I want to talk about the concept of ‘failure demand’ – something discussed in Beyond Command and Controlby John Seddon et al and which I find really compelling.
This idea is that much of healthcare work (and many other areas) is driven by demand created by failing to address the issues that matter most to people. Our systems create blocks and obstacles that make it very difficult to resolve people’s most pressing concerns quickly and fully. It creates further ‘shock waves’ of demand, as people seek alternative ways to navigate the obstructive system.
This failure to solve is not related to individual factors like skillset or dedication of the staff in the services; it is created by how our systems – such as supply chains, appointment systems and IT systems – function. Despite good intentions, many of these factors that are intent on creating efficiency and improving performance actually serve to disrupt the process of solving the problems that most matter to people.
John Seddon attributes these sets of circumstances to a ‘command and control’ culture, where management practices have been set up to standardise and micromanage pathways of practice. The effect of this is to create more failure demand, as such tight control does not allow for the spontaneity and flexibility needed to solve the huge variety of human problems that present in health and care settings.
The proposed solution is to design systems from the ‘client up’. “Design against demand – focus on what creates value for customers in their terms…” –focus on what some would say ‘matters most to you’, the person in question. Allow systems that can react to need in the moment and seek to resolve problems completely in real time, and prevent more spin-off demand from unresolved issues – failure demand.
Sounds great and makes a lot of sense. I can see how we create huge amounts of failure demand in our system. Time-restricted appointments, lack of continuity, ‘doctor knows best’ suggestions, pharmaceutical-led pathways. Focusing on the person’s real needs and values, and designing systems that do not create failure demand, seems compelling – it is likely to reduce workload and improve staff satisfaction.
Breeding passivity I started thinking, where does this eventually lead? People come to services with issues that generate a personalised and effective response. That’s great in that situation – problem resolved, back to living the life that person has reason to value. However, I worry about systems that are only focused on simply solving people’s problems, without also focusing on how to keep them in the driving seat. I think we need to pay attention to the manner in which we work with people in resolving their problems.
I worry that we will breed ‘passivity’. People could stop thinking for themselves because the systems are too focused on thinking for them, and sorting out their issues whenever they occur. In some situations, this sort of help is literally a life saver– physical, mental, emotional or social crisis averted. But what happens if this is always how a system works? Does everyone learn that it is better to leave the thinking to the ‘experts’, always better to ‘check in just in case I’m missing something that someone cleverer than me might pick up’? Do we then develop ‘passivity demand’ as people perceive that the health care system has become so good at offering us a fix, we feel compelled to ask every time, rather than think for ourselves? We inadvertently create a disengaged population by virtue of having systems that just ‘fix’.
People could stop thinking for themselves because the systems are too focused on thinking for them, and sorting out their issues whenever they occur.
Avoiding passivity demand While it is essential to reduce failure demand by designing person centred systems, this needs to be balanced by being mindful of not conversely creating passivity demand.
I think this means designing systems that, in seeking to help people resolve their problems, also seek to teach them how to do as much of the solving as they can themselves. Teach a man to fish rather than just giving the fish. Systems that as far as possible avoid ‘doing to’ people and aim to ‘do with’. I would call this a ‘coaching approach’, seeking the resources that people have themselves and practising in a way that recognises and develops these assets, supporting people to find solutions to their problems.
I think this means designing systems that, in seeking to help people resolve their problems, also seek to teach them how to do as much of the solving as they can themselves.
Clearly people have different abilities. The ‘activation’ language talks of varying skills, knowledge and confidence to self manage. Amartya Sen paints an even broader picture, talking of capabilities that take into account people’s freedom to achieve the things that they have reason to value- his ‘Capability Approach’. He recognises that the opportunity (freedom) that we have to pursue what matters most to us is dependent on many factors. This includes our personal skills, knowledge and confidence, but also our social context, our culture, factors inside and outside our control.
So, in considering how we address passivity demand we will have to tailor our support to the individual needs and circumstances of that person. We move away from blaming an individual for ‘not taking responsibility’, towards considering how our systems can consider the whole picture of someone’s circumstances. It’s not always easy, and I’ve definitely failed at times to achieve this with some patients, especially working in the confines of our current primary care system. I look forward to purposeful efforts to redesign how our systems function to enable a coaching approach.
I think this is the way to develop the Universal Personalised Care approach our NHS Long Term Plan calls for, and to reduce failure and passivity demand. We have services that seek to address each other’s unique issues in ways that also seek to empower and up-skill people and communities. We flourish together within the ultimate constraints of a mortal life.