Neal Maskrey is a former GP and visiting professor of evidence-informed decision making, Keele University
Jamie Hayes is an executive and team coach, honorary professor of medicines optimisation, Cardiff Metropolitan University
Helen Maskrey is a retired public health pharmacist
John Seddon is an occupational psychologist, specialist in organisational change, and visiting professor at Buckingham University Business School.
Once upon a time in a green and pleasant land there lived Gatekeepers and Wizards who looked after the poorly People. But gradually the People had found it more and more difficult to see the Gatekeepers and the Wizards when they were poorly. Then there had been a dreadful plague and there was now a new King and a new Minister. The Minister had convened a Great Assembly, for he was determined to make the National Poorliness Service work better, for the good People of the land deserved it. But it was not clear to him how to make things better, and the King did not have much gold to spend.
A Wise Gatekeeper from the Centre for Evidence-based Wizarding had already explained that treating every single poorly Person according to the many scrolls that were now written was quite wrong. An individual poorly Person might want different spells and potions from another person, and it was impossible to predict in advance which treatment would world for an individual poorly Person. The brain of the King’s Minister was already hurting.
And People have different priorities, one from another. They want the potions and spells that fit their own preferences rather than being told what to do by some Clever Wizards from far away who do not know them.
But the Wise Gatekeeper had not yet finished. “Now, Minister, I should like to turn to a second unintended consequence of Evidence-based Wizarding. Measurement of whether Wizards and Gatekeepers follow the scrolls written to describe how poorly People should be treated has become part of a “Command-and-Control” industry. Much of the King’s gold – which of course comes from the People paying taxes – is now spent on collecting data on whether the scrolls are followed and writing specifications for how the work should be done. And worse, there are Inquisitors checking whether the work is being done according to the specifications and, even worse, the Wizards and the Gatekeepers and Human Angels are spending lots and lots of their time checking data and getting ready for The Inquisitors instead of helping the poorly People.
“All this is quite wrong. Instead, the National Poorliness Service should pay attention to what happens in Public Services when “Systems Thinking” is introduced. Systems Thinking is a powerful approach to problem-solving that focuses on how and why elements within a system are connected and how they influence each other. . I think I should hand over now to my colleague, a Wise Wizard-Psychologist who knows much more about this than do I”.
The Wise Wizard-Psychologist rose to his feet. “Meeting performance targets, rather than looking after the poorly People, in Systems Thinking terms, is not “value work.” Much time spent recording in great detail what care has been provided for poorliness is part of the reason why it is so difficult for a poorly person to see a Human Angel, a Gatekeeper or a Wizard.” And People have different priorities, one from another. They want the potions and spells that fit their own preferences rather than being told what to do by some Clever Wizards from far away who do not know them.
“Golly gosh” said the Minister. “I will have problems with the King’s Civil Servants who believe in specifications and data collection and command and control. Because for a long time all they have done is tell many Kings and Ministers that the work of the Wizards and Gatekeepers will only get better if it is standardised and measured. Indeed, the King’s Civil Servants have not had any other useful ideas for many years.”
“Yes you will,” said the Wizard-Psychologist. “For two score years and ten I have studied the King’s public organisations and how to make them work better. I have written many scrolls about how public service organisations are run with “Command and Control”. You may remember that many years ago a very fierce Queen Margaret developed something called ‘New Public Management’ – a belief that costs will fall and quality will rise if work was standardised, specialised, and measured. Indeed, many public services have been subjected to “New Public Management”; the result is that there is scarcely a single Public Service of which the People and even the King can now say is working well and of which we can all be proud. This approach has largely gone unchallenged in the National Poorliness Service for many years.
When People are fearful they do not perform well. And when this goes on year after year it is no wonder that many Gatekeepers and Wizards are saying they are too old and too tired to do this work, because this work is not the work they went to Wizarding School to learn.
“As we have heard, much of the King’s gold is now being spent on collecting data and writing specifications for how the work of the Wizards and Gatekeepers should be done. There are Inquisitors checking whether the work was being done according to the specifications. Even worse, the Wizards and the Gatekeepers spend lots and lots of their time writing down in great detail everything they do for a poorly person in case the Inquisitors check what they have been doing, instead of being able to look after the next poorly person. And then they spend much time checking data and getting ready for The Inquisitors – again instead of helping the poorly People.
“A learned scroll was written many years ago explaining that a command-and-control approach means that the Inquisitors are looking for “Bad Apples” among the Gatekeepers and Wizards. If there are 8000 Gatekeepers in the Kingdom and we assume that perhaps 3% are truly “Bad Apples”, that means there are 240 of them. If the Inquisitors correctly identify 99% of the “Bad Apples” they will find 238 correctly but miss 2. The bigger problem is the Gatekeepers who are not “Bad Apples”. There are 7760 of them, and if the Inquisitors are right 99% of the time when they assess those good Gatekeepers, they falsely identify 78 Gatekeepers as being “Bad Apples” when they are perfectly good Gatekeepers.
“Imagine the damage caused to the National Poorliness Service by the Inquisitors. Every single Gatekeeper spends days and days getting ready for the Inquisition visit. And then many Gatekeepers are falsely accused of not being good enough, and every single Gatekeeper fears being accused of this. When People are fearful they do not perform well. And when this goes on year after year it is no wonder that many Gatekeepers and Wizards are saying they are too old and too tired to do this work, because this work is not the work they went to Wizarding School to learn. And the Inquisitors need much of the King’s gold to do their work, which does little good and much harm.”
The Minister looked very troubled indeed. This was not what he expected to hear.
To be continued…
Acknowledgement.
The authors wish to thank Nigel Mathers, Paul Hodgkin, and Andrew and Barbara Herd for introducing the world to the parables of Wizards and Gatekeepers, See: Mathers N, Hodgkin P. The Gatekeeper and the Wizard: a fairy tale. BMJ. 1989; 298. DOI: https://doi.org/10.1136/bmj.298.6667.172
Deputy editor’s note – see also:
The gatekeepers and the wizards revisited (Part 3): Evidence-based wizarding: https://bjgplife.com/the-gatekeepers-and-the-wizards-revisited-part-3-evidence-based-wizarding/
The gatekeepers and the wizards revisited (Part 2): The National Kindness Service and shiny crystal balls: https://bjgplife.com/the-gatekeepers-and-the-wizards-revisited-part-2-the-national-kindness-service-and-shiny-crystal-balls/
The gatekeepers and the wizards revisited (part 1): Seventy eight years of fairy tales: https://bjgplife.com/the-gatekeepers-and-the-wizards-revisited-part-1-seventy-eight-years-of-fairy-tales/
Machin A R, GPs are far more than gatekeepers,
Featured Photo by Artem Maltsev on Unsplash
