Unintended consequences Jake Chapman explains why unintended consequences arise from many policies aimed at improving public services and suggests ways to avoid them

Jake Chapman BA, MA, PhD, FRSA is a systems expert and former professor of energy systems at The Open University

NHS CONFEDERATION policy director

As a result, the LAS lost 75 more staff

Nigel Edwards once asked; 'Why is it that

that year than it would have done through

good individual policies, based on strong

normal attrition.

values and even common sense, often

With the cost of recruiting and training

lead to disappointing results? Or worse,

each member of staff at about £20,000,

produce unexpected adverse effects?'

replacingthem cost the service £1.5 million.

{Edwards 2002}

This is an example of the problems inherent

The answer lies in how policy makers and

in command-and-control management.

managers think about the organisations they manage and how these organisations

Systems thinking

implement their policies.

Modern systems thinking challenges the

Many policy makers and managers think

kind of mechanistic thinking implicit in sci-

of organisations as machines. This is evident

entific management and command-and-

in much of the language they use, such as

control implementation policies.

'stepping up a gear', 'changing direction' or 'the levers of power'.

i

It differs from mechanistic thinking in two fundamental ways.

The machine metaphor is built into

First, mechanistic thinking simplifies com-

'scientific' management and its associated

plex situations by breaking them down

command-and-control style approaches,

into manageable parts in a process called

and is attractive to policy makers and man-

reductionism. Systems thinking also simpli-

agers because it promises them control and

fies but does so by discarding detail while

predictability. But there can be unintended

retaining the connections between the

consequences for them if they presume that

parts.

these qualities are always available.

Second, mechanistic thinking presumes that there is one correct view of a situation ,

Case Study 1

a view that can be established by the 'facts'

In 2001, ambulance services across England

of the matter at hand. In contrast, systems

received an extra £21 million to improve

thinking acknowledges that in any complex

category A performance. However, this

situation there can be many different and

additional allocation ended up costing the

valid perspectives on what is occurnng and

London Ambulance Service {LAS) NHS Trust

what the problem is.

£1.5 million. Keywords >• Management: theory > Management: leadership > Management: change

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Systems thinking regards organisations as

The bulk of this money went to services

complex, adaptive systems: systems because

outside the capital. These services used the

the whole is more than the sum of the parts,

funds to recruit more staff, most of whom

complex because activity is the result of

came from the LAS.

multiple interactions between autonomous

nursing management Voi 12 No 4 July 200S

PLEMENTING

agents, and adaptive because they respond to changes in the environment so as to preserve some internal structure. Thus, by use of systems t h i n k i n g , organisations are expected to behave unpredictably and to respond to changes

POLICY

ACTIVITY 1. Allow 10 minutes Identify unintended consequences that bave arisen in your workplace. To what degree can this be accounted for in terms of complexity?

in surprising ways. Moreover, if complex organisations are managed mechanistically, unintended consequences will occur.

In order to provide the public with an indication of how local hospitals are performing

The differences between mechanistic and

and to incentivise trusts to perform better,

systems thinking are iilustrated by PIsek

the government introduced the star rating

(2001), who compares throwing a lump of

scheme.

coal with throwing a live bird.

One of the results of this scheme has

The trajectory of a coal can be calculated

been a reduction in the level of co-opera-

quite precisely using laws of physics and it is tion between hospitals, in some cases to possible, using this approach, to ensure that

the detriment of patient care. For example,

it reaches a specified destination.

before the scheme was introduced, trusts

It Is not possible however to predict the

in the same geographical areas could agree

outcome of throwing a live bird, despite its

to pool their emergency care resources to

motion through the air also being governed

reduce waiting times in A&Es.

by the same laws of physics.

