Free Beer!

beerRight, hopefully the title will have drawn you in (I’ve fallen for it myself three times whilst writing this blog post). If you stay to the end you’ll see the reason for it anyway. Unfortunately this time I’m not going to dazzle you with my rudimentary childlike drawings, but as usual there’s a (very badly) ‘hidden’ systems message.

Deming talked about how about 94% of performance is down to the system and only about 6% attributed to the people in it. This might fly in the face of conventional thinking, but let me give you an example of why it’s true. I’m a fast(ish) police response driver. I drive as quickly and safely as I can to emergencies to help people and catch baddies. Performance targets for response times mean nothing to me because they change nothing about how I drive. If I or other police response drivers don’t get there within the target time it’s usually due to systems conditions outside of our control, such as the proximity of resources, amount of resources, road conditions, traffic conditions, weather and so on. Systems conditions.

94-6 pie chart

Yet most performance management focuses on the individual. “Why did Team ‘A’ fail to get to three Grade 1 jobs (or immediates / whatever you know them as) yesterday?” It’s that ‘WHO’s to blame?’ mentality again. It MUST be a ‘person problem’! Well perhaps the police station is at the wrong end of the division. Maybe there aren’t enough bobbies on response to meet predictable demand. Perhaps an unhelpful deployment policy or lack of vehicles stops them from deploying effectively. Chances are, it’s a systems condition.

Therefore, in these circumstances it’s a waste of time blaming individuals. I refer you to the pie chart (which is shamelessly ‘borrowed’ from this excellent blog post by Think Purpose. The precise percentages aren’t worth arguing about, either – the principle is solid). The system is always responsible for the majority of performance.

Okay, so this brings us to the ‘free beer’. Thanks for staying with me and enduring the systems bit. Here’s the everyday story that makes the point…

handful of change2

I went to the shop last night and bought some non-specific beer-type drink that might or might not begin with the same first three letters as my surname. As I left the shop I had a bad feeling that I’d been overcharged. Even my GCSE-level maths instinct alerted me to check my change, and Lo-and-Behold – I found I was £1.50 out of pocket. (You might laugh but that’s serious money to me these days; it could buy 15 blog views to help game my own performance framework for a start).

Anyway, I went back in and spoke to the first person I encountered behind the till, who happened to be the shop manager. Even before speaking to her, I’d guessed it was a ‘systems problem’, but when I told her I’d been overcharged, her immediate reaction was that the girl behind the other till must have made a mistake ‘because she’s new’. (The poor girl was within earshot as well. Bad skills!) I suggested it was unlikely that it was her fault as all she had done was scan the items and charge me at whatever rate the till had come up with, so the manager went and fetched a can of the same brand of, um, ‘health drink’, and scanned it. Guess what? The machine registered the wrong amount. Machine error, not human error. So much for technology.

Guilfoyle GuinnessIn any case, the silver lining in this situation was not only did I get my £1.50 back, but the manager gave me an extra can of the black stuff for free; hence the name of the post. (I reckon her employee deserved two though).

Lessons? Well, it goes back to the point about assumptions. It disappointed me that the manager’s immediate reaction was that her staff member must have had screwed up, rather than the system (see my blog post ‘Potted!’ for a similar story). What does that say about the dominant type of management thinking when it comes to judging performance or attributing blame?

Remember, the greatest opportunities for improving performance lie in the system, not the individual. If you want faster response times, safer hospitals, better service and happier customers, the best way to achieve it is through building an effective system, not leaning on the workers or blaming them when something goes wrong.

It also saves on payouts for errors or poor service – even if this is only the cost of one can.

About InspGuilfoyle

I am a serving Police Inspector and systems thinker. I am passionate about doing the right thing in policing. I dislike numerical targets and unnecessary bureaucracy.
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16 Responses to Free Beer!

  1. Dave Hasney says:

    Poor managers will always try to berate the indivdual to ‘prove’ they are proactive managers. Any attempt to change (or buck against) a corporate system is seen (by too many) as a management weakness, or disloyalty to the ‘system’ which higher ranked managers have worked their way through.

  2. That’s just unfair! If it was a shop where the staff member has to type in all the prices themselves, sure, but if it’s scanned then it’s the database’s fault for being wrong!! The poor checkout person.

  3. John says:

    I still don’t understand why we have a performance target for the time taken to attend a call when a) it’s meaningless b) it’s fiddled and c) it was scrapped along with the rest of the Policing Pledge.

