Today is Groundhog Day. I’m not joking the 2nd February really is Groundhog Day.
Groundhog day is a much loved North American tradition, but according to the Oxford Dictionaries, it also stands for something else; “a series of unwelcome or tedious events that keep recurring in exactly the same way”. In other words, a continuous loop of the same old awful stuff.
By coincidence, I’ve had a bit of a ‘Groundhog Week’ with something tedious and unwelcome; the ‘tyranny of best practice Cybermen.
You know, the crowd who constantly repeat the mantra “services can only be improved by the identification of best practice and its widespread application. It will be enforced through a process of target setting and performance management. There will be no deviation, it will be adopt or justify” (with possible re-programming if you fail to comply).
This simple, ‘one size fits all’ solution to every problem, no matter how complex the situation, is a bit frustrating. For my own peace of mind I thought I’d rehearse the arguments once again.
Best practice is not good practice, and neither of them are are the new practice that emerges in complex situations. The practice you adopt is hugely dependent upon the situation and trying to force people to use best practice that doesn’t match their situation can be huge waste of time and potentially damaging. I’ll explain a bit more:
Best Practice. The idea of best practice is something that has very much developed from industrial activities. Essentially you have a highly predictable, straightforward context. If you perform Task ‘A’, you will always end up with Outcome ‘B’. The process is the same wherever you do it.
The types of activities this might involve include; paying invoices, running the heating system in a building or maintaining the engines in the delivery vans. There is always the ‘best’ ways of doing something. Deviation from this method is not as good as the ‘best’.
Good Practice. For very many areas of activity there are multiple ways of achieving a good outcome. Situations are much less predictable and Task ‘A’ might not be the right thing to do to achieve Outcome ‘B’. You might need to try something different and people will adopt different methods, influenced by their knowledge, skills and experience.
This is a complicated world where you need to trust the judgement of experts to read the situation and get it right. Good practice from one situation may not be transferable to another situation. You can however adapt what is good elsewhere and apply it in the situation, its all about adaptation not rigid adoption.
When I think back to my school days this is exactly what some of the teachers did. They adapted ‘good practice’ to fit the situation and achieve a good outcome.
New Practice. When you think about the complex challenges currently facing public services, with increasing demand and declining resources, this is entirely where we sit. The ‘right’ answers, and methods by which you get there are not known. You have to look out for something new that emerges. It is not possible to predict exactly what is going to happen in response to any activities carried out.
Large scale challenges like tackling obesity, helping people with complex needs live independently or dealing with organised crime need to be worked out through a process of ‘safe to fail’ experiments. The chances of someone else’s best practice working in your complex environment (particularly if it is forced onto you) seems unlikely.
Understanding the Context is important. I cannot stress this enough:
- Best Practice, great for straightforward, highly predictable, situations. There is one ‘best’ answer.
- Good Practice, applicable in complicated situations where there is more than one right answer. Need to rely upon experts to ‘read’ less predictable situations and apply the method that works.
- New Practice, the answers are unknown and the situation is complex. Outcomes are unpredictable and you need to experiment with ‘safe to fail’ pilots to see what works.
This isn’t a world of one size fits all, and any ‘adopt best practice or justify why not’ Cyberman approach is only relevant in very specific simple situations.
I feel better for that. If you want read something more detailed on this I’d recommend:
- Dave Snowden’s, Harvard Business Review paper, ‘A Leaders Framework for Decision Making’ and the Cynefin Framework, (see picture above) where simple, complicated, complex and chaotic situations are explained in detail.
- Complex Care Wales, (@complexcarewales). Have a chat with Matt, it’s like the intellectual equivalent of a work out with a Mixed Martial Arts Coach. You’ll be stretched to your limits, but know it’s good for you.
So, what’s the PONT?
- Best, Good and New Practice are not the same. The situations where they apply are different.
- There is a place for Best Practice, but it is highly specific.
- An ‘adopt best practice or justify why not’, is not a silver bullet and may actually cause more harm than good.
Finally, when I first posted this in 2014 I said……I do hope I’m not going to have another ‘Best Practice Tyranny’ Groundhog Day on the 2nd February 2015. If I do, I’ll re-blog this post…… looks like not a lot has changed. Happy Groundhog Day and have a look at this video of Groundhog Day Explained, it’s good fun.
