Integrated neighbourhood place multidisciplinary health and social care example
How we co-designed neighbourhood place based locality relational working with the NHS and a local authority multi-disciplinary team. They were given permission to decide how to deal with focusing on a person whole needs, using relational human learning system principles.
This example highlights an approach of how the intentions of the new operating model for health and care published by the NHS in 2025. It highlights what reform might look like to develop neighbourhood integrated health between the NHS, local authorities and social care. Its outcomes coincide with the three priorities: “hospital to community”, from “analogue to digital” and from “treatment to prevention”. Its core shift, using relational human learning systems, is to a more preventative and empowering model of care, particularly in relation to higher intensity users, which is delivered closer to people’s homes.
The example demonstrates four key dimensions:
1. What can we learn when a multi-disciplinary team focus on doing the right think for people, without the restrictions of their current organisations in the locality of place.
2. What shifting from a command and control approach is, for leadership and management.
3. What might a new systemic operating model look like, and what needs to shift to make this happen.
4. A method for reform, avoiding the pitfalls of attempting to place a new model ontop of what we currently do.
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 includes the community, family circumstances, and everything that surrounds the life of an individual.
In England we have designed how we do health in a complicated way. By fragmenting the various 'services' and privatise provision. This has unleashed barriers that prevent effective health from being realised, and it has led to spiralling demand, and increasing amounts of non-value work. A systems approach is particularly apt to make sense of how this works, and how we might design alternatives. Systemic change 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.
What if we could get a group of front line people working in health, put in a room and give them permission to test and learn different ways of working that are independent from the current rules, procedures, behaviours and thinking. What could we learn from that team after a six months of working directly with people that need help in a community?The team were together for about 9 months, and I was working with them most of that time 2-3 days a week.
- The test and learn team consisted of an occupational psychologist, a physiotherapist, 2 nurses, a social worker, an operational manager. They were full time, and led by consultants.
- The leadership team consisted of a senior leader, and operational managers. They spent some time every week on this work, and received related coaching by a consultant.
This is what we did, and what we learned.
In England we have designed how we do health in a complicated way. By fragmenting the various 'services' and privatise provision. This has unleashed barriers that prevent effective health from being realised, and it has led to spiralling demand, and increasing amounts of non-value work. A systems approach is particularly apt to make sense of how this works, and how we might design alternatives. Systemic change 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.
What if we could get a group of front line people working in health, put in a room and give them permission to test and learn different ways of working that are independent from the current rules, procedures, behaviours and thinking. What could we learn from that team after a six months of working directly with people that need help in a community?The team were together for about 9 months, and I was working with them most of that time 2-3 days a week.
- The test and learn team consisted of an occupational psychologist, a physiotherapist, 2 nurses, a social worker, an operational manager. They were full time, and led by consultants.
- The leadership team consisted of a senior leader, and operational managers. They spent some time every week on this work, and received related coaching by a consultant.
This is what we did, and what we learned.
The purpose of this work
This test and learn experiment was created to explore what is possible if the health and social care system is completely redesigned from a different perspective; avoiding the major barriers that we face when undergoing change.
The relational test and learn methodology
Systems thinking is not just a set of tools, it also frames design and implementation methods. We used the tried and tested method below to guide us through this transformation, that is specifically designed for redesigning complex services - created by John Seddon and called the Vanguard method. It is based on systems thinking and used the concepts of relational working, Human Learning Systems and 'test and learn'.
test and learn systemic design method
What we learned about the current system
Before we started to explore new ways of working, we spent some time (6 weeks) understanding how the current health system worked using systems thinking methods.
We reviewed 116 cases on the system in total. From those, we found that only 58 were real demands into health and social care. This points to the fact that one persons complex needs was split into multiple disconnected demands. The team also found that the current workflow path was full of unnecessary steps and often ineffective in dealing with the peoples issues. This was characterised by the person being taken through a series of rule driven complicated steps, that that did not contribute to dealing effectively with the persons problems.
We reviewed 116 cases on the system in total. From those, we found that only 58 were real demands into health and social care. This points to the fact that one persons complex needs was split into multiple disconnected demands. The team also found that the current workflow path was full of unnecessary steps and often ineffective in dealing with the peoples issues. This was characterised by the person being taken through a series of rule driven complicated steps, that that did not contribute to dealing effectively with the persons problems.