  4. Oscar Riba says:

    The computer is never wrong.
    The computer is never wrong.
    The computer is never wrong
    The computer may be wrong.
    The computer is never wrong.
    The computer is never wrong.
    The computer is never wrong.

  5. yo mo says:

    The 94/6 is [respectfully] a load of sweaty pods, it’s based on an observation by Taylor from a single experiment, a sorting task if memory serves. It’s been repeated without context so often, that it has become dogma.

    It only holds for the simplest of examples, as the complexity of the ‘purpose’ increases, humans have to be given greater freedom/responsibility to act. Therefore the percentage of human error increases. Particularly when under stress, and facing unfamilair or novel circumstances.

    It’s possible to ‘shop around’ and find any number you fancy, from 94/6 to 6/94. [In your line of work you might like to have a squint at the performance of the CPS and see what the numbers are?]

    And the system vs people categorization is a bit dubious, I won’t give a lesson in set theory, but ‘system’ contains people plus ‘process’. You can’t take 6% out of a set and then compare it against the complete set logically.

    Regarding missing I grades, it does depend where one draws the system boundries, to me the problem is just one of resources. Fix that and most problems vanish, it even ameliorates external factors that aren’t part of the ‘system’, weather, road and traffic conditions etc.

    Managers can try to hammer staff, but if there are not enough of them it won’t make any difference. {If I was saddled with running a sector, I’d be writing NUTS on the log, every time it occured and send the problem upstairs for them to solve.]

    Better go, before all the Deming fan boys start searching for the instruction book that explains the 12 essential steps to correctly sharpen their pitchforks and the mandatory precautions to be taken before deploying the optional burning torch.

    I’ll pop back in a while, when all the squealing has died down {JOKE] and go through why ‘predictable demand’ is a complete fiction. [Reserve me a pinhead, I’ll bring the angels].

    (In case anybody is confused, No Units To Send).

    • Dude, I’m glad you’re back. I was worried about you. Come on, drop me an email at and we can have a chat. The Taylor stuff is way off the mark by the way 😉

      • Jane Elliott says:

        Hi simon,
        You would be very surprised when tell you about the origin of the 95 rule. Apart from wrong
        Geoff elliott
        07979 241348

    • NUTS? And I thought you were displaying a knowledge of military history!

      I read someone elsewhere talking about Deming’s “85/15 rule”. Hmm. I guess the proportions don’t really matter, because the new fault-line is about beliefs. Between systems thinkers who believe you should act on the system, and command & control thinkers, who believe you should act on the players.

      Thus, if you are a command and control thinker, the Mid-Staffs NHS scandal was down to poor management and poor staff. Bad people. The answer lies in more training, changes of personnel, more inspection. More of the same.

      If you are a systems thinker, you believe the failure was down to the system – poor performance regimes and incentives, poor departmental structures and lines of responsibility. Bad system. The answer lies in changing the system and changing the thinking that designed it. Do something different.

      Take your pick. My sense is based on what happens when you take people out of one system and into another. The same people who were once seen as lazy, underperforming and obstructive, can suddenly become motivated, committed and effective. And vice versa, of course.

      So, is the response performance an issue of resources, individuals, or system?

      The current system of incident grades and types was developed as a result of the Audit Commission deciding that the previous approaches were inefficient and haphazard. Through various iterations involving HMIC, ACPO and the Home Office, a certain system developed…
      – ‘response’ is a ‘specialist’ function, and response teams have their own specialist terms of reference, skills profile, performance measures, etc. Their resource levels are usually determined by formulaic models
      – incidents are classified into types determined by us (crime, traffic, dispute, other, etc), and all calls have to fit into one of these types
      – each incident type has to be dealt with in set ways, allocated to certain units only, and require certain procedures to be followed
      – each incident requires a pre-set response time (grade), which determines who goes and when
      – managers assess performance on the basis of % attendance of certain grades within certain target times. The targets accept a certain level of failure.
      – calls are received by one set of staff who are usually measured on how many calls they can deal with in the shortest possible time. The jobs are then passed to another set of staff who have to find a unit to attend within the target time. Someone else then goes to the job. Each function has their own targets and priorities
      – incident counts have become performance measures in themselves. There are national standards for when an incident should be recorded, and what it should be recorded as. Crime incidents are compared against crimes to identify any misrecording. ASB incidents are counted as performance targets. Domestics require completion of additional forms and arrests. All these are subject to considerable inspection and audit.