Picture source. Groundhog Day http://acplkid.wordpress.com/2012/02/02/happy-groundhog-day/
Spot on Chris. It takes a brave person to blog about the different types of ‘practices’. Whether sceptics like it or not, the type of practice is dependent line you said on the circumstance. See you same time, same place next yearM
Interested to know how NICE pathway (http://pathways.nice.org.uk/pathways/dementia) fits with ‘safe to fail’ experiments in example of caring for people with dementia. What sort of ‘practice’ would this be and should 211 CCGs, 152 local authorities, service providers etc all be doing these experiments?
Detailed response below.
“Large scale challenges like caring for people with dementia…..need to be worked out through a process of ‘safe to fail’ experiments”.
I am really unclear what you are advising/suggesting/recommending here and whether this is a personal view and/or view of the Audit Office.
With an estimated 700,000 to 800,000 people in the UK with dementia, are you recommending ‘safe to fail’ experiments for hundreds of service providers and/or each individual and their carers, families? What types of ‘safe to fail’ experiments are you suggesting/recommending to be used in this area and how would you keep track of them? Would you need individual consent for a person with dementia to take part in a ‘safe to fail’ experiment?
Before I respond to your comments I must point out that these are my views only. It is very clear that this post, along with all of the others I’ve every written are my views alone.
In response to your question, the point I was making is that there are very many ways to respond to a complex situation. The right or best answer may not be known and we need to work out what is the best approach. Low predictability in these situations means that a single prescribed approach, that worked elsewhere (best practice) is only going to work if the circumstances (all of the variables) are exactly the same.
In response to your question am I recommending ‘experimentation’ on individuals, carers and service providers, absolutely not. The word ‘experiment’ was in the context of ‘trying different things’ to establish what works most effectively in the circumstances. I am concerned that you may have seen the use of the words ‘experiment’ and ‘safe to fail’ from a negative perspective and apologise if I have caused you any offence.
From my own experience of two very close relatives having dementia we tried different things to see what worked. Trial and error / safe to fail experiment has been very much part of my life for 4 years. Providing care was complex. The situation changed frequently and in the case of one of my relatives, the situation changed on a daily basis over the last two months of their life (this time last year). It was absolutely necessary to adapt and try different things to establish what worked best for them in the circumstances. If something worked we did more of it, if it didn’t work we stopped and tried something else. At no stage do I recall anyone, at any time, looking for the NICE guidelines to provide the answers to our situation.
I think there is a link here to how individuals, families, streets and communities deal with the complexities of modern life. Doing things ‘street by street’, ‘community by community’; adapting things to fit the local circumstances has a growing support. Building upon the existing strengths and abilities of individuals and communities will be more effective than imposing a national framework of best practice stating this is what an ideal community should be like. When I think of some the communities I know, the first thing they would do if someone tried to impose a best practice model upon them is vigorously resist it. Doing things as a family unit worked for us as dementia carers and my relatives, not national framework best practice documents.
Once again I apologise if I have caused you any offence over the reference to dementia and safe to fail experiments to develop solutions. This was not my intention. I hope you are able to understand where I was coming from and how this has been shaped by my personal experiences of dementia care.
Finally I must stress this is TOTALLY MY OWN OPINION.
I looked at the paragraphs talking about:
“New Practice. When you think about the complex challenges currently facing public services, with increasing demand and declining resources, this is entirely where we sit…..Large scale challenges like caring for people with dementia, helping people with complex needs live independently or dealing with organised crime need to be worked out through a process of ‘safe to fail’ experiments……”
In these paragraphs you are talking about the complex challenges currently facing public services and where ‘we’ sit.
I can see where you are coming from now. Rather than ‘public services’ and ‘experimenting’, it was more about how people caring for people with dementia may respond according to the circumstances and you gave some examples from your personal experience which were helpful.
Your personal description does not seem to fit the general meaning of ‘experiment’ (http://bit.ly/LKar8d).
So, going back to the original text of ‘New Practice’ and the ‘complex challenges currently facing public services…’ and ‘where we sit…’. This needs to be explored further. Does the dementia care challenge and the possibility of ‘experiments’ still apply from the viewpoint of a public service and its responsibilities? Should a public service use a NICE pathway or leave the situation for the carers, family and community as in your example? How do you negotiate who does what and who is responsible for what activity in these complex situations (ie State, NHS and Care Services, Individual/carer/family)? What happens when the care network in the community breaks down – do health & care services become a safety net? If the solutions to problems are driven more bottom-up from communities do you actually need pathways, guidelines, standards at all in health and care services for dementia or is it ‘safe to fail experiments’ (some form of adaptation by carers/families/community to the current situation using services that they may come across)? How do people within communities find the necessary knowledge and develop the skills needed to respond eg how are people connected to reliable and trusted sources? Should they be reimbursed for the important care they provide? How would health & care services engage with communities to encourage and develop these local resources and provide appropriate funding where necessary?
