The stretched middle

My wife works in the NHS, the biggest employer in Europe. The NHS, providing free health care to all, has been a remarkable achievement. But there are many signs that pressure is building within the NHS at all levels – staff are unhappy and stressed (in my wife’s team alone, more than a quarter of the staff are absent with long-term sickness), finance is increasingly tight, more and more legal claims are being brought against doctors. Every now and then the system breaks down somewhere and horror stories emerge of badly neglected patients. Politicians are coming under increasing pressure to do something.

I was speaking to Cathy recently, a colleague of Dasha’s, who has worked within the system for more than 30 years, and asked her how she deals with all this. Her response was, in effect, “So long as I have a good team, I don’t mind.” She works in a team of 20 people who provide care in the community and she likes and respects most of the people she works with and that’s enough for her.

Organisations of any reasonable sort of size (let’s say over 30 people) can be crudely divided up into “tops”, “middles” and “bottoms”. At the top are the controllers, pulling the levers of power and hoping that they will get the response they intend further down the organisation. They tend to be strong on left-brain thinking, analysis and planning and they like to feel in control. Since it is pretty much impossible to really ever be in control of an organisation (you can certainly influence it but control it – never!), they are also quite good at pretending to themselves and others that they are in control. You can’t really blame them for this – the owners, the distant people who appoint them, expect them to be in control so they are obliged to pretend. One of the problems with this is that it gets in the way of them realising that they need information from the bottom in order to know what it is they are trying to control.  Smart people at the top know that without this information they are worse than useless.

At the bottom we have the doers – people like Cathy. This is often the most satisfying place to work. If you have a good team around you, you can often ignore (most of the time at least) problems in the wider system. Their job is to get the work done within the constraints handed down by those above. They tend not to spend much time thinking ahead, or on strategy or big picture stuff – if they do, it can just get in the way of them doing their work in the moment.  Yet they do need information about the big picture, in order that their work makes sense as part of the patchwork, and so that they can coordinate with others at the bottom to avoid duplication or gaps.

Then there are those in the middle – the multi-taskers. They have three critical functions. One is as a communication medium. They facilitate vertical communication, so the tops know what is happening at the bottom and the bottoms know where they fit in the system. Since the tops and the bottoms tend to think differently, they also speak different languages so the middles need to speak both languages. To communicate effectively, they also need to be good at filtering, sifting and distilling information – it is no use to the few at the top if the middles simply relay up all the information from the many at the bottom – the tops will quickly be overloaded. So the middles need to be good at extracting the essence and passing that up, and passing back down whatever comes from on high, translated so it makes sense in the local environment inhabited by the bottoms. Middles also have to be effective in horizontal communications – speaking with other middles to ensure that there is coordination across the organisation.

The second principle function of a middle is to appoint, monitor, supervise, inspire, hold to account, mentor and in general “manage” (there are so many complex and often hidden meanings in that simple word) the bottoms.

The third function of a middle (as indeed of tops and bottoms too) is to monitor, hold to account, and general manage themselves in their own tasks. This may be the hardest and most important of the lot.

Not surprisingly, the supermen and superwomen who work as middles in large organisations tend to get stretched, and the larger and more complex the business, the more stretched they get. It is rare to find a middle who can even do one of these critical and, let’s face it, usually very demanding, functions really well. To expect them to do all three well is fanciful. The way large organisations, whether private or public, tend to deal with this is to add more and more middles into the equation, promoting some of them to supervise the others. This can improve things for a while. After all, as studies have shown, almost any intervention from above can have a short-term positive effect, mainly it seems because those below like to think those at the top are paying attention to them  (in one study, lights in a factory were turned up and the result was a measurable improvement in production productivity.  At the end of the study, the lights were turned back down again by mistake and productivity improved again!).   But since such an approach doesn’t address the fundamental problem, mostly what you get is a bigger wage bill (and the middles cost a lot more than the bottoms, though of course not nearly as much as a top) and often less efficiency, because the system gets more complex the more layers you add. What’s more, the organisation gets filled with professional managers who understand the theories of being a middle better than they understand the actual work of the organisation. This can be okay if they spend a lot of time with the bottoms, but because they have elevated salaries, many of these professionals feel it is beneath their dignity to spend a lot of time with the workers – so they hang about with other equally un-informed middles.