      In terms of predictable demand (and predictable failure):
      – the profile of incident demand is very predictable
      – response times are often missed at shift changeover times
      – It gets busier for response teams on Friday and Saturday evenings. Most of the calls at these times involve alcohol, violence, domestics. There’s also a lot involving mental health. This is usually the time when other specialist units and other public services are not available to respond
      – most shoplifting is reported at places where store detectives are employed, or where there is little preventative security. Most ‘drive-offs’ take place at certain pumps at certain petrol stations. Most pub fights take place at certain pubs only. Most offenders have previous convictions. Most children who go missing have gone missing before. I could go on.
      – whilst the types of incident demand are very predictable, the skills/capacity of the response teams are not always matched to deal with the profile of demand, and they need to call in extra specialist support. Intoxication requiring medical help, domestic abuse requiring on-going intervention, mental ill health, missing children in care, arrests for crime requiring further investigation.

      So is the “I Grade” issue just a problem of resources (isn’t that down to the system also?), or is it a product of the way incidents are handled, graded, typed, and allocated? Is the answer to put more staff into ‘response’? (Where would you take them from? How would you pay for them?) Or is there a better answer through redesigning the system?

      And if rather than try to attend an incident you wrote NUTS on a log and sent it upstairs, you’d risk being charged (criminally) with misfeasance in public office.

  6. Bob pleb says:

    Yo mo, according to your logic, the more complex the situation the more human errors. The policing setup is very complex. Its humans who set up the system to cope with the workload……the very ones who are without the current frontline experience, the experience which you say helps to hone the most efficient response…..

  7. yo mo says:

    It is currently ‘stupid O’clock’ [in my timeframe] as I type this so it will have to be short.

    Mr G. Didn’t mean to be away so long but I had to go and ‘Comand and Control’ some stuff before it went ‘Nine Bob Note’. We may have to have a ‘tussle’ about the influence of Taylor. 🙂

    Wiggies. Having very quickly read your comment [sorry it’s late] you are right, and if you will let me have a few days to get round to reading it properly [sorry again] I’ll get back and do the sort of reply it deserves.

    The NUTS thing was a bit light hearted, but there is a serious point behind it.
    Lets try this scenario, all units are tasked on important jobs that will tie them up for hours, 2 RTC’s, and a suspects on with a decent chance of a grab, [you will know better than me], and in rolls a ‘Chardoney called me a bitch, on Bookface’ only the latter would get the ‘NUTS’ treatment, if and only if it ‘smelt right’. But even that is like walking a tightrope over a cess pit full of pointy sticks.

    Bob. [purple link means I know you from somewhere else, propably Gadget], this goes outside ‘systems’. I can only think of very [dog] rough reply, which only answer the latter half of your comment [did I mention it was late?], It’s hard to explain in a few words, you, I, we, want the best person for the ‘job’ in the ‘job’, but to be the best person they must know how all the other ‘jobs’ work. Rough as a badgers @~#e, but the best I could come up with given I should be in my pit.

  8. I’ll look forward to your response! ‘NUTS’ was an American commander’s reply when invited to surrender by surrounding Germans during the Battle of the Bulge. The Germans could translate the reply, but couldn’t figure out what it meant… I’m looking for the analogy here – I think it’s about not speaking the same language and not understanding what’s being said, because the same words mean something different depending on your view of the world.

    There are exceptional periods when there are an exceptional number of incidents. But the emphasis is on the word ‘exceptional’. Response officers will now howl with anger and say that that is what it’s like all the time. Bear with me. If it’s always like that, it’s not ‘exceptional’, and there is something wrong in the system. If it’s predictably like that, then there must be some things you can do in a systems thinking way to improve the situation:
    – increase the resource levels, because if you don’t deal with the work there and then, a lot of it will come back again as failure demand
    – look at the way the incidents are being dealt with, because it’s likely that there is a lot of unnecessary/wasteful activity in the various procedures that have to be followed
    – adjust the skills mix in the responding units, because it’s likely that there are jobs happening that the response team are probably not equipped to deal with
    – look at what is causing these incidents in the first place, because it’s likely some of that demand is failure demand (things not dealt with the first time round), or else can be shut off if someone did something to address the underlying causes
    – look at lines of responsibility and performance priorities, because it’s likely that these are not well aligned to deal with the demand

