Some thoughts on leading measures - with education as an example

Leading measures are things that tell us how we are performing, right now, against things that matter. We are not very good at measuring them. Instead we measure things like percent compliance against a protocol, or satisfaction rates, or exam pass rates. These are all lagging measures - they happen after the event and do not really tell us very much about what we can do to improve. They also don't usually tell us whether what we are doing is actually very helpful/desirable; and as a consequence of this tend to lead to 'gaming'; in which individuals or organisations tend to alter their behaviour in order to hit the target. "Hit the target, miss the point" as my mentor Andy Brogan would say.

The trouble is that the lagging measures are so engrained in all that we do in healthcare that it's very difficult to start thinking differently. So I find it helpful to think about things in which I have only a rudimentary understanding of the process, but I have quite strong views (as a citizen) of what matters. Education is one example, and so here are some thoughts on what matters, and how I might measure these as a school governor. With thanks to @Primary_Ed for the structure around growth mindsets.

1. It matters that my child enjoys school
Ask a child when they turn up for school in the morning if they are looking forward to it.

2. It matters that my child has a 'growth mindset'. 
Note I, personally, am not interested in whether my child has learned any facts - this is what Wikipedia is for. But it does matter that they know how to learn, and they know how to access facts, make sense of them, and use them to solve real problems and be interested in the world around them.

I think I would want every child to show me a balanced example of these things about their work, either in books, or in the classroom:

a. This work is OK - but is it my best work?
I know what I am going to do next to make this work better
I understand what I am doing at the moment and am now practising making sure I can do it well.

b. I have made a mistake - and this is good because I can learn from it
I have made a mistake and I know what I need to do next to learn from it
I find this work hard but I am working hard to understand it

c. This work is awesome - I'm on the right track to being the best that I can.
This is work I didn't think I could do before, and I have worked hard to get here.
I am good at what I am doing now and I am enjoying using my new skills

I really think it is very important we ask children about their attitudes to mistakes : 
I am happy when I make a mistake
I won't be told off if I make a mistake. 
My teacher helps me know what to do next if I make a mistake
I like to help my friends if they make a mistake and I know how to do it.

There are other things in the growth mindset that look at how children approach problems ("This is too hard"; "I can't do French"; "I'll never be as good as her"; "I can't get any better at this"; "I give up") that might be measurable. I am hoping they are, to some extent, captured in the measures above (so for instance, the measure of 'awesomess' is a personal one, and reflects, to me, the extent to which the teacher knows the child and what constitutes challenge and success for them)

3. It matters that my child has enjoys a rich variety of experiences
I'm not sure how I would measure this. How about something like "Number of things my child does that are led by a specialist who is not their usual teacher."

Sex registers and pathology testing

I'm off to London to talk about pathology. On the way I have been listening to the latest Freakeconomics podcast on the economic cost of sex offending. It's big, and lifelong. Society exacts a high price, in a way that is unique amongst all offences. One of the biggest costs is associated with sex registers, which effectively proscribe offenders from even attempting to live a normal life. But this may be the price society exacts for a crime that is seen as most heinous.

What I find interesting, though, is the effect of registers on offending rates. Zero. I don't think this is very surprising. And perhaps it's also not surprising that registers have a wider effect on society. So house prices fall by 4% if you live within half a mile of a registered sex offender in the US.  But then there is the fear they engender. It suddenly becomes a lot easier to imagine your child becoming a victim. And of course it is fear of crime, rather than probability of being a victim of crime, that is the biggest problem, especially for those of us with enough time and resource to be able to search registers.

So the link with pathology? We have created an industry in monitoring of chronic disease which is supposed to make people feel safe, and cared for, but which has actually done the opposite. It has made people live in fear of deviation from the median, and encouraged treatments and health behaviours that lack evidence of actual benefit (as would be defined by the citizen); chasing arbitrary targets that are, at best, a step removed from the true purpose of what we're trying to achieve.

My response to this social disease of iatrogenic harm? I see it as my responsibility, as a pathologist with some degree of influence, to ensure that we act as stewards of pastoral care - only delivering testing when it makes people better. Not using testing to create layers of anxiety. The link here with crime? As a citizen, I see the main role of law enforcement agencies is to make me feel safe. This may involve tackling the causes of crime, but this can only be a part of it. Sex registers most definitely take you away from this purpose - even if they worked (they don't) they make you feel unsafe. The role of health care is similarly not to deliver a long life - it's to make me, as a citizen, feel cared for. We need to start remembering that.