Point taken on the use of the word ‘experiment’.
Lots of question you’ve raised that need some serious thinking.
I’m In the middle of a chaotic week, so I’ll have to wait until the weekend.
Better still we could talk it through over a cup of tea.
Hoping to get to London in the not to distant future, we could catch up then.
Hi Mike, you seem to me to be hitting on many of the issues that are currently playing out under the banner of ‘coproduction’. In my own view, despite the zeitgeist of the word, it has always been the only way to do good work, with them, rather than to them.
I get the popular perception of the word ‘experiement’ and what that may cunjure, around mad scientisist and smoking beaglkes. From my own experience, the rather dry and idealised policies and pathways, necessitate the practice if small, even daily, tests of change at a very personal level. When helping shop-floor teams (my job) they complain about the ‘experiement’ being driven out of practice by top down reforms, and process standardisation. The dissonance between theory and practice is tangible. My opinion of this gap, is deeply influenced by watching a fab team around a particularly challenged family, talking openly about trying a few little experiments and going with whatever seems to work. In each case the experient was sufficiently small and flexible to be able to make mistakes without causing undue harm. A difficult balance of risk and autonomy that required deep interpersonal insight, albeit within a defined scope of practice. Inspiring! The word experiment now means that, in my head.
Experiment here makes me think of ‘tinkering’ as described by AnneMarie Mol. Here is a short Lancet article which introduces the concepts http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)60971-5/fulltext
Thank you Anne Marie,
That was really helpful.
I do like the description:
“This is tinkering. Doctoring, if you like. Most diabetes nurses are good at it. As control is illusionary, as all the elements involved (bodies, technologies, food, colleagues, what have you) are capricious.”
‘Tinkering’ may well be a good option in complex situations.
Hi Chris, thanks for the splendid ‘big up’ which will probably put people off, talking to me HaHa! Honest tweet me @complexwales.
A couple of really interesting points here, especially in Mike’s question. Firstly, absolutely lovely lay description of the different practices. Dave’s paper is a cracker but can take some time for the newby to complexity, to get their head around.
With regard to NICE, which issues guidance not practice compliance, is the old carrot of what constitutes evidence? When dealing with inanimate objects, machines, or fundamental phenomena eg physics, then yes get some peer reviewed replicateable published evidence. Then of course there’s publishing bias. For every study published demonstrating a positive correlation between an idea and outcome, there are on average 50 unpublished studies that didn’t, and is therefore not worth publishing. The moment guidance is published of course, it begins to be out of date: the world carries on regardless of NICE and stuff is often repealed and updated. There’s a good case for not jumping too quickkly. Evidence don’t work quite so well with biology, living things, which are, as you say uniquely context dependent.
The next lovely little brain bender that pops up for me is that horribly abused word, “pathway”. It’s used for everything from injecting a dangerous drug to the entire life of some poor soul who’s been given a label of some kind. If you’ve got a highly predictable predetermined end point, a highly specified start point and a series of limited options to get from one to t’other, then yes that’s a pathway. You need some specialist knowledge to navigate the options, but it’s NICE and neat and monitorable. As you say good practice. That’s a pathway, fits into the ‘complicatedness’ of Cynefin and NICE occassionally gets it’s knickers in a twist, confusing this with best practice, which has little optional flexibility. Don’t get me wrong, best practice is a requirement of some work, like administering a dangerous drug. I don’t want Flossy making it up when she walks in the room. Do it properly every time! Complying with best practice is essential but very, very limited, mostly to tasks and tools. Accepting that even administering a dangerous drug it’ll be different for fat, thin, young, old people and you have to very tightly specify the boundaries of the best practice.
Dementia is a great example of neither or these. Somebody with Dementia, may well need some best practice, and some options in pathways, but whether or not to use any of them is uniquely personal. I truly bow to your much more detailed understanding of the real lived experience on this count. But let me quote my Uncle Bob, a cantankerous old shit, who hasn’t much liked the company (he’d say interference) of other human beings for his first 70 years and he has no intention of changing that now, “I’d rather slit my own wrists before letting someone else wipe my arse”. He has Dementia and may well change his mind as his condition changes, but what he fears most is losing his wonderful world-rich mind. I know exactly where he’d tell you to stick your best practice!
To re-word a lovely sentiment from @lose_the_label:
Hello, I am Bob
I have Dementia
I, am not Dementia
I am Bob
Thanks Chris, great post and a crucial debate for true person centredness.
PS my personal opinion with no intention to offend!
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