Failure demand – implications for research nurses and the way we work

Don’t panic!!!  Those of you opening this up thinking what on earth is she talking about are probably experiencing the same thoughts I was a few years ago when someone first explained it to me.  Failure demand?  Eh?


I was working on a study a while back and the paperwork was getting way behind for various reasons. I was getting frustrated as I couldn’t see how to move forward and sort out the blockages.  Then I came across the work of John Seddon and it transformed my way of thinking.  Hopefully you will see how this concept can fit into our day to day and enhance our working practices.  Once you learn about failure demand (if you don’t already know about it!) it will transform the way you think about systems design and how we organise our work.  You will hopefully be able to see how we can make our systems better for our patients.  And you could save yourself a lot of time and energy in the process.  This is for everyone working at any level.  Stay with me guys…


So, the idea behind this concept is that all of the work we do every day can be categorised in 2 ways.  The work that the system is designed to carry is called value demand. Value demand is good and is what we are meant to be doing. On the other hand, Failure demand is work (“demand”) that is produced by a failure to do something right (for the customer) in the first place.  John Seddon gives the following examples of typical types of failure demand:

  • “I don’t know how to fill in the form”
  • “I don’t understand your letter”
  • “When will I get my money?”
  • “I don’t agree with the decision”
John Seddon – Systems Thinking in the public sector



How many times have we posted questionnaires out to patients, only to have them returned partially filled in, not returned at all or filled in at the “wrong” time.  Have we had misunderstandings over follow-up visits, have people coming in had trouble parking, delays in being seen, had missed appointments due to errors in the computerised appointments system?  Problems with the system impacting on the patient’s day to day experiences and the quality of our work.


Doing the work correctly in the first place and avoiding failure demand can also save many hours.Well, obviously.  Yes, it is obvious in some ways but why do we find ourselves stuck in these unhealthy patterns going round and round feeling powerless to change things and getting bogged down and swamped because of things that could be changed for the better.  Hmm.

Consider CRF completion.  I guess in this case we can think of value demand as a) getting the data collected and correctly recorded on the CRF and b) submitting that data to the study team.  Anything outside of that is arguably failure demand.  Having a stack of outstanding CRF pages to fill in which if done at the time of the event would have taken minutes could be seen as unnecessary work because unlike at the time you now have to get notes out, chase members of the MDT, look up blood results etc, chase patients for questionnaire results… do you see where I’m going with this?  Obviously there are going to be times when things crop up but if this is happening a lot and you are noticing a pattern then it’s maybe a good time to start asking if there are things we could be doing to change the system to improve the efficiency of the time we spend on our work.


How do we identify out potential recruits to studies? Are there system design problems that we could maybe have another look at to improve the experience for the patients.  Remember they are at the heart of all of this.   Being busy in itself doesn’t mean we are being productive.  Producing more work doesn’t necessarily lead to improvement in delivery.  We should be continually asking ourselves if the work we are doing the right work to achieve value demand for the service we are offering.


If you feel powerless to make changes, have a think about how you can go about making suggestions to those who are in a position to do that.  John Seddon is highly critical of any “command and control” management set up but quite often this is where we find ourselves.  I have always been a very strong believer in leading from wherever you happen to find yourself.  If this is as a relatively junior position so be it.  You always have to power to say “no” and advocate what you believe is best for your patients.  Over the years I have learned that it’s not always about what you say but also how you say it.  People naturally want to defend themselves if they feel they are being attacked.


There is a whole lot more John Seddon and his team have to say about systems thinking than I can fit in a quick blog post.  I find it fascinating and insightful.  I would thoroughly recommend looking into if further no matter what your role.  I’d recommend starting by trying to get a copy of the book “Systems thinking in the Public Sector” – there are many case studies that tell the story of how Seddon has developed his thinking.  He says of the book:

“The purpose of this book is to illustrate how ‘bureaucracy and red tape’ have driven public services in the wrong direction.  The cost is not just the cost of the bureaucracy itself; there is an additional cost because the changes being mandated by that bureaucracy are the wrong things to do.  The bureaucracy has made services worse, and public sector morale has been sapped.

If investment in the UK public sector has not been matched by improvement, it is because we have invested in the wrong things.  We invest in the wrong things believing them to be the right things.  We think inspection drives improvement, we believe in the notion of economies of scale, we think choice and quasi-markets are levers for improvement, we believe people can be motivated by incentives, we think leaders need visions, managers need targets, and information technology is a driver of change.  These are all wrong-headed ideas.  But they have been the foundation of the public sector ‘reform’.”

He presents quite a revolutionary concept; a way of thinking that has the potential to cut waste and improve productivity dramatically.  It’s worth a looking and judging for yourself.

If you are interested, you can also have a look at his website for some examples from health and social care

I’d love to know what you think!



Photo by Isaac Smith on Unsplash




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