12.9.14

Order Order

So in the Houses of Parliament, it's Prime Ministers Questions that gets most of the news. But a lot of the deeper and more searching work is conducted in the committee rooms with the various Select Committees.   They typically cut to the quick, and are wonderful combination of  authority, focus and personality.

No one is out of scope for the select committees.   Ministers, Chief Constables and Chief Executives get "invited" to attend to "give evidence" and be "witnesses".  And there are often the charismatic and forthright committee chairs, that take no prisoners.  So there's a couple of examples below.

And with recent cases of witnesses correcting themselves some time after giving evidence, some committees are now seeing fit for some witnesses to take the oath, with hand on the bible, "to tell the truth, the whole truth and nothing but the truth".  That makes it purgery for anything that not the truth there and then.   It's a powerful turn of phrase to set the scene for the witness..... "The Clerk will now administer the oath to you"

Not only is there strong directness but the role of evidence and data seems to be getting more profile.  Here's a couple of examples of the staggeringly direct and demanding challenge from the committee chairs.

Public accounts Committee on Out of hours GP services in England

Monday 1st September 2014.

The audit commission reported on this topic...  Out-of-hours GP services cost an estimated £400 million in 2013-14 and an estimated 90 per cent of GP practices have opted-out, and delegated the service.

Again here's the committee purpose...."This inquiry will challenge the Department and NHS England on their oversight and assurance of out-of-hours GP services, on the performance of the system and on the level of public awareness of out-of-hours GP services."

Oversight is such a great term with its different definitional options. It's both "overview" and "overlooked".  Can be great to describe "overview" but infer over "looked".  That feels like the case here.

So Margaret Hodge is in the chair, questioning the Chief Exec of NHS England, and the Director of Acute Care


"You should know it. With the greatest respect"
  • "You out to have the basic data rather than just give an example"

  • "You see, you don't have data on anything"

"You don't know it's value for money. You don't know because you don't understand your cost base.
"You're creating an absurdity of it"
"I don't know what that means. It's a non answer".


Hodge referring to whistleblower evidence..
"The data that was being provided was falsified....there was no monitoring through the system that enabled that to emerge"
Then some super lines from Richard Bacon...
"The chairs question was about cost not quality" 
"That was not my question neither was it Mr Pugh's"
"That was the question to which we were looking for an answer...and it was striking to me that you didn't know that."
"You need to understand your cost base and I don't think you do.  You have to understand your underlying cost base and you don't".
And some back and forth from John Pugh creating a turn around answer.....
Pugh... "Have you done any drilling down into the figures?" 
Willet... "We haven't got a breakdown and we don't know the individual breakdowns and the individual consultations and ratios" 
Pugh..."But I'm surprised at that as that's quite a key factor to know on terms of integration of services" 
Willet..."Those data better understood locally.  There's going to be a variation from locality to locality" 
Pugh..."But a variation is a concern". 
Willet... "And that's were we have to get to measure the all fragments in the same way.  Look across the system to see how it's performing"
And then the build up to a strong challenge....
Willet... The "local health economy working with the public will need to decide how best they want to provide and offer the service and what is the best arrangement.   Walk in centres remarkably different, across the country where they were what they did, whom they were supported by".
Pugh... "You didn't have information centrality on the extent to which GPs were sub-contracting".
Willet ..."We have a complete inventory of the whole country and we can tell you exactly what the position is"
And then comes the simply sublime intervention from Sir Aymas Morse - Comptroller and Auditor General of the National Audit Office - responding to a real sense of flippancy from Willet in that last response.
"That's really great.  So you're collecting more information.  All we're trying to push you towards is to make sure the information is sufficiently coherent that you know whether the out if hours service is value for money or not.  We're not telling you to collect all the info that could possibly be asked for everywhere  in the world or things that are burdensome. Just asking you take a logical approach to putting something together that allows you to make good judgements at the centre. Is that fair?"
 "And we agree with that" Stevens


Home Affairs Select Committee on Child sexual exploitation in Rotherham .