    I note that you automatically started talking about ‘response’ and ‘I Grade’ jobs, and talked about the problem of ‘response team’ resources not being matched to response team workload. But these terms are recent inventions. I didn’t start my service in a response team, because they didn’t used to exist. ‘Response’ teams were invented in the mid-90s. The logic was that if you introduced different grades of incidents, you could reduce the number of jobs that needed responding to quickly, and thereby cut the size of the teams that responded to them quickly. This allowed managers to create new ‘specialist’ teams (neighbourhoods, squads, prisoner processing, etc) to deal with ‘slow time’ work. The shrunken fast response teams could only do basic initial actions though – anything more protracted or complex would need to be passed on to someone else… which could only be the slow-time specialist teams. What this created was a system built around lots of specialist teams with narrow terms of reference, lots of handovers, lots of delays, lots of failure.

    Now the answer is not to turn back time to a mythical golden age when everything was great. It wasn’t. Service was haphazard, the technical/professional quality was often poor, and local policing was undervalued. But my main point is that the current system has a lot of in-built inefficiency, and the fix to that is not necessarily to chuck a load more resources at it. The more sensible fix is to design a better system, I suggest.

  9. yo mo says:

    Bob my last answer to you makes no sense in the broad light of day even though it seemed perfectly lucid when I wrote it. That’ll teach me.

    The problem you describe, and whether it is a system problem depends on where you draw your boundries? To me it is an organisational problem, there are too many layers in your organization.

    You wanted a nice sleek racehorse and you got stuck with a giraffe, and now the head can’t tell that the feet are standing in a big pile of lion sh!t.

    Once the ‘head’ loses touch with what is going on, ‘on the ground’ anything can happen, none of it good. They might do nothing, they might start ‘weather vaning’, leaping onto the latest fashionable thing to do, or they might have been told a lot of rubbish that has no relationship to the real conditions and start rowing in entirely the wrong direction.

    (The rot starts in the private sector when there is lots of money to go round, jobs that used to be done by one person with an assistant, suddenly requires a ‘Director of Sanitary Consumables Replenishment’, two ‘executive assistants’, a ‘Customer Feedback Co-Ordinator’, and a whole host of other ‘non-jobs’, just to make sure there is paper in the traps

    .But in the private sector, the second the wind changes and money becomes tight, it is all dismantled within weeks, the public sector don’t seem to be able to do this as quickly.)

  10. yo mo says:

    Wiggs, you are an un-utterable beast, for posting even more well thought out, cogent, and sensible thoughts, before I’ve even had a chance to digest the first lot 🙂

  11. yo mo says:

    I don’t understand this ‘binary’ divide between ST and C&C, you can have both operating at the same time perfecty well.

    To stretch the military analogy until it goes ping. ST is a strategic planning/problem solving tool and C&C is tactical, operational, struggling for the right word? an operational ‘mode’?

    I don’t know the full SP on East Mids, forgive if I won’t comment on it directly. And look at the various solutions you outlined from the different ‘styles’ and my reaction is “a little from column ‘A’ and a little from column ‘B’.”

    Training, yes if needed. Change personnel, perhaps IF the problem is really the personnel. Additional inspection and additional procedures, not happy about this one, if the system is failing because of over working the staff, then piling on more work is not going to help.

    There can be poor systems, and some of the incentives are frankly perverse leading to all sorts of distorted priorities, in the Healthcare context the ruling principle should always be ‘is this the best thing for the patient’.

    You described the Audit Commission’s finding that the previous system was ‘inefficient and haphazard’ and then go on to mention that various ‘agencies’ were involved, and a system ‘developed’ through ‘iterations’.

    I have a very jaundiced view of these sort of things and I’m probably picking up on key words and infering a meaning you didn’t intend, so I’m going to ask you to indulge me for a moment.

    When I hear about a solution that have been ‘developed’ by external agencies through a process of ‘iterations’, it makes my teeth itch. I’ve seen a few of these before and they always seem to go the same way.

    It starts with a sort of sensible plan, perhaps a bit rough round the edges, but mostly decent. And then all sorts of special interest groups start sticking their oar in, and carving out little bits of territory for themselves to the detriment of both the plan and the people that are supposed to run it or work under it.

