Service Design in health and social care, using a systems thinking Buurtzorg approach

The Setup

The Problem to Solve

Taking care of people, their health and welfare needs, their social issues, and their relationships. This has to be one of the most complex systems that anyone can work in. Especially as this has to include the community and family circumstances, as well as the individual.

In England we have made it particularly complex, by the way government has seen fit to design the overall health and social care system. By fragmenting the various 'services' and privatise provision, this has unleashed forces that guide the behaviour of a miriad of organisations with different competencies and rules.

A systems approach is particularly apt to make sense of this complexity. It strips out the artificial barriers that are put in the way of doing the right thing, and allows a design of an effective system to emerge.

Many authorities are now experimenting with integrated working. The government and the NHS have recognised that the way forward is more integrated care. Sustainability and transformation plans (STPs) drawn up by eath authority are now focusing on transformation and localisation of care.

Personalisation, patient centered, community, integration, community assets, key worker... They are all pushing against the monolithic approach of treating everyone the same. Now that this approach has proven itself, lets get going with what we have learned works.

Increasing demand into the health system, and signs of increasing waste in processes has been a factor in public healthcare for a number of years now. In particular, there has been a recent awareness amongst managers that the servcice that was being delivered was not a good service.

The Plan

To create an example of what is possible if the system is completely redesigned from a different perspective; eliminating the major barriers to effective working.

A full-time team was put together of all the disciplines required to deal with citizens who have community health needs. The team included an operational as well as a senior manager, and the team had direct links with the hospital, GPs and specialist health services.

The service design methodology

The service as it was

What was found

The team found that the current system was very inefficient and ineffective. This was characterised by high levels of waste in the operations. But more importantly, the citizen was being taken through a series of rule driven complicated steps, that that did not contribute to dealing effectively with the persons problems.

Doing the right thing

66% of demands, as they were recorded on the referral system, did not match what the person actually needed.
People returned to the service in 71% of cases because we do not accomplish what is necessary.

Their need

In over half of the total demands, the person had no idea they had been referred to the service.

Understanding

We realised that the neither the staff nor the IT system, had an understanding of what the real needs of the person were. Formal assessments were widening that gap in understanding.

Management

The managers had no idea how the service was truely working, and changing the service that made it worse, not better.
Half of all work that the staff undertake in the old system is of questionable value, and may not be necessary.

Costs

By focusing on cutting cost, the causes of cost increased the total cost.

Staff roles

The staff hardly ever used their full competence, they became automated to simply undertake daily activities.

The system design

The design of the system was highly functional, designed to deal with standard clinical activities. Individual referrals were crfeated from a rule based 'sausage machine.'

The demand, the need

All demands and needs were complex, requiring a team based approach to looking at the problems to remedy.

The information

The information recorded almost never reflected the true nature of what mattered to the person. And much of what was written was of no value to anyone.

The system itself was so complicated, that there was no realistic way that the staff in the system could function well, despite individual or team efforts.

The reality

The managers realised that they were partially responsible for this situation as they had put in a series of assessments and rules that were designed to help staff to follow a standard process, to reduce risk, and to minimise cost. Those in the work were bombarded with increasing levels of demands on their time, creating a highly stressful and activity focused mindset, resulting in low morale and a personal distancing from what really mattered to patients.

It was realised that citizens core issues were often not resolved until too late, resulting in months or years of unnecessary treatments. Citizens would bounce around the public health system with little progress of improvement to their overall lives.

The Experiment

Applying a systems thinking perspective to this problem

The team took 35 demands from end to end, and focused on the needs of the citizen by applying a set of new operating principles to each person. This allowed the team to learn how to approach and deal with people in a way that focused on getting them back to a stable and healthy state. The barriers to making this happen had to be temporarily suspended, as were any time or other restrictions.

They were so conditioned by rules, that the team were surprised at how difficult it was to learn how to actually listen and understand someone's life context free of pre-determined structures.

New working principles

A case in detail

Summary of all the cases

Step 1 Understand me & what matters to me

Each team member took the demands, and the first step was always to understand the nature of why the person had come to them in the first place. In most cases this required a visit, that continued until they developed a level of trust and got to learn clearly the circumstances about that person.

Understand each person in their environment and those around them.

Discard assessments and actively listen

What is their environment like? Who visits? Any relatives? Are they happy? What are they not saying?

What matters

Step 2 Decide the best agreed course of action

This is about assessing the whole situation of the person, their environment, and their friends and family. In the majority of cases what was required had little to do with clinical help. There were few restrictions placed on the team, and they were able to pull on any of the clinical expertise from anyone in their team if needed.

Step 3 Keep ownership, and maintain the person to get back into balance

We are engaging with them and are directly available at the end of the phone if required. Whatever the team think needs recording is written down. This is where we don't simply close the case, we ensure that they have got to a place of stability.