As far as I can work out, this is more or less what’s been happening in the NHS. People like Cathy carry on with their jobs but more and more they get weighed down by the pressure from the middle. I would love it if someone would measure how many managers have been added in the NHS in the last 20 years, as a proportion of the whole, and what the impact on patient care and efficiency (both important measures) has been.

An innocent outsider reading this might begin to wonder “Do we really need the middles?”  This previously heretical thought is starting to occur to more and more tops (and indeed to middles and bottoms).

A talk at the RSA couple of weeks ago highlighted one of the most successful examples of taking this idea and pursuing it with rigour. Buurtzorg is a not-for-profit healthcare provider in the Netherlands. There is not a single manager in the place – instead it runs itself as multiple self-organising teams comprising 10 people each, who have broad responsibility for their own finances, scheduling and other key decisions.  They do have “coaches” who fulfill the vital communicating function which is normally the responsibility of middles. But these coaches are not managers and they don’t have the power or responsibility that goes with it. Apart from anything else, there are simply not enough coaches for them to be able to pretend to manage anything. Buurtzorg has achieved remarkable success already. The most important indicator is the effects on patient satisfaction, which is far higher than in other organisations performing a similar role in the community. Staff satisfaction is likewise very high. By another measure too, they have been extraordinarily successful – in the space of just 10 years, Buurtzorg has grown from a group of 10 people to an organisation of more than 8,000.

Of course an organisation needs to be adapted to fit its context, and contexts vary massively from country to country, and industry sector to industry sector. So we don’t know how this approach might work, say, the oil sector in Texas, in aerospace in France, in pharmaceuticals in Sweden, or in the transport sector in Japan. But more and more examples are emerging of organisations taking this route to solve the problem of the squeezed middles. W. Gore, Vitsoe, Happy, FAVI, Sun Hydraulics, to name but a few. And this is not to mention open source communities and other on-line (Wikipedia, Flickr) and off-line organisings (Burning Man) that are radically re-thinking the way we organize. I dream that one day this sort of thinking will start to permeate the NHS and other great but troubled institutions.

For this to happen of course, we will also have to answer another question – having dealt with the middles, what you do about the tops?  That is a question for another blog post!

Multiple causes, multiple responses

“For every complex problem, there’s a simple solution. And it is wrong.” Anon

I have been having lower back pain recently. It has happened occasionally in the past but this is the worst I’ve had – on Tuesday I had to walk with a stoop.

I am fascinated by how many possible causes there are. One friend suggested it was about me needing “support”, another that it was to do with finances. I read in a book that a stagnant liver is often a cause of lower back pain. Then there is the physical side. A couple weeks ago Dasha had a new treatment couch delivered – it must have weighed over 120 kilograms – and I dragged it across the lawn in its cardboard box to her therapy room. I’ve also been chopping logs for the woodburner recently and I don’t really have the build or the strength for swinging a heavy axe. So perhaps I strained something. I might need to strengthen my stomach muscles, as my brother suggested.

It could be any one of these causes, but I suspect it is a combination of them. I do feel the need for a bit more support at the moment, our finances are not in the state I would like them to be, I had overloaded my liver just before the back pain was at its worst with heavy and rich food, and my stomach muscles aren’t as well toned as I’d like them to be.

We are complex systems, we humans. Although some seem to think we are merely physical bodies, most of us intuitively know that we are far more than that — we have an emotional body, a mental body, a soul and who knows, maybe more. And the subtle interaction of all these different parts is far too much for one person to properly understand. When looking to respond appropriately to a mini-crisis in a complex system such as lower back pain, a systems approach that addresses multiple causes is the right one.

I think about all this when I hear that the government is, yet again, planning to make radical changes to the health service. Whatever the intentions, and whatever the thinking, we know that they will get it wrong, because they are not viewing the NHS as a complex system. They believe that they can fix it from on high. It is like trying to grow a plant by physically rearranging the atoms, rather than by gentle nurturing. A healthy health service can only emerge from millions of individual actions by those engaged in it every day, making decisions as semi-autonomous, empowered individuals.  We need to get the management system out of the way, and free up those who are dying to simply do their job and serve patients. What will then emerge is multiple different responses to the crisis at multiple levels – and from these responses, a healthier system will emerge.

