The complex world of early interventions

The economics of early intervention are obvious to everyone, with examples all around us. “A stitch in time saves nine” is a well-known trope because it speaks to a simple logic. If you don’t intervene early with a tear, that tear will increase in size, leading to more cost to repair. Or, in our fast-fashion society, the disposal of the garment.

When it comes to customers, citizens and patients though, disposal is not an option. If a customer is falling into debt, a citizen is struggling with tax payments or a patient is slipping into mental illness, we, as service providers (and the designers of those services) need to recover those people. The goal is for customers to service their debt, for citizens to pay tax and for patients to be well.

Yet the more work you do in these fields, the more you see quite plainly the need to intervene much earlier, before the problem mounts. The cost of recovery in every case is more than the cost of prevention. To the provider and to the individual.

National Illness Service

I attended the excellent Meaning Conference in Brighton this week. Maff Potts closed the conference to a standing ovation after he spoke from openly about his mental health problems. After the death of both parents in his teens he understandably ran into considerable personal trauma. Yet a job at a homeless facility pulled him out of chaos. He spent the next few years running social care services of different sizes, but he’s not that positive about their effectiveness.

So he’s now set up the Camerados, a grassroots organisation essentially aimed at early intervention in mental health. What Camerados do is wonderfully simple. They create Public Living Rooms. Volunteer Camerados sit in these Public Living Rooms and wait for people to wander in. They then take the time to chat to them. This simple approach: allowing people to share their woes, be vulnerable, share a chat and a laugh – is the early intervention lots of people need in their daily lives, where depression and anxiety constantly poke at the edges. It’s an elegant and heart-warming initiative. (Get your free Public Living Room box here).

The NHS is a misnomer. As anyone who’s been to A&E will tell you, the service is excellent if you have an acute need, but not so good if you have a chronic, creeping need. I speak from experience, as someone with 20 years of persistent, undiagnosed pain. Camerados shouldn’t need to exist, but it has to, because the NHS struggles with the economics of early intervention.

Like any other organisation in the modern world, it works to short-term budgets, 3 year strategy cycles and 5-year leader cycles. The business case for early intervention often takes many more years to realise. And you can’t often track the money saved, because the acute issue has been avoided. Accountants find early intervention a real conundrum. Humans don’t. A stitch in time has always saved nine.

Debt

One of our teams recently completed a piece of work for a bank, looking at how we could help prevent customers from falling into debt. Taking a human-centred approach, we quickly discovered that the customer’s journey into debt and collections was rife with missed opportunities, counter-productive actions and an overall ethos of ‘just enough, just in time’. What was being called ‘early intervention’ wasn’t nearly early enough.

And the economic difficulty of early intervention is compounded here, because (shhhh) banks make money out of customers in debt. And when customers miss payments, more money is made – whether inadvertently or otherwise. No-one likes this situation (least of all the regulator), yet to fix it, we owe the situation a degree of honesty: the economic case for change here requires a compelling upside before anyone will make the change towards preventative care and early intervention. The alternative to making money out of customer failure is to make money out of customer success – to help customers become better users of debt. But this argument of Long Term Value vs Short Term Gain, is notoriously hard to win.

Extinction

Another speaker at the Meaning Conference was Clare Farrell, one of the co-founders of Extinction Rebellion. This was a profound talk, with no punches pulled. The climate crisis is a result of our total failure to intervene early. It was Climate Change for 30 years, but then it has become Climate Crisis for this very reason. With some powerful people in the world still failing to reach stage 1, ‘recognition of the problem’, we can see how problematic ‘early intervention’ has become.

The cost of recovery wasn’t really talked about. Depending on whose data you read, that ship has perhaps sailed. What Clare was really talking about was the cost of coping – of just dealing with what is now a chronic problem that has set in - which is in the trillions. Coping hangs off the end of recovery – it’s where chronic failure establishes itself. In every service context, chronic anything is wildly expensive for the provider and human. Ask my doctor. Ask my wife.

The next speaker, Miatta Fahnbulleh from the New Economics Foundation, talking about how the Green New Deal provides a way out. The Green New Deal is an enormous exercise making an economic argument for early intervention – even though it’s now a case of late intervention. If we do it, we stand a chance, if we don’t, we don’t. That was the clear conclusion. But you can hear the policymakers and politicians sucking their teeth. Even for the ones who accept the climate crisis, they will be looking through the narrow lens of a business case, which struggles to handle external costs and woolly benefits like ‘human wellbeing’. In this way, the Green New Deal probably looks very risky. Not to me.

Conclusions

Our failure to intervene early is deep and long-running. We seem perpetually biased to the quick fix. A stitch in time may save nine, but most people no longer know how to sew. It’s a classic behavioural bias that we’d all rather the glamour of building shiny new things than the essential trudge maintain existing things – whether humans, services or products.

We put too much emphasis on the individual’s agency, as they slide into problematic behaviours and habits – whether health, debt or profligate carbon usage. Our egos as leaders mean we look for the rapid turnaround, at the expense of the harder perhaps more impactful long-haul. As shareholders, we look for quick returns and grow impatient if ROI is too long coming.

Early intervention is a clear service pattern and as service designers, managers and leaders, we need to look out for it everywhere. Here are some rules of thumb:

Positive human futures: We have never had so much power to recognise problems. Data is all around us. In her Surveillance Capitalism book, Shoshana Zuboff talks about Silicon Valley selling ‘human futures’ – eg selling our propensity to vote a certain way to the highest bidder and then manipulating us to achieve that outcome. This is the real fear we should have about giving our data away. (Incidentally another speaker, Paul Mason talked elegantly about this and his book Clear Bright Future is well worth a read). We should be turning those human futures to our advantage – helping identify behavioural patterns of struggle sooner and then designing human-centred interventions that create wellbeing.

Data stewardship: To achieve this, the service needs to reassure that the individual can place their trust in the provider to collect data as a steward of their wellbeing. The civil service code and banking values / regulations need to be updated to make this clear

Redesign the system: The sooner a service intervenes in a problem, the more likely it will be to salvage that customer, get them back on the straight and narrow, and generate loyalty. However creating the business case for achieving this is complex, especially where the system currently generates revenue and profit from customer failure. Often externalities need to be considered within that business case, which will be challenging for many to accept. Either way, this is a clear case that, to put the customer at the heart, you can’t just redesign the horizontal journey. You need to work on redesigning the internal system logic that underpins economic decisions. And these will likely be different for different vertical teams eg the team selling the credit are likely not currently incentivised to prevent long term debt problems.

Small and early: Don’t underestimate the small intervention very early. The beauty of the Campaniros is just that. A short dose of human empathy, when you’re having a bad day, breaks the isolation and shame associated with mental health. A chat and a cup of tea is another established trope. It is a very human form of early intervention and much cheaper than recovering someone from chronic mental illness years down the line

The unacceptable risk of chronic coping: At a human level, we can’t continue as we are. We face multiple crises – of mental health, homelessness, and the biggest – climate catastrophe. I’ve talked before about the reward for services that serve people at a human level – that help intervene in people’s lives and lead them from confusion into recognition, understanding, and action. The failure of late-stage industrialism and managerialism is the failure of our current service systems -political, business, health - to intervene early in all of these crises. Yet these service systems are all human-made and can be remade. This is the job for today.

“All the suffering there is in this world arises from wishing our self to be happy. All the happiness there is in this world arises from wishing others to be happy.” Shantideva

Become a Camerado here

And thanks to the organisers, speakers and attendees of the Meaning Conference. This blog post literally came to me in the shower this morning, Wouldn’t have got there without y’all.