Written by By Jo Gibson and Brendan O’Donovan
Although providers of public services would mostly proclaim a primary commitment to their service users, the unfortunate truth is that a study of the system from the citizen’s point of view reveals a very different reality. Despite best efforts from dedicated public sector workers and well-meaning leaders, getting a service can often resemble an obstacle race or negotiating a maze.
The maze is a system problem, not a people problem. Many public sector systems have evolved a warped view of their purpose in response to external and internal pressures. As a result of these pressures, organisations often lose sight of what happens to the citizen on the receiving end. Much to everyone’s frustration; service users, staff and leaders alike, organisations become focused around the needs of the regulator, the commissioner or central government.
Whether the service is life insurance, road maintenance or domiciliary care, we should always start from a deep understanding of what matters to the individual receiving the service. It involves taking a person-shaped rather than an organisation-shaped view of the citizen’s needs, or in Vanguard terms working from the ‘outside-in’. There is thus no better illustration of the principle in action than in what we’ve broadly termed ‘people centred services’ (i.e. public or third sector services such as health and social care, housing, benefits and policing). Importantly, viewing these systems in this way allows us to identify and eventually remove what we call ‘system conditions’.
Why system conditions matter
System conditions are the things that explain why a system behaves in the way it does. They form the framework within which those delivering any service have to operate. They are important for three reasons:
- They shape performance, positively or negatively
- Sustainably improving a process is rarely possible without changing the system conditions that frame it
- As manifestations of flawed management thinking, system conditions point to the strongest lever for change in the system – altering the way people think about the design and management of work
Some system conditions are present in any service: for example, the use of measures. What is measured and how, will dictate how a system will work (‘what gets measured gets managed’). Often measures are imposed as arbitrary targets. A classic is the four-hour wait time target in hospital accident and emergency (A&E) departments. The intent of the measure is to help manage perceived high demand for urgent medical treatment. In fact, it leads to people either cheating the figures or cheating the system: for instance, holding patients on trolleys in corridors or in ambulances having first seen a triage nurse and thus officially falling within the four-hour target. This is a great example of what is termed a single-loop solution to a complex problem. Of course, ‘doing things better’ is a classic single-loop solution to a complex problem. A double-loop solution would be ‘doing better things’, in this case working to understand the true nature of demand and then design a system capable of reliably managing it. As those who have studied A&E demand know, most (up to 80%) is demand that shouldn’t be there in the first place and only presents there because other parts of the end-to-end system are not working as they should.
We have clients who, having understood the true nature and frequency of demand, have been able to redesign the whole system to remove much of the repeat and inappropriate demand altogether. This has the effect of releasing system capacity to focus on getting it right first time for the individual. Improving individual resilience leads to correspondingly reduced demand and resource pressure on the service.
Organisational roles and structures are another ever-present system condition. In most people centred services, the system is structured so that an individual’s life is split into segments, each handled by a different professional specialist. In a simple adult social care system this involves many contacts, with the citizen required to tell their story at each one. In one case, an individual was obliged to repeat their history more than 200 times in two years. This is not exceptional; indeed it is ‘designed- in’ in current systems, governed as they are by a perceived imperative to manage cost by embedding costly professional expertise deep in the system where its use by the patient or service user can be strictly rationed. Reaching these professionals means undergoing repeated assessment and referral – often ending with treatment refused on the grounds that ‘your condition is not serious enough … (yet)’.
The alternative is a service structured around the whole individual citizen, with a focus on understanding and responding to their life priorities. Some leaders are reshaping services to remove splits between functions, sometimes even barriers between organisations. To enable this real integration, the purpose of the service is redefined to relate directly to what matters to the citizen and helps them to lead the life they want. New operating principles ensure that they only have to tell their story once and a single individual is assigned to work with them throughout.
Substantial change depends on ‘a vital few’
There are many other system conditions, including performance management and incentive and reward schemes, reporting requirements (to ‘feed the machine’), demands of IT, standard policies and procedures, the commissioning process, and regulation and inspection. Yet in any one case substantial change normally depends only on ‘a vital few’. A common one is decision-making remote from the work and abstracted from the end-user’s context. A good example in people centred services is the Department of Health’s Continuing Healthcare (CHC) funding process for people who need ongoing personalised health and care to ensure either a good quality of life or in some cases a good quality end of life.
Under the current system, to get funding requires two 124-page assessments to be carried out, one by a nurse and another by a social worker. A panel then sits every 6-8 weeks to decide. In one health service studied, out of an annual total of 400 cases only 10 were refused on initial presentation; eventually, after much delay, all the cases were agreed and funded. Predictably, the information received by the panel is incomplete and has to be chased up. The governing CHC framework makes it clear that funding decisions should be wholly based on need and not on funding and budget. If that is the case, why have a decision-making process disconnected from the work? From studying the current system, it is clear that, in reality, money is the biggest driver, and the logic behind the design is the need to control spending to meet the budget. Not only is the design an utter waste of time and resource, it removes decision-making from those with knowledge and understanding in the work.
One health and social care system decided to remove this system condition. Instead it is experimenting with the revolutionary idea of letting the workers make the decisions, freeing up time spent on paperwork actually to meet the individual face-to-face and jointly work out what good care for them should look like. The key worker for the case is responsible for understanding the individual’s complete end-to-end story and, with support from an integrated team, for taking informed joint decisions with the individual as to proportionate support. No longer are decisions about care taken by a group of people disconnected from the work and with no knowledge of the individual circumstances. The worker is trusted to do the right thing based on understanding, continuity and trust.
Another system condition responsible for much failure of service to meet people’s real needs (and often make them worse rather than better) is standardisation of response. In current people centred services response to demand is prescriptive and based on pre-set standards. In adult social care this manifests itself in a prescribed assessment of need carried out by a social worker, with standard questions which may or may not have relevance to the person and their needs. On that basis the social worker decides what support, if any, will be forthcoming, in the shape of a care package consisting of up to four calls a day, their timings determined by staff workloads, travel distance and time, rather than what matters to the individual. One consequence is that people who, with the right kind of support, could perfectly well live independently become dependent on the calls. In other words, the care package is over-specified. Or the care package fails to meet the underlying need and breaks down, eventually resulting in hospitalisation. Analysis of hospital demand reveals that this under-specification scenario is played out with depressing regularity.
In some redesigned services, starting from a different set of principles, the organisation delves into the need behind the demand by taking time to conduct a ‘what matters’ conversation. Once a bond of trust and understanding is established, the task is to help the individual help themselves, by identifying with them their strengths and capacities, along with those of their family and community networks. We call this ‘designing against demand’. In people centred services, the value work consists of listening to and understanding a patient/service user’s needs as the only way of understanding real demand and planning an appropriate and effective response.
Removing system conditions: a lever for change
Although it is vital to understand system conditions, we don’t recommend that you start there. We believe system conditions are best understood as the causes of waste. Their importance emerges from the process of studying performance – you learn what prevents and enables services to be truly person-centred. Understanding the biggest causes of waste leads you to the ‘vital few’ that offer the greatest leverage for change.
Identifying and removing, or at least containing, the constraints imposed by system conditions is essential to developing a more effective service. It allows the service to be redesigned around the individual citizen, and enables the organisation to devote its energies and time to understanding and responding to what really matters to them.
Joanne Gibson
Brendan O’Donovan
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.