In a recent post, I explored whether we are really debating the underlying principles of emerging clinical-community partnerships to address social needs. My worry is that health care’s aims and ways of working have the potential to damage the core of what makes community-based organisations effective.
One of those ways of working is to organise around pre-defined outcomes but, as today’s interviewee, Toby Lowe, tells us this form of performance management has been proven not to work in complex social environments – the very environments that these clinical-community partnerships have been established to work in.
I first spoke with Toby as part of my Beyond Systems project and caught up with him off the back of his new report, Exploring the New World: Practical Insights for Funding, Commissioning and Managing in Complexity.
Pritpal: Let’s start with what you were doing before all this complexity stuff.
Toby: I used to be the Chief Executive of a charity that helped people who didn’t have the opportunity to make art, to make art.
Pritpal: Well, that’s an appropriately complex first sentence! Give me an example.
Toby: We worked on a programme for young offenders. The young people did twenty hours a week of youth work, 4 hours of which were arts activity provided by us. The local government manager behind the programme could see the value of the arts activities to the young people he was responsible for so he gave us £30,000 a year to be part of the programme.
Pritpal: And then something changed.
Toby: Yes. In about year eight of the work the Council adopted an ‘outcomes-based accountability’ approach. The manager said to us, “In order to give you your £30,000 next year, we need you to claim that you’re preventing youth re-offending.” I said to him, “But you know that claim is impossible to make. We only do 4 hours with them a week and it’s impossible to say those 4 hours is what makes the difference.”
Pritpal: How did he respond?
Toby: His response really opened my eyes. He said: “I know that it’s not true. I just need you to claim that it is on this form.” I saw the reality of trying to manage using outcomes as targets – it causes people to stop telling the truth to each other.
Pritpal: Isn’t that a bit of a leap from one experience?
Toby: It wasn’t just one experience. I started talking to my fellow Voluntary and Community Sector (VCS) chief executives. They were finding exactly the same thing in all the different policy areas they worked in. They were being asked to prove that their work created outcomes that were far beyond the scope of their actual work. And because everyone knew this – commissioners and VCS leaders alike – everyone just stopped telling the truth. They were producing figures which bore no resemblance to reality, and everyone was colluding in it.
Pritpal: That’s depressing. So, what was all this telling you?
Toby: It made me ask the question: if no-one is telling the truth about what it’s actually like to do the work, how does any of this get any better? When everyone in the system is colluding to produce information just to ‘feed the beast’, how does the system improve?
Pritpal: Good question. So, what did you do?
Toby: It made me talk about it a lot and I ended up having a conversation with people at Newcastle University Business School. They then invited me to become a Visiting Fellow doing research into Outcomes-Based Performance Management (OBPM) alongside my role as Chief Executive. In my research, I was shocked to find that there had been many studies into this form of management and they’d pretty much found the same thing – that when you try and manage using outcomes-targets, it creates gaming and perverse incentives.
Pritpal: Wow. So, why did this form of management persist?
Toby: My analysis was that each of those individual studies concluded that the gaming and perverse incentives were created because people weren’t measuring the right thing, or they weren’t measuring in the right way. The logical next step, then, is to find the right measure, or the right way to measure. This is fine if you’re just looking at one study but when you see the same thing across 10-15 studies it makes you wonder if the issue is not a technical problem with measurement but a basic conceptual one.
Pritpal: Which means?
Toby: Maybe the basic theory underpinning this form of management is just a bad one. I did an analysis that uncovered two key flaws. The first is that the outcomes that tend to get measured are only ever proxy outcomes for what was desired, they’re not the outcome itself. The problem with using proxies as performance measures is that people work to change the proxy, not to achieve the real outcome in someone’s life (the Volkswagen emissions scandal is a great example of this). The second is that in social services it’s basically impossible to say an outcome can be attributed to the actions of an organisation; there are just so many other influences at work. All in all, I thought it was a sorry tale and called it so in an article.
Pritpal: I bet that made you popular!
Toby: I was expecting a lot of push-back. We put on a series of practitioner-facing conferences to share our findings. I was expecting people to say, “What do you mean it doesn’t work? We make it work all the time.” What they actually said was, “Of course it doesn’t work! But what the hell else are we going to do?” It was then that I realised that the job of a Business School researcher was to answer that question. Most public sector and not-for-profit people are neck-deep in the work; they haven’t got time to rethink how it should be managed. So, I switched from being a charity Chief Executive to becoming a full-time researcher to help answer that question: “what the hell else are we going to do?”
Pritpal: You clearly like small challenges. So, where did you start?
Toby: We realised that OBPM fails to deal with the complex reality of the world. It pretends the world is simple and linear. It pretends that what is measurable about an outcome is the same as the experience of that outcome in someone’s life. It pretends that outcomes are delivered by organisations, when outcomes are the products of hundreds of different factors all working together, most of which have nothing to do with those organisations.
Pritpal: That’s a lot of pretending.