Understanding the person ands doing the right thing
66% of demands, as they were recorded on the current system, did not match what the person actually needed. We realised that neither the staff nor the IT system, had an understanding of what the real needs of the person were. So the work that was subsequently undertaken did not achieve the intended outcome 66% of the time!
Demand
People returned to the service with repeat 'failure' demands in 71% of cases, because we do not accomplish what is necessary.
Management
The managers had no idea how the service was truly working, and 'process improvement' and digital solutions had made it worse, not better.
The work
Half of all activities that the staff undertake in the current system is of questionable value, and may not be necessary.
Costs
By focusing on directly cutting cost, this caused costs to increase elsewhere!
Staff roles
The staff hardly ever used their full competence, their roles became automated and driven by episodic activities. Real care reduced.
The system design
The design of the system was highly functional, designed to deal with standard clinical activities. Individual referrals were created from a standard rule based 'sausage machine.'
The demand, the need
All demands and needs were complex, but the system then split them into several independent transactional processes.
Information
The information recorded almost never reflected the true nature of what mattered to the person. And much of what was documented was of no value to anyone.
Reviewing a selection of 58 cases on the system were not clear, we found that:
- 40 were mis-directed to the wrong service.
- 10 were generated by the system itself.
- 3 were related to non-rehab health issues.
- 1 was regarding housing.
- 6 were other spurious reasons.
- 40 were mis-directed to the wrong service.
- 10 were generated by the system itself.
- 3 were related to non-rehab health issues.
- 1 was regarding housing.
- 6 were other spurious reasons.
The reality
The pathway logic itself was so complicated, that despite individual or team best efforts, there was no realistic way that the staff in the system could function well without breaking the rules. The system design was driving the wrong activities and behaviour.
On learning this, the managers realised that they were partially responsible for this current 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. Front lines workers 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 peoples core issues were often not resolved until too late if at all, resulting in months or years of unnecessary treatments. Most would bounce around the public health system with little progress of improvement to their overall lives.
It was realised that peoples core issues were often not resolved until too late if at all, resulting in months or years of unnecessary treatments. Most would bounce around the public health system with little progress of improvement to their overall lives.
Exploring different ways of working
Test and learn
An important part of the intervention design method, is a safe environment to learn and try new approaches. The team were given a physical room and worked for about 7 months disconnected from the current mindset, procedures, culture and ways of working of the organisation. I call this 'the bubble' which is an innovation technique designed to allow for people to come up with new ways of working unencumbered by the current systemic conditions. The team work as a cross-functional design team, across each others specialisms, on the end to end service, by taking customer calls directly into the team.
We started on day one, with a new perspective, a set of principles based on Seddon's 'the liberated method'. Our purpose was to:
- Understand what matters for each person, this determines the approach we take.
Our principles were:
- We make decisions based on knowledge and evidence, not opinion or standards.
- Only do what is needed to create value, enabling the person to gain control.
- Take ownership through the end to end journey with the person.
- Work as a team, without department barriers.
- We are here to learn, and improve.
Rule 1 - do not break the law.
Rule 2 - do not make their situation worse.
The team picked real demands at random, and began to deal with them from end to end - start to finish as defined by the person. They started by listening to the person, without the use of current assessments or rules. This relational approach allowed the team to learn how to focus and deal with people to get them back to a stable and healthy state, and not simply reacting to what was written on the referral sheet. The team had to time restrictions placed on them, and if they needed resources, they had to ask their manager.
The staff 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. It took two weeks of working together, to wean themselves off using standard assessments.
We started on day one, with a new perspective, a set of principles based on Seddon's 'the liberated method'. Our purpose was to:
- Understand what matters for each person, this determines the approach we take.
Our principles were:
- We make decisions based on knowledge and evidence, not opinion or standards.
- Only do what is needed to create value, enabling the person to gain control.
- Take ownership through the end to end journey with the person.
- Work as a team, without department barriers.
- We are here to learn, and improve.
Rule 1 - do not break the law.
Rule 2 - do not make their situation worse.
The team picked real demands at random, and began to deal with them from end to end - start to finish as defined by the person. They started by listening to the person, without the use of current assessments or rules. This relational approach allowed the team to learn how to focus and deal with people to get them back to a stable and healthy state, and not simply reacting to what was written on the referral sheet. The team had to time restrictions placed on them, and if they needed resources, they had to ask their manager.
The staff 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. It took two weeks of working together, to wean themselves off using standard assessments.
What is the matter with you?
Discard assessments and actively listen
What is their environment like? Who visits? Any relatives? Are they happy? What are they not saying?
