Kev the corneal ulcer, and why we need a public service process revolution

Recent news and personal events have got me thinking again about some of the big social disruptors like automation, the ageing population and changes in our work patterns.

Specifically, I’ve been wondering how we adapt to the new social pressures created by these disruptors, and how we stop public services like health and taxation becoming money pits, sucking up ever more resource yet failing to keep up with demand.

One thing which has struck me from my recent personal experiences is the size of the opportunity to slash public service costs by re-engineering processes and exploiting technology.

It’s hardly a new thought, but it strikes me that we are reaching that critical point where this is the only way to keep these services sustainable; if we can’t keep throwing more money at them, the only way to cope with a tenfold increase in demand is to deliver a tenfold improvement in efficiency.

I worked in the airline business for over thirty years, where efficiency and structural cost reduction are constant themes.

I saw many initiatives – charging for food, airline consolidation, outsourcing support functions – which tended to shave a few percent from costs, although these reductions were often offset by trade-offs in other areas like variable costs and brand value.

The big, sustainable changes came from a confluence of technological innovation, focus on the passenger process, lean thinking, and willingness to challenge sacred cows.

I remember sitting in a room of airline managers in the early 90s, scoffing at IATA’s target to eliminate all paper tickets for e-tickets in what seemed a ridiculously short time; we all had our lists of specific exceptions which meant it couldn’t possibly work.

Yet paper tickets are now pretty much ancient history, along with all the added cost of sale they brought with them. Once e-ticketing reached critical mass, we magically found ways to deal with all those exceptions.

More recently I was involved in discussions between airlines, airports and regulatory authorities about sharing data and exploiting artificial intelligence to transform punctuality and baggage performance. Nothing remarkable in that apart from breaking down years of reluctance from all those agencies to share information at that level.

The thought that public services need similar levels of transformation has been triggered by a variety of news stories which show, in different ways, the challenges to public services presented by our changing society.

From a possible ‘over 40’s’ social care tax, to UK Revenue and Customs getting direct access to bank account data, to heart-breaking stories of avoidable suffering and loss from apparent failings in our healthcare system, all these stories demonstrate in different ways that we have is creaking, and we need radical change to stop it breaking completely.

Closer to home, and much more trivially, I’ve acquired an annoying blob on my right eye which I have christened Kevin, Kev for short.

Kev has required countless visits to my local hospital, where I have learned that he is a particularly rare breed of corneal ulcer, hard to diagnose and harder to treat.

I have been prescribed such a bewildering assortment of obscure drugs to treat him that I fear I’ll be banned from the hospital pharmacy.

The good news is that Kev looks like he’s finally on the way out, and once again I’m stupidly grateful to the professionals in our embattled health service for their dedication, hard work and perseverance in getting rid of him.

But I also get the impression that they are struggling, not only with the sheer level of demand on them, but with processes and systems which impede them from doing the best job they can.

In the same way that the airline business has done with its customers, I believe the health service can achieve the transformation it needs to meet mushrooming demand if it focuses relentlessly on the patient process,  on simplification, and on replacing paper trails and locally held records with a single, authoritative and easily accessed source of patient data

Some great stuff has already been done – innovations like the NHS 111 phoneline and the online Patient Access service have made a big difference – and I know there are other Herculean efforts going on to create a lean health service with a single version of the truth for patient data.

But it looks like there is still a very long way to go, and my experience with Kev makes me fear for the sustainability of the service without this radical change.

For example, Kev is a bit of an attention seeker, so lots of doctors in different hospitals have examined him and (look away now if you’re squeamish) swabbed or scraped bits of him off into petri dishes.

There have been at least two occasions when one doctor has not been able to see the results of tests taken by another, either because they don’t have the required access or because test results have simply been lost.

This has been annoying rather than alarming for me because Kev is not life-threatening.  What concerns me much more is the waste of health professionals’ time involved in redoing tests or trying to track down results and redoing tests.

On each of my regular visits to the hospital pharmacy to fulfil Kev’s insatiable thirst for exotic medication, I repeat the same process.

I get asked the same question about what other medication I’m on, I sign the same paper form, and I see the same sympathetic furrowed brow from the pharmacist as they try to work out where they’ll be able to source the latest rare species of anti-Kev drops.

The existing medication question is particularly fun as, not unusually for someone of my age, I’m on four different kinds of tablets as well as my various Kev buster eye drops and, again not unusually for someone of my age, I can never remember what any of them are called.

This means I’m generally good for wasting a few minutes of pharmacy staff time while I try to remember them all.

All my prescription medication is listed on my online patient record – I know, because that’s where I order my repeat prescriptions. If the hospital pharmacist had direct access to this data it would save their sympathy and my embarrassment every visit, but more importantly it would free up their time to do useful stuff.

Most importantly, it would avoid mistakes. If I tell the pharmacist I’m on Nickynockynoosteride when I’m actually on Nockynickynobsteride, which is the one which happens to react horribly with my Kev buster eye drops, that’s a potential A&E slot taken up by an entirely avoidable error.

If everyone who is working so hard to evict Kev had access to all the information they needed from a single, authoritative source, I believe they could save a lot of time and effort. And why not an Amazon style system for ordering and sourcing prescription drugs?

