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.
Already the brain of the King’s Minister was hurting a lot. 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. And now he was hearing that “Command and Control” – measuring what the Wizards and Gatekeepers did and sending Inquisitors to make sure they were doing what the scrolls said should be done for everybody – was quite wrong too.
The Wise Wizard-Psychologist who had studied Systems Thinking in the King’s Public Services continued. Those gathered in the Minister’s Great Assembly listened carefully; for what he was saying went against what had happened and what they had been part of for years and years. It was a tough listen.
This is the extra work caused by a failure to do something right the first time, leading to rework, complaints, or repeated requests instead of the poorly person getting what they need efficiently – usually the first time they are seen by a Gatekeeper or Wizard.
“We have also discovered another way in which much of the work done for the People is not valuable work. This is something called ‘Failure Demand’. This is the extra work caused by a failure to do something right the first time, leading to rework, complaints, or repeated requests instead of the poorly person getting what they need efficiently – usually the first time they are seen by a Gatekeeper or Wizard. Having to see a poorly person a second time because the Wizard or Gatekeeper did not have the correct information the first time – perhaps when the Gatekeepers were closed and a poorly person had to telephone someone who did not know them is failure demand. Or when a poorly person gets poorlier or more anxious due to delays in being seen or getting the right spells and potions. Repeating assessments due to lack of information or confidence in the previous Gatekeeper or Wizard is another cause.
Sometimes failure demand is caused by Wizards and Gatekeepers blindly following protocols laid down in the scrolls from the National Organisation of High and Mighty Wizards, or repeating tests using crystal balls or using spells and potions to try and avoid getting sued by the Wizard Lawyers if things go wrong. A big issue is trying to treat a poorly person’s apparent problem as defined by the scrolls, and ignoring their values and preferences. Finding out the root causes of the poorly person’s problems and considering their overall health and wellbeing usually means fewer spells and potions, and fewer visits to the Gatekeepers and Wizards.
“Failure demand has huge consequences. It is estimated that 19% of all Gatekeeper consultations are caused by it. Moreover, 89% of the demand for frequently attending patients is either partly or wholly due to failure demand. 15% of the poorliest People in the Wizards’ Intensive Care Units experience an extended stay because of failure demand, and 55% of psychiatry cases in the Wizards’ Castles exhibit complexities caused by failure demand. Everyone says demand from poorly People is rising. This is not true. What is rising is failure demand”.
These ideas were new to The King’s Minister because all his life when things were not working properly, he had seen public service organisations creating more and more command and control, more and more Inquisitions, more and more specifications, and more and more measurement. His postbag was full of complaints from poorly People who were telling him they were having to shout very loudly in the courtyards to the Wizards’ Castles to try and get the spells and potions they needed. So in his heart he knew the Wizard-Psychologist was speaking the Truth. He just found it hard to believe he and many others had not seen this for themselves.
“So tell me, what happens when organisations start to apply Systems Thinking to their problems?” he asked. “That is very clear” said the Wizard-Psychologist. “When data is no longer collected in large quantities and where providers of public services are freed to work out their own local solutions to help the People, two things happen. Firstly, capacity in the system increases. More People are dealt with more quickly. And secondly, the People providing the service become happier in their jobs.”
“Well, that would be something” said the Minister. “For all I hear from Gatekeepers and Wizards is how difficult their jobs are, and how they need more gold in order to be happy, and to be able to see more Poorly People”.
So in his heart he knew the Wizard-Psychologist was speaking the Truth. He just found it hard to believe he and many others had not seen this for themselves.
A Wise Gatekeeper who had been Knighted by the King because of his Wiseness, caught the moment. “Minister,” he said, “You have said yourself how wrong it is for us to be thinking of simple solutions to what are complex problems. It is true that it is likely that we need to look at how many Gatekeepers and how many Wizards we have and how many we need, how they are trained to become Expert and Wise, and indeed how much gold they are paid. And there are also many others who work for the National Poorliness Service and they all do Value Work too.
“But they all also do much work generated by Failure Demand and Command and Control. For some people their entire work is sorting out Failure Demand or Command and Control, and for many it is too much a part of what they are now tasked to do. More gold will not fix all of this. It might help a bit, but if we do not do things differently the work will still not be Value Work, and the People who work for the Poorliness Service will still be unhappy, and most importantly the Poorly People will still be unhappy. We have to have a System that works better. After all, it is doing the Value Work that people go to Wizarding School, and Angels School and Apothecaries School and all the other Schools to learn.”
Many people in the Great Assembly were sorely troubled by what they were hearing. “More gold is needed” was all what many of them had said for a very very long time. But what they were now hearing was making them think. Everybody’s brains were now hurting.
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 4): The Wizard-Psychologist: https://bjgplife.com/the-gatekeepers-and-the-wizards-revisited-part-4-the-wizard-psychologist/
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
