It’s the system, stupid!

In last Tuesday’s Guardian newspaper, Eileen Munro of the London School of Economics (LSE), made a telling comparison between the public’s acceptance of systemic explanations for failure in the case of aircraft accidents versus those concerning breakdowns in child protection of the kind that cost Baby Peter his life in the London Borough of Haringey (‘Beyond the blame culture’, 3 November). Munro points out that, in social work, the assumption is that blame can be laid at the door of individuals who are “stupid, malicious, lazy or incompetent”. In the case of aircraft accidents the assumption is that a system fault (e.g. confusing instrument layout) offers a more likely explanation than a bad pilot. Hence, investigations into aircraft accidents are systems based, but in social work they focus on individuals and someone to blame. The public, media and politicians have a need to find scapegoats in one case, but not in the other. Guess which.

Professional management institutes have done shamefully little to wean their members, the public, the media, regulators, and politicians off instinctive assumptions of individual manager responsibility, (in)competence and culpability. In cases of high-profile systemic failure this has sustained baying calls for summary dismissal of managers (such as Sharon Shoesmith, Haringey’s former Director of Children and Young Persons Services) or naïve faith in their retraining (those left behind). High pay for top executives has served only to reinforce the mythical status of the individual leader either as saviour, or as dunce when the system fails. But leadership is only as good as the system of which it forms a part, and on which its improvement effort should be focused.

At its heart lies a basic confusion between what managers do and the concept of management. The former emphasises the skill, qualifications and training of managers. It assumes that more and better managers will result in better management. But successful ‘management’ of a complex system depends on attending to the gaps and spaces. Hence the importance of Munro adopting a systems perspective for conducting serious case reviews to improve child protection. The simplistic equation between managers and management has bedevilled attempts at improving public services for years. The National Skills Academies are offering ‘learning for leadership to transform their services’; they are in danger of repeating this basic attribution error. For those seeking a systems perspective, there is a tool for diagnosing, understanding and remedying instances of systemic shortcomings and failure in management and leadership.