Tuesday 9 September 2014

Chaired by Keith Vaz and "taking evidence" from the previous Chief Constable.

There's a clue of what's to come in the pre-committee published purpose from Keith Vaz.  "The Committee will be questioning those in positions of authority at the time that these offences were being committed on how the sexual exploitation of children on a horrifying scale was allowed to go unchallenged for so long."

Here's some Vaz statements to the previous Chief Constable.


"That's an interesting point. It's not born out by the facts" 
"I don't think your treating these proceedings with the respect they deserve". 
"How would you know that Mr Hughes, when your telling this committee that you don't know about anything else and can't remember anything else" 
"We find your evidence totally unconvincing"
And some reference to the data from the previous Chief Constable.
"Improvement"..."That's not some sort of numerical idea".  "You look at recorded crime figures you look at the data to establish the problems". There were "good relationships with Local Authorities and others who would bring data to me". "I had no knowledge of this". 


What Gets Measured Gets Done...But....

....What gets pressured gets spun.



Targets. Targets. Targets.  A curious thing.  They include not only a prediction of the future, but also a prediction of influence on that future, and specific measurement of all that too.   Seeking that special sweet spot between being both challenging and achievable at the same time.

Of course in some cases it might well be visionary and aspirational, as in the old Eastern proverb ..."Aim for the top of the tree and you'll never leave the ground.  Aim for the moon and you might at least get to the top of the tree".  But more often than not it's about performance, and about success or failure.  Binary rather than multidimensional.

So big headlines around falsification of the measurement of cancer treatment waiting times to meet government targets.  The Care Quality Commission (CQC), the independent regulator of heath and social care in England found that measurements in one hospital, nearly a third of the patient records examined (22 of 66) had been altered to hide "extensive" delays for treatment.

What is measured and targeted sure does get attention and focus.  But once the that pressure tips the balance from being a priority, to being the pure judgement of success or failure, then unhelpful creativity and system redesign sets in.

That might just be managing the system.   There's the example from transport logistics moving electronically tagged parcels.  The sorting centre will bring the parcels inside only once they are ready to process them. Simply bringing them over the thresholds starts the electronic clock.   So best they wait outside until we can start the clock when it suits us.. That may well minimise the amount of time in the sorting centre, but overlooks the bigger picture of overall faster delivery.

It's also possible to entirely design out measurement of failure.  There were maximum waiting times from booking to appointment to see your local GP.  The solution.....take away the advanced booking system so you can only book on the day for the day.  No luck today, then it all starts again tomorrow.

What's disappointing is that the target it set at the minimum acceptable level.  So take the original four hour target for waiting times for Accident and Emergency departments.   So the margins can be managed, for example ambulances can be left queuing before patients are accepted which starts the hospital acceptance clock, and patients can also be transferred to "assessment units" which stops the clock.

That was strongly reinforced, hearing super presentation at the recent Royal Statistical Society Annual Conference (Sept 2014) from the joint academic and medic research team at the University of Sheffield. There's a fantastically clear spike where patients were admitted in the moments before they exceed the 4 hour waiting time.  The target has gone now but by all accounts the 4 hours is still a strong corporate driver.



What's even more staggering is some of the background measurement activities.  Different hospitals measure these things in different ways.  In fact it's possible to stay two nights and still not be classed as an admission.

So rather than the one dimensional focus on four hours, what about a four dimensional focus.....on the number of people waiting for 1hr, 2hrs, 3hs and then 4hr.   The elapsed time is being measured anyway so there's no additional measurement overhead.  That's a much more refined perspective.

Post four hours might well be failure, but how about some success focus too, at the 1hr and 2hr end of the spectrum.  Sure there might then be micro management at the hour margins, but at least it's a fuller and more multidimensional picture. Two A&E departments with identical performance at the 4hr threshold, might well look different when it's unpacked into the hour performance slots.  Even mean waiting times might give a more insightful view.