    [The reason I might be so twitchy, may have something to do with, stand-up rows that may of happened in meetings that may have happened, where I might or might not have said “We are not …….. doing that, if you want to do that you can, but my team is not going to ……. around filling in …….. stupid bits of paper, just so you can produce a pretty picture. If it ever happened, my boss agreed with me.]

    But it never stops there does it? Even when a perfect plan is drawn up as time passes little extra bits get tacked on, jammed in and no end of improvements, that aren’t really until it becomes a cumbersome mess.

    You then described the current system, my first question is did the NCRS come in before or after they started measuring every bloody thing.

    The response time idea is perverse did this come in before Ambo invented the 8 minute target? Which is based on a single survey and it’s accuracy is disputed by many other people because it depends on a very large number of variables.

    The response time metric seems to have had its function inverted, it should be a measure of system capacity, ie. is the sysytem sufficiently populated with resources so that it meets the demand placed upon it. And when it failed that was a signal that the system was under resourced and needed increased resources. It seems to have taken on a life of its own and now has to be met at all times irrespective of the ability of the system to reasonably cope?

    The ‘predictable demand’ is a ‘shibboleth’ that seems to have caught on recently, and it doesn’t exist. And anyone who thinks they can ‘predict’ what is going to happen in the future is invited to slip into a sleeveless ‘Onesie’and then into a saline bath, while I dash out to find a grumpy munchkin in spangly gloves to ‘throw shapes’in front of a big ol’ telly screen. You can forecast what is likely to happen based on past events, but you can never predict. Having got that out of my system I’ll get back to the point.

    There are ‘patterns’ that emerge at a sort of macro level as you rightly point out.

    Response times are missed at change over, would that have anything to do with the number of vehicles available? There might be a station bursting at the seems with officers but if all the cars are still out with the last shift tied up with jobs that need finishing, nothing can happen, unless the job is within 500m of the station. that one seems easy to fix.

    The ‘Night Time Economy’ a failed government policy based on the idea if you gave people virtually unfettered access to alcohol, they would all have a pint and a half and wander off home like good little boys and girls. You would have thought anyone that had experienced ‘Freshers Week’ would realise that was never going to happen ever. And alcohol seems to be the agravating factor in all the examples you list, perhaps it’s time to reverse the policy and go back to reduced hours again. Who do the extended hours benefit? They are very popular with people aged between 18 and 30, but I wouldn’t call waking up covered in 3 different types of your own body wastes exactly a benefit. The only people that would really suffer are the drinks companies, and they don’t have a powerfull lobby influencing government do they, oh! hang on.

    There is a problem that every other agency shutters the doors at 5 o’clock and they will continue to get away with it until a) something goes wrong and they are called to account, or b) the people they are dumping on stop taking it and push back.

    In my little fantasy kingdom it doesn’t happen very often, because when it does a simple plan is put into action. Problems go up, right, they should go right to the top, and drag the head man or woman out of bed. Who should then ring the head muppet from the agency concerned and demand that they sort it out. Magic things happen every time I’ve used it.

    I was a little puzzled by the shoplifting thing because there seemed to be a mystical middle ground that was immune, and then I realised I was being an idiot. Security on scene, more likely to be detected and no physical security=easy pickings. Derrrrrr, smack forehead.

    As you say the list goes on and on but how many ultimately are resolved by the action of the police, I’ve expressed that really, really badly.

    Shops and petrol stations that get continually robbed get gripped by their insurance companies, who either whack up the premiums or refuse to insure them unless they sort out their security. Fights in pubs usually smash the place up, customers stop going and insurers or the brewery step in.

    I won’t go on but a lot of stuff is not really a police ‘thing’, Mispers that are just absconders or no-shows, when it’s definately known they are at friends 5 miles away are a job for the responsible agency, and if I can pop to fantasy island again, now everybody wants to mimic private industry, it’s time they paid for the services they are consuming. That would focus their minds very quickly.

    I need to bring this to a close and try to have a stab at answering your final question.

    I can’t answer it, I can only say what I would do if faced with the same problem. The work must carry on, even if it requires a short term increase in resources at extra cost.

    And having gained a breathing space, then is the time to have a good hard look at every single aspect of the ‘business’ and analyse every single activity and see if it contributes toward the ‘business’ objective. Using the word ‘business’ is very, very clumsy, because policing is a function that is unique and requires a different mind set from running a custard factory.