What matters to you?
This is sometimes called strengths based approach from a person-centred perspective.
We did not use this exact diagram in this work, but this gives a good indication of how we went about Understanding over time.
The new design
After several months, the team had taken 35 people through the new principles. A new way forward began to emerge of both the process that we could take people through, and how we might work together as a team and with our managers. Importantly for the managers and leaders, we also discovered what elements in the existing system had to change to enable this new way of working to be supported and allowed to operate successfully. What barriers had to be shifted.
In addition, the team measured the outcomes of their experiments and compared those with what would have occurred in the current system.
In addition, the team measured the outcomes of their experiments and compared those with what would have occurred in the current system.
This is the new way of working the team created
Step 1 & 2 Understand me & what matters to me
Each team member took 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. Listening and learning about their issues, and whatever they wanted to tell us. We discovered that this was often about life issues, living situations, relationship problems. That activity continued until they developed a level of trust and got to learn clearly what mattered to that person.
Step 3 & 4 Decide the best agreed course of action
Discussing various options with the person. There were few restrictions placed on the team, and they were able to pull on any of the expertise from anyone in or outside their team if needed. And they were able to attempt to apply whatever actions they decided to.
Step 5 & 6 Keep ownership, and maintain the person to get back into balance
We are engaging with the person and are directly available at the end of the phone if required. This is where we don't simply close the case when we finish our activities, we ensure that the person has got to a place of stability. And whatever the team decide needs recording is recorded.
We close the case when we have agreed with the person that we have provided enough support. If they contact us again, the same team member is assigned the case again.
We close the case when we have agreed with the person that we have provided enough support. If they contact us again, the same team member is assigned the case again.
After the completion of the experiment, the team with the manager and leaders prepared for the prototype. For this to occur, the concepts and methods had to be formulated and designed to a level of operational detail. A new process and new measures emerged, and the diagrams below demonstrate the difference in the way of working.
The old health assessment and referral workflow
From: The current system - transactional and functional, and has no single point of ownership
To: The new system is based on a network of communication and single point of ownership
the new ownership network and strength based model
Simply looking at these diagrams does not describe well to a reader what the design looks like, the team used Lens story to help to bring that out.
Purpose and our relationship with people in need
The actual purpose of the service that the managers focus on, drives the behaviour of staff. In the NHS this purpose is an internally driven focus based on cost and a raft of measures. This real outside-in purpose of a service is often never discussed or understood openly. But we did discuss it, and we came up with our strengths based purpose.
Old purpose
'What is the matter with you', and then 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
' What matters to you', and how can I help you to achieve balance in your life.
It drives me to focus on what matters, and to only do those value activities that I need to.
As we were examining the service from a citizen perspective, the relationship we have with them changed...
Relationship with people moves from; engage with us (on our terms), to engage with you (what suits you).
Power moves from; power over others, to power with.
These are two fundamental changes to the way that we perceive how our service interacts with people. We began to understand what putting the person in the centre of the design really was about.
Relationship with people moves from; engage with us (on our terms), to engage with you (what suits you).
Power moves from; power over others, to power with.
These are two fundamental changes to the way that we perceive how our service interacts with people. We began to understand what putting the person in the centre of the design really was about.
Len, a case study as presented to the senior leaders
The power of story-telling, to describe a complex situation, is profound. If you want to experience what this is actually like to be taken through a strength based prototype by the team, and you have about 16 minutes, you can experience it below, Eleisha talking about Len. Senior managers of the ICB were in the audience.
Health and Social Care strength based Integrated Care System prototype. Len's Story.
The outcomes & failure demand
The key question we had was; if the services are redesigned around this new purpose, what do you think will happen? Will delivering a personalised service cost more? The first table below shows how we designed how to measure outcomes for one person. We then followed up, in the second table, by the outcomes for all the people we worked with.
How we designed the measures, using one person we worked with, Anne
My problem – I have complications with my wrists, and everything I touch feels hot. It is a rare 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.
My problem – I have complications with my wrists, and everything I touch feels hot. It is a rare 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
Non value work 10 hours
People involved 19
Handoffs 17
Documents 33 pages
IT systems used 6
End to end time 100 days
Outcome No real improvement in my life
Non value work 10 hours
People involved 19
Handoffs 17
Documents 33 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
Non value work 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.
Non value work 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.
Before we took this case on, Anne had been bouncing around the service with five referrals that had no meaningful impact over two years.
The solution was not about 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 nearby 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.