However, since the scheme's introduction,

The coal and the bird could have the same

if one of the trusts has a zero star rating

weight and similar chemical composition;

because of excessive trolley waits, the oth-

what differentiates them is their internal

ers may be less inclined to share resources

organisation. The bird is a complex, adap-

because they know that they will have their

tive system and, as such, is neither predict-

own systems stretched by patient transfers

able nor controliable.

from zero-star trusts.

o

CONTINUING PROFESSIONAL DEVELOPMENT This material is drawn iron) the Open University course T188, Making Policies Work; Systems thinking in government and management. This online course shows how public sector managers can learn to put systems ideas into practice in their work. Much of the learning is developed through exercises that increase awareness of how peopie think and perceive, T188 is presented twice a year, in May and October, For more information on this or other Open University courses, access www,open, ac.uk/courses or call 0870 333 4340

nursing management Vol 12 No 4 July 2OO5

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c Thi5 wariness is made even more acute if

So to the degree to which current police

one or more of the other trusts are them-

policy on drugs succeeds in reducing

selves near to losing stars because of long

drug supplies, it exacerbates the criminal

waits in their A&Es.

and health problems the policy aims to

In effect then, rating individual trusts reduces the incentive for them to co-operate to improve overall performance. This is an example of what could be cailed a 'toxic incentive'.

reduce. Feedback of this sort is common in complex systems and, if ignored, will generate unintended outcomes. Another common source of generat-

This is because the sort of aitruistic behav-

ing unintended outcomes is a failure to

iours that are required to support a system

appreciate the goals and perspectives of

wide approach to patient pathway moderni-

significant participants or stakeholders.

sation are not encouraged by the organisationally focused star systems.

This is especially the case when policy or management in large organisations is controlled from the centre, where the

Ignoring feedback

prevalent belief is often that the centre's

There are severai ways that unintended

view is the 'only' view.

consequences can be generated by using a meclnanistic approach to management One of the most common of these occurs

ies should see at least 80 per cent of

when policy design or management inter-

patients within 24 hours of presenting

vention ignores feedback that is present in

has undermined the operation of my

the system.

local surgery.

An example of this can be found in the poii-

I live in a rural area, where many people

cies widely used to tackle the use of illegal

prefer to make their appointments with

drugs.

the surgery several days in advance, so

It is well established that the use of iliegal drugs such as heroin leads to an increase

that they can combine their trips to the GP with other activities.

in crime among addicts who need to raise

But to meet its target of seeing at least

money to buy their drugs, and that the cost

80 per cent of patients within 24 hours

of their additional healthcare needs has to be

of presenting, the surgery has stopped

borne by the treasury.

accepting appointments in advance

To reduce the supply of drugs, police and customs officers can target drug suppliers and importers.

- and, by doing so, has inconvenienced most of its patients. It follows that, whoever was responsible

If this policy succeeds, the supply of drugs

for setting the target had not foreseen its

will be reduced. But, if the supply of drugs is

consequence in rural areas such as mine.

reduced, drug dealers wili pay more for less

This problem was also raised during the

drugs and so will either increase the 'street price' of their drugs or 'cut' their drugs to increase their volume, or both.

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To take a personal example, the government's target that doctors' surger-

last election campaign (BBC 2005). Unintended consequences can also occur when policy makers or managers

An increased street price of drugs means

are too focused on particular goals and

that crime will increase as addicts steal

thereby fail to spot how changes affect

more often to obtain their drugs, while an

other aspects of performance.

increased mixing of drugs with other chemi-

Here is an example, compounded

cals will increase the health hazards associ-

by a failure to differentiate between

ated with drug use.

patients.

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PLEMENTING

Case Study 2 To improve the treatment of breast cancer,

Avoiding: unintended consequences

the government established a target for

There are several ways that policy makers

urgent referrals. This requires that suspected

and managers can check for, and hence

cases are referred to specialist consultants

avoid, unintended consequences.

within 14 days. There are two ways in

Perhaps the most important step is

which women can be referred to specialists:

to see the organisation, or network of

through the mass screening programme car-

organisations and agencies and teams,

ried out by GPs or by attending breast care

as a system.

clinics run by consultant doctors.