    Nobody with any sense would use the tactics common in the private sector unless they were either very stupid or completely fruit loop. The usual slash and burn would be excessively wasteful of highly trained and hard to replace staff. And police functions cannot be weighed on a strictly cost basis, mor should they ever be.

    You may call it redesigning the system, but my starting point would be “why are we doing ‘X’, where does it fit in with what we MUST to do, and if there is no MUST, what would happen if we stopped doing it.

  12. Thanks for the compliment!

    There’s a lot to take in here, and it’s obviously difficult for someone outside policing to understand some of the history and current baggage. I had a lot of baggage to unlaod myself!

    You’re right about things starting off with honourable intentions, and then going through various iterations until they end up being something misguided. NCRS was intended as a way to escape the focus on crime stats and the perennial debate about how accurate they were. Rather than worry about whether a crime should be recorded or not (why? because of performance target pressures), take the victim’s word for it. In the end, everything will balance out, since everyone will be doing the same thing. However, as a result of changing the counting rules, recorded crime stats went up. There was then a political outcry at the ‘rise’ in crime. It was apparent that some forces were more compliant with NCRS than others, and so the Home office spawned an industry in compliance checking and statistical comparisons. The current Govt has a policy based around the public wanting to see their local crime stats in order to hold their police to account. The public therefore have to have confidence in the stats posted online. Forces must therefore all be complying with NCRS.

    For info, much crime recording is not an absolute science – situations vary from case to case, and you have to make your best guess as to what has happened.

    Response times missed at changeovers. Think about it. Most jobs take a while to get to, deal with, get back, and complete. There is no budget for overtime. So if you’re due off at 10pm, and a non-urgent job comes in at 9.30pm, you’ll need overtime to deal with it – or you pass it to the next shift. They in turn will take a while to get out, so it’s likely to be 10.30pm before someone can go. This problem affects all shift working services, not just police. The problem lies in shift patterns, and there is a limit to what you can do within working time regulations. With limitless resources, you could of course have wide overlaps – but then you would also have huge inefficiencies through excess staff for most of the remaining time. Shift pattern design and rostering has always been a major headache. There is no perfect solution.

    The response time target is not based on science. They’re arbitrary times based on what we think the powers that be think they can sell to the public. Are you happy with a 4 hour response time? Or a 1 hour? Or a 10 minute if you live in an urban area, or a 15 minute if you live in rural area? They effectively became service level agreements. For this level of resource, we will provide this level of response.

    Glad you got the shoplifting thing. More shoplifting takes place at a) those places where they are better at catching shopliters, and b) at those places which have pretty poor security.

    I don’t understand why you disagree with predictable demand. It is a bit of a macro thing of course. I can’t predict exactly where and when a crime will take place, but most cops have a pretty good sense of where trouble is likely to occur. Of course, if you go there to try and prevent it, and thereby disrupt some of that offending, then it may look as if you wasted your time patrolling an area where nothing happened. Most teams know that they need to be inside/outside certain pubs at certain times, otherwise it will kick off. As a result, it didn’t kick off. Was that efficient patrolling or a waste of time?

    Unfortunately most commercial enterprises take a commercial approach to crime losses. Crime loss = £1000. Cost of crime prevention measure = £1005. Therefore it costs more to prevent the crime. Therefore it’s not worth doing anything. It’s as basic as that. Similarly with missing children.

    The more interesting question is about whether C&C and ST can exist side-by-side, or whether there is a fundamental split. Maybe in the purist world of manufacturing. C&C in policing, of course, has different implications. We have to rn all our incidents through command and control. The bigger the incident, the more important it is that C&C is clear. But I’m talking here about the C&C which is the opposite of ST. Senior cops and political masters are usually C&C thinkers. If things go wrong, it’s because someone let the side down. Maybe the target was wrong, and needs to be changed. But basically, you need to tell people what they have to do, set them targets, measure how well they perform against those targets, and reward/punish based ont hat performance.

    What I’m seeing now is that many of the reactions to police failings, Mid-Staffs, many other failures, is that senior politicians/bosses say there was nothing wrong with the system. Instead, the fault lies with the individuals who were clearly at fault, or with the IT which couldn’t do what it should have done, or with the inspection regime that failed to stop it from happening.

    I tend to see it as a failing of the system (which the politicians/bosses put in place). Some of those system failings are not easy to fix (eg, shift patterns vs resource limitations) – but they remain system failings, not individual failings.

    Hope that helps!

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