This is also why a study published in the British Medical Journal [24] reported that the offer of self-management support to patients with chronic conditions had no significant impact.  Indeed, practices that participated in this study negotiated the time that would be given over to the study.  The outcome of these negotiations assured priority for biomedical work and arguably allowed for no lateral, i.e. holistic implementation of self-management support from within the system.

Contrary to popular opinion, it is not clear that privatisation of services will help either.  As the profit motive drives outcomes for the benefit of shareholders the same principles of demarcation in the form of cherry picking apply.  This is already creating a two-tier system where complex cases are ignored because they are deemed unprofitable.  Already there are documented instances of NHS patients who are sent to private subcontract providers for surgery that, when complications arise, are told to re-enter the care system via an NHS primary care practise or A&E.  Clearly complications are not factored into such contractual agreements.  Complications erode profit margins, something unacceptable to shareholders and CEO’s with performance based contracts alike.

While on the theme of profit, in a value added or manufacturing economy wages are not the largest bills faced by employers.  Even where that might be the case, manufacturers design better widgets that sell for more to compensate for an increasing wage bill.  Another, albeit limited option, is for manufacturers to increase the rate of production.  More work, more pay.

However, a fundamental change has occurred.  Britain is now primarily a service-based economy.  In all service based economies wages are the largest single cost faced by employers.  Improving services in order to charge more typically relies on improved product support in the form of better medical equipment for the healthcare industry or better tools and materials for social housing maintenance work.  In both cases the employer incurs additional costs for which there is only one form of compensation if profits are to be maintained. That compensation is to reduce the wage bill and enforce organisational demarcation in the hope of achieving greater working efficiencies.

Hence we see employers in service-based sectors of the economy take on fewer employees or slash numbers of existing employees.  Also, wherever possible, employees with fewer and fewer skills are employed.  This modus operandi lowers wages in order to maintain profit margins.  Employers then achieve further savings by using part time and zero hours employment contracts.  The ‘coup de gras’ in this effort to maintain profits is demarcation.

As a result we see local authority subcontract painters seal meter boxes and gates shut.  In turn, vulnerable adults bankroll energy companies when bills are overestimated because the meter cannot be read and access for people with disabilities is obstructed via a jammed gate.  Correcting errors like these clearly increases costs and decreases working efficiency.

Leonard Cheshire Disability reports that local authorities now schedule fifteen (15) minute care visits as the norm for older adults needing care and those who have disabilities.  A representative for local authority adult social services managers responded by saying, “this fits the bill in most cases”.  In cases where this practise doesn’t fit the bill, how will the increased mortality rates that are sure to arise represent efficiency savings?  Will local authorities manage their upcoming responsibilities to deliver health care combined with social care in the same manner?

Organisational psychology long ago recognised the fact that individuals regularly relieve themselves of responsibility when things go wrong within systems/cultures driven by strict role demarcation.  Good people, as most are, deny responsibility when they encounter circumstances they are required to ignore by job description because of demarcation policies.  How else can people live with themselves when things go wrong?  Passing responsibility on is symptomatic of a natural human protection mechanism without which people would make themselves ill. Remember, exposure to enforced helplessness is traumatic.  Denial is the first response when trauma is experienced.  Symptomatic of this denial is local authorities’ nationwide lack of accountability.

Organisations that honestly embrace the core constructs of self-management are essential if the trends outlined above are to be reversed.  The same constructs would also go a long way to assuring accountability on behalf of local authorities and their subcontracting partner organisations.