POLICY

This means taking into account the

The mass screening programme is good at

interactions between various units,

identifying cases with standard symptoms

groups and individuals, and generating

and, for women identified in this way, the

an overview of how they work together

target has improved treatment rates. How-

There are several detailed checks that can

ever, the only route open to women with

be carried out to help with this.

less obvious symptoms is through the breast

1. Analyse the system from as many

care clinics. But waiting times at these clin-

different perspectives as possible,

ics have increased since the target was set

taking particular note of those with

because of the increased referral rate from

different goals and ways of explain-

the mass screening programme.

ing what is occurring. View any pro-

As a result, women with hidden symptoms

posed policy, intervention or change

often end up waiting longer to see special-

from these different perspectives

ists than other women, yet their need to see

with the aim of understanding how

specialists is usually the greater.

the organisations, agencies, groups and individuals involved are likely to

ACTIVITY 2. Allow 5 minutes Explain which of the following three causes best accounts for the example given below: feedback in complex systems, failing to account for different perspectives, being too focused on a single goal. It had long been recognised that junior hospital doctors were often expected to work too many hours. To provide hospital trusts with an incentive to tackle this problem, the government introduced a system involving additional payments that were made to junior doctors according to the intensity of their work. But the scheme ended up costing more than twice as much as expected, because it was the junior doctors who were incentivised: as a result of the scheme, they started keeping meticulous records of how many hours they worked and, as a result, received larger compensation.

respond. 2. Identify as many of the feedback loops operating as possible and identify which will be affected by the proposed policy, intervention or change, 3. Envisage the system operating with the policy, intervention or change already in place and aim to identify as many concomitant changes as possible. Then explore the consequences of these additional changes on the overall operation of the system. Few people involved in the design of policy or management interventions can be open enough for this to work because, to be an effective policy maker or manager, one has to be focused. So, even if someone were to follow this procedure with their proposed policy or intervention, it is unlikely that they would spot the unintended consequence.

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ACTIVITY 3. Allow 10 minutes Reflect on the LAS example given earlier. Which of the three checks described above would have demonstrated the unintended consequence, and why? Explain how likely you think it would be for policy makers to have spotted the problem?

However, looking at the examples, it is clear that the people involved in meeting targets could have described in some detail how they would respond to them. The point here is that it is not just the perspective of the people affected that counts but also their detailed knowledge of what it is they are being asked to do.

Conciuslon There is undoubtedly significant consul-

The problem w i t h the LAS arose

tation between policy makers and man-

because policy makers failed to appreci-

agers on the one hand and operational

ate the perspectives of either the drivers

staff on the other about policy issues,

or the recruitment staff.

but the prevalence of unintended conse-

Both would have known that advertising for new crews would attract applica-

quences across the health service reveals that this is inadequate.

tions from existing staff in different areas,

One of the key reasons for this is that,

but it seems unlikely that senior policy

all too often, policy makers are divorced

makers considered this possibility

from implementation and receive too lit-

It is clear that there is one fairly foolproof way that unintended consequences can be anticipated: asking the people who are affected by policies. For example, recruitment managers

tle feedback on the effectiveness of their designs. Similarly, many managers fail to take account of feedback from previous interventions.

of an ambulance service know that a

In conclusion, policy makers and man-

significant number of applicants come

agers should obtain the views on out-

from other ambulance services, hospital

comes and problems from all the peo-

managers have no trouble anticipating

ple who will be affected by the policy

the effects of star ratings, nurses in rural

or inten/ention they plan to implement,

surgeries know the importance of being

including how they would respond were

able to make appointments in advance,

such policies or interventions to be intro-

and clinicians involved in breast cancer

duced n m / o u

care know the importance of picking up the difficult cases. Many unintended consequences arise from of using targets largely because they are deeply embedded in scientific management and its mechanistic view of organisations.

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REFERENCES

BBC (2005) Blair Promises Aaion on GP Row. news.bbc.co.uk/l/hi/ijk_politics/vote_2005/ frontpage/4495865, stm Edwards N (2002) In Chapman J. System Faiiure. Demos, London. PIsek P (2001) Why won't the NHS do as it's told? Leading Edge. October, 1.

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