Hendrik Ascheberg, Vanguard Consulting

‘Hi, I’m Paula, and I used to be a nurse’.

It was a simple greeting, but it took my breath away.

Being a change consultant can be a tough job, but it has some incredibly rewarding moments. This was one of them. Paula had changed her mind.

When I met Paula for the first time, I learned how important her profession was to her. Having gone through years of studying, training and on-the-job learning, she valued her profession highly. She was extremely proud of being a nurse. There is nothing wrong with this: but for her, everything she did was based on her nursing qualification. The job was all about taking blood pressure, following detailed procedures and filling in forms.

A change in perception

When I heard her say she used to be a nurse, it was clear that something profound had taken place. The old Paula would not have said that. She had completely changed the way she perceived herself and her profession. So what happened?

Paula was part of an experiment among a team of nurses (district and ward), occupational therapists, physiotherapists (both community and ward) and social workers. As part of the experiment, the team was given the power to do anything necessary to help patients, short of causing harm or breaking the law. Other than that, all rules and policies were suspended. No more long-winded monthly panel meetings to approve trivial budget changes; no process maps detailing how to proceed; no standardised referral forms.

The team was free to experiment.

Instead of filling in a 100-page admission form, full of information that was never used; the team established what really needed to be recorded.

Instead of following procedures, team members focused on using their judgment and expertise to build a relationship with the patient, understand the person in context and get to grips with what really mattered in their life.

Once they understood the patient, the team could draw on the expertise, when needed, to help the patient, and the patient’s network, help themselves.

In one case, the team helped an older woman short on confidence after a fall to use public transport again, so she could stay mobile and socialise. Paula twice accompanied her on a bus ride to help rebuild her fragile confidence. This would have never happened in the old regime. The go-to solution was to fill in a form, order equipment or set up homecare. To help someone take the bus wasn’t regarded as appropriate use of an expensive professional’s time. It wasn’t something professionals do.

New system logic

In the light of the experiment, the team concluded that the bus ride wasn’t so expensive after all. Team members learned that the true cost of a service is all the cost of all the activities – the assessments, the home care, the visits to the GP and the hospital. As an intervention, helping someone to take a bus is cheap by comparison. But more importantly, it helped the woman to help herself. Being mobile and meeting her friends in town is what mattered to her. Not helping her to do that, leaving her unhappy and depressed, was both less effective and, taken globally, much more costly.

Through helping people one by one, Paula and the team began to understand how the system had medicalised problems to such a degree that staff were quite unable to see what people really needed to live the life they wanted. Not one of the assessments dutifully carried out by different professionals identified what truly mattered to their patients. In the old system, each patient told their story up to 10 times, but no one actually listened or understood the real needs everyone has – for socialising, maintaining good relationships, having enough money to be able to make decisions or feeling valued by society and being able to contribute to it.

As they came to understand their patients, Paula and the team also began to understand themselves and each other. They understood the importance of an individual’s skills and expertise, beyond their professional qualification. The focus became the patient, rather than the mechanical, technical or medical issues.  Paula changed her mind.

Just do it

The team also began to realise how different it felt to work in a team that does not have traditional roles. Any member of the team was able to ‘pull in’ expertise from colleagues and learn from the episode rather than ‘passing the client on’ to another professional. Team members were so used to writing referrals and seeking permission from managers that it took them time to realise that they could in fact – just do it.

After a while, their confidence growing daily, the team began to see how much the system cramped judgment with form-filling, seeking permissions and justifying decisions. The system served itself, not patients. Accessing and managing different budgets drove up total costs and, more importantly, drove down service quality for the citizen.

For patients, the outcome was mind-blowing. They were now able to live the life they wanted to lead, rather than the one the system told them to live. The help they get is based on what matters to them, rather than what matters to the system.

At the same time, the team feel rewarded and empowered by making a difference to people´s lives. Rather than leaving their brains at the front door, they use their skills and knowledge, make their own decisions and take responsibility to help citizens, not to tick a box, write a report or fill in a budget application form.

This also means lower costs for the service and therefore for the community. There is more time for staff in front of the client instead of sitting at the desk. By experimenting with the Vanguard Method, Paula now works in a completely different way.

‘Hi, I’m Paula, and I used to be a nurse’. Paula is still proud to use her nursing skills, but even more proud to have discovered how much more she has to give.

Hendrik Ascheberg

Read similar articles in Edition Two of The Vanguard Periodical: The Vanguard Method in People Centred Services. Ask for your FREE hard copy or PDF.