Sunday, 11 November 2012

Blame the system

A couple of mornings ago, George Entwistle was given a going over by Charlie Stayt on BBC Breakfast. It was nothing like the going over that he had been given by John Humphrys on the Today programme, but it made him squirm.

We’ve seem George squirm a lot in recent weeks. It hasn’t been pretty, and at times it hasn’t seemed fair. But what was interesting about this particular episode is that Charlie was attacking him for expressing the sentiment that in the light of the Newsnight fiascos, it was important to see where the systems had failed, and seek to address them.

The answer that Charlie appeared to want was that George would seek out the individuals to blame, and punish them.

I suspect that this would have been part of George’s approach, but it is clearly not his manner to approach the issue in such an overtly belligerent fashion. In fact his managerial style seems to have been much more gentle than that, and right now, that is not what people want from him. They wanted to see him rattle his sabre, and make a bloody nuisance out of himself, to create the impression that something had been done.

There is something to lament among all of this. I can’t deny that George did a poor job of painting a good picture of himself - at times it was excruciating to see. But there is something about blame that he gets, that you see very few people publicly acknowledge. He tried to maintain that the decision-making behind Newsnight was a function of the system that exists. He placed a great deal of emphasis on systems, and how they work. A lot of the answers that he gave seemed to centre on sorting out the system, rather than focusing on the individuals. He appears to have been mocked and vilified for doing that, but I think he has been treated a little harshly.

A chap called Paul Batalden is credited with the quotation, ‘every system is perfectly designed to get the results it gets.’ It’s a good one. He wasn’t trying to say that every system is perfectly designed, but rather the product of a system is never better or worse than one could have expected, providing that one has a good understanding of how the system works.

It seems that we put an awful lot of focus on personal responsibility, and in particular, on personal blame, but we rarely pay much attention to the set of circumstances that lead to people making the decisions, or taking the actions that lead to scrutiny.

This is something that affects us a great deal in healthcare. Sometimes, the price for failure is high, and sometimes people make decisions, or take actions that result in harm. It is easy to spend time reflecting on the specific decision or action, but it is much harder to spend time reflecting on the circumstances that led to the person making that decision or action.

Every time a doctor makes a mistake, there are a whole range of factors at play, and you can perhaps boil down the issue of blame to a single question: did the working environment that that doctor was working in maximise the chances that he/she would make the best possible choice for the patient he/she was treating. If the answer to that question is ‘yes’ then it is perhaps valid to focus on the decision made by the individual, but if the answer is ‘no’ (and I would expect this to be the answer most of the time) then at least some of the reflective time needs to be spent on examining how the performance of that individual could have been improved by the environment that they work in.

Personal responsibility still exists - there is no excuse for individuals being reckless, lazy or unkind, but we need to recognise that individuals will perform better if the circumstances around them support their efforts.

George Entwistle clearly understands this, which is why it is a shame he felt he had to resign. I would have been interested to watch him see through a process of rehabilitation that was not founded only on blame, but recognised the need to focus on systems.

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