Step 4 Close

We close the case when we have agreed that we have provided enough support. If they contact us again, the same team member is assigned the case again.

The new Design

The current health workflow

The current system - transactional and functional, and has no single point of ownership

The new system is based on a network of communication and single point of ownership

new network based health workflow

Purpose

The actual purpose of the service that the managers focus on, then drives that which the staff focus on. Subsequently, the measures follow thta purpose to ensure that the purpose is achieved.

The purpose of a service is often never truly described openly.

Old purpose

To work on the task infront of me, as quickly as possible, following all the rules.

It drives me to lose sight of actually helping someone, and I feel relieved when I can refer it on to someone else.

New Person centred purpose

Understand what matters and help the person to achieve balance in their lives.

It drives me to focus on what matters, and to only do those things that I need to.

And if the services are redesigned around this new purpose, what do you think will happen? What will happen to costs?

Detail of the measures the team captured

Buurtzorg design in community health

If you want to experience what this is actually like to go through this, and you have about 16 minutes, you can experience it here, through Eleisha and Len. This is what some senior managers saw.

Outcomes

As an example, this is what we found about one of the people, Anne

My problem – I have complications with my wrists, and everything I touch feels hot. It is a condition that is not curable.
What matters to me - I need help to live as normal life as much as possible. I need help dressing, cleaning the house and cooking.

What we found about our current way of doing things

Value work 4 hour 20 min
Waste work    10 hour
People involved    19
Handoffs          17
Documents              33, 132 pages
IT systems used      6
End to end time 100 days
Outcome              No real improvement in my life

When we helped Anne in a joined up way

Value work          5 hours
Waste wor           1 hour
People involved    5
Handoffs              0
Documents      3
IT systems used 6
End to end time    10 days
Outcome             I manage my problems myself now

The solution was not in fixing her chronic condition, it was actually about helping her to continue to live her life as normal as possible. What we provided was adaptations and advice.

We also found a teenager who lived neardy that needed help with her reading and writing, which Anne was very happy to help with, in exchange for the teen helping around the house with cleaning.

Before we tookthis case on Anne had been bouncing around the service with five referrals that had no meaningful impact over two years.

This was a typical case that would bounce round the community health office, and over time the service user would either make repeated demands, or lose interest and stop connecting with the health service. A typical failed outcome that shows how we can spend lots of time going round in circles.

It's tempting to view this experiment work as simply introducing a 'single point of contact', or a 'multi-disciplinary hub', or 'sharing data'.
The reality is that the real change is in the thinking and approaches of those in the new system, in Anne's case above, one person actually did most of the value work with a new decicion framework and the ability to make local decisions.

It took senior managers to give the team permission to avoid what we needed to:

ignore departmental cost centres
don't refer on, keep ownership and get advice from others if needed
aim give the service user whatever help they need when it is not a clinical solution.
only use the paperwork that needs to be completed, and only do it once

Measures

The summary of all the cases taken in the experiment

The number of assessments,
No of people involved end to end,
No of referrals,
Total number of hours spent on the cases,
Face to face time as a percentage of total time,
Estimate of that demand returning into the system,

down 64%
down 32%
down 41%
down 14%
from 46% to 60%
from 71% to 0%

All the demands taken were complex, highlighting the fact that a flexible and non-standard design of the work should be the norm.
By getting good understanding, and work with the cases end to end, we reduced repeat demands into the service from 71% to almost 0%.

Leadership and management

Role of the manager is based on trust & knowledge to delegate certain decisions.
The reality that the manager does not have or should have all the answers. Learning & uncertainty should be recognised as good leadership traits.
The manager must be able to distinguish between staff working hard vs staff working on the right thing.
My job is to help make a team work effectively through understanding what makes a good team work well, and to ensure staff have a good job to do.
Understand that culture & motivation is an outcome of my leadership.
Understanding that the system is a result of my design and my thinking.
A standard approach to making decisions and processes hinders the work and creates waste.
Learning happens within the work itself.
I recognise that truly Understanding a person is essential to this service, and I have to ensure it happens when we are busy.

The effect on the team

The team developed a new way of working together, that allowed them to be open and honest with each other.

We work on our relationships with each other and I bring my whole self to work.
We support each other with no conditions.
I now see my whole work here completely differently, I don't want to go back to my old work.
I am now using all my abilities, it fulfills me.
I am motivated as I connect directly with the outcomes we we are achieving.
My manager supports me.
I enjoy coming to work.

