I have recently been struck by the parallels between two large organisations in the health sector. One is a major pharmaceutical manufacturer, the other is the NHS. There are many differences between them, one is a global organisation, the other UK-based. One is a significant commercial entity, the other a public sector body and the fifth largest employer in the world. Yet both have at least one remarkable thing in common; a system of inspection designed to provide reassurance seems to be limiting their effectiveness.

In the 'Big Pharma', there is a never ending stream of inspections from public health authorities around the world. In the NHS, a never ending demand for data to alleviate the concerns in government as the system comes under increasing stress. Both processes are driven by an ultimate desire to assure the end user that what is being done is safe. A sensible and indeed laudable aim.

'What gets measured gets done' is an old and familiar phrase. If we pay attention to product or patient safety then those measures improve. But over what time frame does this hold true? And is it the measures or the safety that gets better?

One of the characteristics of working with complexity is that cause and effect can be dislocated in both time and space. In other words, the nice neat causal relationship between action and consequence cannot be easily established. If we carry on regardless of this, either blind to its implications (or pretending it is just not true because we cannot see any other way to work) we heap complication upon complication as we try to mitigate the effect of each negative occurrence.

This is all about the illusion of control. If we inspect another element of the production, packaging or distribution process we believe we make it safer and reduce error. If we  'hold people to account', 'hold their feet to the fire' for waiting times going in the wrong direction, we delude ourselves with this illusion of control. We honestly seem to believe we can make a difference when over long periods of time, despite all our interventions, the numbers get worse.

Lots of things are going on. One has been well known in manufacturing improvement circles for some time. This is that the only measures that really improve performance  are the ones the teams doing the real work need to measure themselves in order to get better at their work. The teams themselves choose these measures, design them, use them, adapt them and discard them when they no longer add value.

Another thing that is well known is that once someone other than you is made responsible for your work you take less responsibility for it yourself. So if the Secretary of State is calling the hospital chief executive every Monday to demand an improvement in performance, accountability has passed in large part to the two of them, neither of whom is seeing any patients. When the FDA or other regulators are demanding of the quality assurance teams data on process, the same thing has occurred.

So we see the growth of the quality industry and the corporate centre who manage the relationships with regulators and government inspectors. The locus of attention has moved from the real work to satisfying an external construct. It becomes a game and gaming becomes endemic. A whole industry grows around the process whose purpose becomes perpetuating their activity and whose outcome is rapidly rising cost for marginal gain.


The stories of gaming in this field would be amusing if they weren't so costly. A favourite is the story of the local authority chief executive who realised a low score for 'leisure' would mean his authority failed to achieve a top rating as a whole. He therefore instructed staff to all join the library. A take up of several thousand new members boosted the scores and the council was graded top of the rankings. Did any resident notice the difference?

And so data has become the enemy of the real work and not its friend. It has become so complex and manipulated that its power and meaning is lost. What it means to do a good job is no longer obvious and subject to expert interpretation.

The solution is to remember that people own what they help to create. Stop expecting change to come from centrally imposed regimes. You can't make work meaningful in this way. Recognise that change happens where people are doing the real work. Credit them with the same good and moral intent that you so easily assign to yourself. Create opportunities for people to take back accountability for what they do and they will repay your confidence in them, time after time after time.