Yet many dismiss such an approach. Take a painkiller, they say, find a quick and easy solution so we can move onto dealing with the next crisis. They don’t have the patience for these slower, longer term but ultimately more effective approaches. Funny, there seems to be a high percentage of such people in politics (although, of course, there is an aspect of this in all of us). No doubt this is in large part due to the nature of the political system! Certainly the interaction between the health service system and the political system seems to be an unhealthy one.

As individuals watching all this, all we can do is intervene in the system where we can. Be kind to the nurses who treat us, resist unnecessary vaccinations and routine application of antibiotics, take greater responsibility for our own health. In short, be the change, as Gandhi put it, and trust that our little intervention can make a difference, even if only a small one. This has to be more effective (and certainly more healthy for us) than searching for or advocating a single, simplistic solution.

As for my back, it is feeling a lot better already. It is great when you find one solution that addresses multiple causes. Dasha came home and gave me a treatment, meeting my needs for support, and also providing physical relief. I have also cut out cheese and meat for Lent – my liver is grateful. The longer term work is to do regular exercises to strengthen my stomach muscles. It is adopting these longer term, regular healthy habits that can really make a difference to our lives.  And aren’t those the hardest ones?

Meeting customer demand? Don’t make me laugh!

“If I had asked people what they wanted, they would have said faster horses” Henry Ford

How often have I heard it said that what drives business behaviour is customer demand. Why do supermarkets sell so much food of low nutritional value?  “Customer demand.” Why do auto manufacturers continue to make highly inefficient vehicles when for years they have had the technology to make far more efficient ones? The same “customer demand”. British newspapers continue to fill their pages with stories about murders and rapes and celebrities because “that’s what the public want”.

This is a convenient and simplistic truth, but it is far from the whole story. Because it would be equally true to say that businesses shapes and drives customer demand. 30 years ago in the UK, for example, customers were not demanding strawberries in winter, mangoes or papayas. The supermarkets spotted an opportunity to increase sales and introduced these offerings. Sometimes businesses even manipulate the customer to get them to buy. This can be very subtle, such as carefully choosing which goods to place at which height on the shelves to maximise sales. Or it can be not subtle at all. General Motors and other auto manufacturers succeeded in shutting down large sections of public transport in the 1930s and 1940s in the US to make people more dependent on cars (to read more on this story, search for “Great American streetcar scandal”).

Yet there are limits to how far a businesses can go in influencing customers, even strong brands like Marks & Spencers. 15 years ago or so they invested heavily in boosting their organic food offer, trusting that customers would see the benefits. They didn’t – people weren’t ready for it at that stage. “One of the biggest mistakes we’ve made“, Marks and Spencers  called it at the time. Of course there is far more interest in organic food these days – they were just too early.

A more mature way to understand the business/customer relationship is to view it as co-evolution. Neither is wholly independent – the businesses don’t passively sit and wait to see what the customers want, nor does the business cynically manipulate the customers into buying what they are selling. There is a co-evolution, a co-creation going on. As is happening in nature all the time.

Of course it doesn’t stop there. Businesses and their customers are embedded in a complex living systems we call society, which in turn is part of a larger complex system which we call the planet, which in turn is part of a larger complex system we call the universe. A business co-evolves in relationship with its staff, customers, suppliers, neighbours and the universe.

Many of us intuitively know this. But it is not a popular view.  This is partly because the public don’t want complex explanations to complex problems – they want simple solutions and someone to blame if things go wrong.  Those who sit at the top of the corporate tree are expected to “run” the business. They have to present the illusion that they are in control in order to justify their excessive salaries. Yet the simple truth is that they are not in control and cannot be.

Yet I also sympathise with the CEO who is facing an investor analyst asking questions about his or her plans for the business. Can you imagine what the analyst would say if the CEO explained that he couldn’t really say because the business was in co-evolution with its customers and with the universe! He’d be wheeled out in a straitjacket. It’s much easier to explain that he is looking to drive growth through pro-actively meeting customer demand. This is what the analyst expects him to say. He is, after all, also in co-evolution with the organisation.

It seems to me that perhaps our greatest need as a society at this time is to co-evolve in our understanding and patience so that we accept that some things are complex and are not in anyone’s control. And that we need spaces where we can have deep discussions to explore big complex issues.

Complex isn’t it? Time for a cup of tea….