This is a team member, an Occupational Therapist, explaining how her behaviour in the current design was driving her behaviour in the wrong way (1 min)

The learning

In this health system, services like this develop such waste and poor outcomes due to the functional nature and standardisation of the flow of work. The learning from a managers perspective, was that if they truly looked at their service end to end, and that by understanding that the real demand and what matters to people should drive the work that we need to do. So, unless the systemic problems were redesigned, no amount of changing of rules, procedures, or IT system results in real sustained improvement

Delivering care across existing systems will be a key development for the future of service delivery and evidence suggests that a “systems thinking approach” will be required to understand the environment and the complex interactions within it.
Commissioning for Effective Service Transformation, NHS England

You can read another case study, about Bob whom we learned lots about how to do things right

Bob's journey

Design thinking, Service design and Systems thinking Section

If you want to know more about the detail of the design and systems thinking methodology used, it is described in this section...

The approach that this piece of work took combined Design Thinking principles with Service Design and System Thinking. Each 'thinking' is woven into the overall methodology, so that in one morning, the conversations will always start with what matters to the end user, and incorporate an end to end perspective. We challenged everything. The underlying principles of this work are to do with person centred design, that basically follow those developed in approaches like the Buurtzorg organisation in The Netherlands. The development of the team was in the direction of becoming a self managed team.

The Plan was agreed with the client - but they already had experience of this type of approach, and they know that they could not rely on a fixed outcome - it had to be part of the Understand. But what might be interesting to the reader is that this is really about Transformative change. In this type of change, which is a wicked problem; part of the discovery is to find out where we were going to go. I say we, because this involved transforming peoples thinking as well as the service.

The team - Transforming thinking is something that happens when people decide to explore and accept other possibilities. So, the team that went through this had to be officers from the organisation, plus a manager. They had to undergo the journey, and the only way to do that was for them to actually do it themselves.
My role as the consultant was as a facilitator, and as a coach. I would give them the right tools at the right time, and they would develop the outcomes. So, no nice clean diagrams from me, they were all generated by the team.
The managers - several managers through the hierarchy were dicretly connected to this work. In particular one manager was increasingly participating. They had to start by being part of the team, and they had to learn. Slowly over time they started to learn new ways of interacting with the team and allowing officers to come up with the solutions. The team manager had to learn how to work with an empowered and self managing team. Whats the role of the manager when the team are self managing?

The Methodology

Open each section to read more about the methodology used

Understand

Understand is the analysis of the current system, its performance and the impact on the customer. The customer being the person needing help. The approach that was used was to take a team of front line staff and the manager through a series of stages of learning and prototyping - they started by understanding what mattered to the people calling in. They also mapped out all the activities that they took to complete the end to end flow.

Systems thinking - The start of the process has to be to ask why are we here - our purpose? Design thinking - And then we have to understand HOW we achieve this purpose from an outside in perspective. Then we can truly get the customer experience, fully in our mind. In this case we were not able to do this until the prototype stage, this is because this work is so complex, that it was only by trying to design a prototype did we truly understand what mattered to them.
The nature of the demand, its variable nature, and its complexity was very high. The nature of the system under consideration was basically an open system, whose boundaries we had to set far wider than they were used to.

Design thinking - The team spend a few days on developing a workflow map for several examples, that contained each activity. This map is only useful if it tells us something. So, we identified the value and waste. The team were stunned.

Systems thinking - we had to ask ourselves how effective the current system was? The answer was, we didn't know. But we knew that it could work lots better.

experiment & prototype

With a non-transactional workflow, it is not easy to see a new way forward. So, I had to do some work to get the creative juices flowing. These are front line staff that had the old ways of working drummed into them, for years. So...

Design thinking - In the first section of the work, the team worked hard to understand what they could from their expriences and from data. The main place to start was the beginning, which was to Understand the person needing help. Sounds easy, but the team had to go and actually find out.
Background - Staff understand their patients, they do this through assessments.
Learning - they learned that by using assessments, this stopped them from them from truly understanding, They learned that Understanding people was really, really difficult! It took several days of coaching and repetition for those team mebers to push aside their current thinking and approaches,a nd learn to listen with no pre-conditions. This variety was key to helping the managers to understand about the nature of variation and standard approaches that restricted that variety.

Design thinking - The team then went on to the next stage, which was to summarise and make sense of what they had understood. But not from a purely medical or professional perspective, but from the perspective of the persona nd those around them.
What we did - we discovered that we had to release our boundaries of our mind, to be able to thik of solutions how to help people that they actually needed. Rather than those that we would provide as standard.
Learning - that we had to learn completely new ways of listening, evaluating, working collaboratively, and then assisting.

What we did - the team worked through 35 people in ways that were now, and in ways that were defined by the persons needs and circumstances. They had permission to apply new approaches, stop doing things that they didnot think they needed, and not be restricted by the current operational constraints. The manager ensured that the team were doing the right thing with regard to safety and risk.