I know this instantly throws up loads of problems and objections. The ones I can think of offhand are concerns about data privacy, impact on jobs, and the size of the challenge to create a single unified data and systems platform in a service which is working flat out 24 hours a day, seven days a week.

I think a number of data privacy objections can be overcome by people’s increasing willingness to trade privacy for utility, and by our growing capability to create self-securing distributed systems.

I would much prefer a pharmacist to be able to check existing medication automatically and reliably rather than have me to perish from a fatal Kevbuster incompatibility or, more likely, terminal embarrassment over not being able to remember what the little blue pills are called.

And there are technologies which could easily look after the distributed security aspects in the age of Blockchain, although older technologies like SAML, AD/LDAP and application level security could do a lot of the job where most of the sharing is going on within the service.

Would this be doing people out of jobs? Given how understaffed the NHS is, and that this is likely to get worse, I believe it’s more about giving people the breathing space to do their jobs properly, help more people, and taking away some of the drudgery and bureaucracy which stands in the way.

I guess that if you’re a manager in the health service reading this, you may be shaking your head or your fist at my naivety, and/or muttering imprecations about turning super tankers in a bathtub.

I sympathise, having personally experienced just how much inertia can hold you back when you need to make transformational change, when I managed a department in a large ‘legacy’ corporate.

I’ve seen It work, all it needs is superhuman levels of perseverance, patience, focus and will. All you need to do is to go through process by process, system by system and do all that good stuff from Lean and the like. Continually identify and eliminate the biggest wastes, focus on the runners and repeaters, set 100% or 0% targets where they will make the most difference, and stick at it.

It doesn’t need to be about the grand designs – an incremental approach can help. When it comes to challenges like overhauling your core data and systems in a pressurised operational environment, people tend to  talk about changing the engine while you’re driving in the fast lane, and after a while that can become an excuse and an apology for lack of progress.

Stick in a battery and start moving the stuff which is important, visible and easy. You’ll gain momentum, deliver tangible benefit more quickly, and hopefully end up in a Tesla one day without noticing.

But enough of Kev, and enough tortured metaphors. The other local news is that I’ve been doing my first tax return in 14 years, and it’s got me thinking about simplification and data too.

In 2004, HMRC wrote to me, telling me I was boring. Actually, what they said was that, because all my income came from employment covered by PAYE, I didn’t need to complete a tax return – in other words, I wasn’t interesting enough any more.

It was only when I left my long-term employer in 2016 that I moved out of the relaxed, sunny meadows of PAYE into the cruel hinterland of self-employment.

You’ve probably spotted that naïve thinking is a speciality of mine. In this case, my first naïve thought was to wonder why managing my tax as a self-employed person couldn’t be as simple and transparent as it was under PAYE.

If HMRC could get the information they needed to work out my tax from my employer, why couldn’t they get the same information directly from my business bank account?

It’s a naïve idea because taxation when you are self-employed is much more complicated, there’s much greater scope for tax evasion, and the thought of HMRC having direct access to your bank account is frankly terrifying.

Yet it wouldn’t be the first entrenched way of doing things to be challenged and changed by naïve thinking.

I believe there are many sole traders and limited companies whose tax affairs could be managed using a set of straightforward algorithms, and I don’t think I’m the only one who would be prepared to give up some privacy in return for avoiding that annual January 31 panic.

Just as the Health Service is coming under impossible strain as people live longer, I believe that our taxation services will come under similar pressure as the economy changes and fewer people work in traditional employment.

To keep up with demand, they need to go through the same process of streamlining and exploiting automation and shared data.  Automating tax returns for self employed people is just one example.

Technology and changing demographics are revolutionising how society works. We need to transform social services in line with this to deliver exponentially more capability at the same or less cost, or those services will start to collapse.

It’s exactly the same kind of transformation we’ve seen in business, from supermarkets to banks to airlines. Disruptors have driven the use of lean processes and automation to deliver step reductions in the cost of delivering their services.

Transformation in the airline business has driven a new deal with the customer. As airline customers we have shown that we are largely prepared to trade the luxury and personal service aura of traditional air travel for slick, automated processes and the lowest fare.

There’s a hackneyed argument that the public sector is slower to change because it doesn’t have the same competitive pressures.  I think this is only partly true, particularly now when pressure on government budgets is so strong.

However, I do think there is a tendency for public services to leap to the glib solution of outsourcing when faced with the challenge of slashing costs.

The issue with outsourcing is that it doesn’t in itself deliver step reduction in costs.

It can deliver economies of scale and drastically reduce your fixed costs, but if the outsourcer is doing stuff in basically the same way as you were then the economies of scale may be marginal, and if the level of demand is fairly constant, you’ve just exchanged a set of fixed costs for variable ones don’t actually vary much.

Add in the new cost of managing the outsourced contracts and, whilst you may achieve savings of a few percent, you’ll never get the 70-90% unit cost reductions we need in public services like the NHS and HMRC.

That scale of reduction can only come from single-minded focus on eliminating wastes by transforming processes and exploiting technology, and by engaging with the customers of the service to take them on the same journey.

Add in the power of artificial intelligence, and the vision of an empowered public service, able to service exponential growth with incremental increases in resources, becomes achievable.

As for Kev, he hasn’t left the building quite yet, but I’m hugely grateful to the bunch of dedicated folk chasing him out. I just wish it didn’t feel sometimes like they’re doing it with their shoelaces tied together.

 

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