Toby: Right. So, we realised that whatever comes next has to start by recognising that the world is complex rather pretending it away. Luckily, there were a few public sector commissioners and charitable funders already doing things differently. Working with the not-for-profit think tank Collaborate, we asked those managers how they experienced and responded to complexity in their work. They talked about how managing in complexity required relationships and trust. They especially described three activities:
- Trusting the intrinsic motivation of people doing the work on the ground
- Using learning as the driver for performance improvement
- And creating healthy systems because only healthy systems produce good outcomes
That’s a horribly distilled list of what was a series of fascinating insights that we told in detail in our first report, A Whole New World: Funding and Commissioning in Complexity.
Pritpal: Paul Taylor of Bromford talked about 1 and 2 in my recent conversation with him. So, what was the reaction to your report?
Toby: We didn’t think many people would care! But it really seemed to strike a chord. We had over 300 organisations say to us: “We are working like that!” or “We want to work like that!”. What the report seemed to provide was a language which enabled people to talk about how they were working, and a framework which explained why it was important.
Pritpal: If so many people were working in that way, or wanted to work in that way, did you think the question of what the hell else to do was answered?
Toby: No. It made me realise that people were trying to an answer the question but were often isolated in their efforts. We saw two things that needed to be done: we needed to connect the people working in this way, or interested in working this way, so that they could begin to share practice and experiences with each other; and we had to find out more about the detail of the practice to see how it worked in different circumstances.
Pritpal: Tell me about the latter.
Toby: Perhaps one of the most important things we learnt was that the language of complexity is off-putting for many. Just the word ‘complex’ sounds like a bad thing. So, rather than keep saying things like ‘working in a way that’s informed by complexity’, we listened hard for what that actually meant on the ground. We heard three things: Human, Learning, and Systems.
Pritpal: Ok, let’s take them one-by-one. Human?
Toby: People who work in a way that is informed by complexity use the language of ‘being human’ to describe what they do. This means recognising the variety of human need and experience, building empathy between people so that they can form effective relationships, understanding the strengths that each person brings, and deliberately working to create trust between people.
Toby: They also speak about learning and adaptation. They describe how their work is not about delivering a standardised service, but rather a continuous process of learning which allows them to adapt to the changing strengths and needs of each person with whom they work.
Toby: People working in this way recognise that the outcomes they care about are produced by whole systems rather than individuals, organisations or programmes. Consequently, to improve outcomes, they work to create ‘healthy’ systems in which people are able to co-ordinate and collaborate more effectively.
Pritpal: This is all well and good but whenever I’ve met brave, community-oriented practitioners trying to do things differently they eventually get shut down because they can’t produce the metrics that their funders want to see. Have you seen solutions to this?
Toby: I’ve not seen solutions, as such, but I am seeing funders and commissioners start to work differently, partly through our efforts to engage them. We’re helping those with money to recognise that every time they ask for particular outcomes they get in the way of the work. Things do appear to be changing. We’ve now got more charitable foundations offering ‘core funding’ – rather than funding based on pre-defined outcomes – and even some public sector commissioners prepared to invest money without asking for pre-defined outcomes.
Pritpal: I’m enthused but worried. I’ve seen excellent work closed down over the years, despite saying similar things. How are you going to sustain your work?
Toby: Hah! Good question! I think what is working in our favour, ironically, are the drastic cuts that local governments have seen through the austerity agenda. In the past, the inefficiencies of target-based approaches were ‘overcome’ by throwing money at the problem. That’s no longer an option and so people have had to face the fact that OBPM simply doesn’t work and cannot be made to work. We’re offering them a concrete and viable alternative with case studies that prove it works. Our task now is to turn this way of working into a movement, to make the Human Learning Systems approach the new normal.
Pritpal: Another one of those small challenges you really like. How can folks join the movement?
Toby: Obviously, I hope they’ll read the new report. We also have a bunch of presentations online, and we have an online community of practice that they can join. I also think people should also be holding funders, commissioners and service managers to account if they continue to use OBPM models. They don’t work so they’re wasting money, often public money.
Pritpal: Truth to power, as they say. I wish you well in all this. It’s sorely needed and long overdue.
Toby: Thanks, Pritpal. Keep fighting the good fight!
I’m not sure that interviewing interesting people trying to overcome the chasm between systems and citizens is really “fighting the good fight” but I am sure that Toby’s journey is one that people in health care cannot ignore. As the sector seeks to create deeper partnerships with community-based organisations, it needs to think hard about how performance is to be measured. Simply applying its outcomes mindset – a mindset that is also baked into the so-called value-based health care movement – is clearly likely to lead to the gaming that forced Toby and his fellow Chief Executives to stop telling the truth. This would only serve to further the divide between health care and communities, with the former claiming that targets are being hit while the latter knows from bitter experience that life is simply getting worse. I hope health care leaders listen to Toby’s experiential and academic knowledge and think hard about how they participate in these emerging partnerships.
The photo behind the title is by Ross Findon on Unsplash.