The solution was not about 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 nearby 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.
Failure demand - This example above was a typical case that would bounce round the community health office. Over time the person would either make repeated demands, or lose interest and stop connecting with the health service, representing a typical failed outcome that shows how we can spend lots of time going round in circles. This bouncing around, which is endemic, can be characterised by the term failure demand; defined as the demand placed on the system, not as a result of delivering value to the 'customer', but due to failings within the system. (Seddon). Failure demand is an hidden characteristic that is a key indicator of a poorly designed system.
Measures and outcomes
The summary of all the 35 people we worked with in the experiment
The number of assessments undertaken dropped by 64%.
The number of different people involved in each case dropped by 32%.
The number of referrals made dropped 41%.
Face to face time with patients rose from 46% to 60%.
Returning demand dropped from 71% to 0%.
Total hours spent by staff was 14% less.
The number of different people involved in each case dropped by 32%.
The number of referrals made dropped 41%.
Face to face time with patients rose from 46% to 60%.
Returning demand dropped from 71% to 0%.
Total hours spent by staff was 14% less.
Not only did this way of working created better outcomes, it is more efficient, takes less resources, and reduces total demand.
In addition, the team noted that 66% of the demand originally recorded on the current system, did not match the real problem to solve. So, the current system is designed to fail in 66% of cases.
All the demands taken were complex, highlighting the fact that liberating front line workers to adopt a flexible and non-standard design of the work was appropriate. This is in contrast to a non-complex demand like; I have sprained my ankle (with no associated issues).
By getting good understanding of the person and their context, and work through the cases end to end, we reduced repeat demands into the service from 71% to almost 0%. This points to the fact that a mis-aligned design of a service simply drives up demand.
By getting good understanding of the person and their context, and work through the cases end to end, we reduced repeat demands into the service from 71% to almost 0%. This points to the fact that a mis-aligned design of a service simply drives up demand.
To see more about the measures method and how the team developed them
The new leadership and management behaviours
These new behaviours emerged by the managers working together with the team, and understanding how they needed to act to ensure this new way of working flourishes, to manage risk, and to create team learning.
- My role as a manager is based on the trust in my teams to delegate certain decisions.
- Liberate the front line to allow them to do the job they have actually been trained for - within an agreed framework.
- I do not have nor should I have all the answers. Learning should be recognised as good leadership traits.
- Understand the difference between risk avoidance (decisions that deny), and risk management (allow free choice).
- I must be able to distinguish between staff working hard vs staff working on the right value work.
- 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 our 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 listening and 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)
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john mortimer - dont tell me
What happened to this work? The mean and leaders had agreed to take the prototype and make it work in a locality. Then Covid struck... And that was it!
The learning
In this health service, services like are typically full of such waste and poor outcomes, due to the functional mechanistic design and standardisation of the processes people are told to follow. The learning from the whole team was that if we redesign our services end to end, starting with understanding the real demand and what matters to people, that then drives the work process that we need to follow.
The current system creates its own failure demand - people bouncing around the public sector, unable to get the support they need.
The current system prevents change - The team uncovered the barriers to this new way of working that were present in the current system. The managers realised that unless the systemic problems were redesigned, no amount of changing of rules, procedures, or IT system results in real sustained improvement
The depth of change - The current system cannot be improved, it needs to be redesigned.
The following learning is a summary of that the team learned during this prototype:
The current system creates its own failure demand - people bouncing around the public sector, unable to get the support they need.
The current system prevents change - The team uncovered the barriers to this new way of working that were present in the current system. The managers realised that unless the systemic problems were redesigned, no amount of changing of rules, procedures, or IT system results in real sustained improvement
The depth of change - The current system cannot be improved, it needs to be redesigned.
The following learning is a summary of that the team learned during this prototype:
- Redesigning health from the persons perspective does indeed improve all measures significantly.
- The role of management has to change to be supportive of flexible ways of working.
- Costs are reduced by acting on causes of cost. Cutting costs on their own, often increases overall costs.
- Causes of costs are acted on by making decisions at the front line.
- A persons journey through health needs to be flexible, not standardised.
- Front line staff need to have roles that allow for flexibility, and ownership of a person they are caring for.
- Front line staff have to be able to work with other colleagues together, without barriers.
- Different front line roles collaborate and work as a team when they are located in the same room.
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
The barriers to effective health reform
- This work highlighted the key barriers inherent in the current system design, that prevent this way of working from being embedded.
- The way that services understand people is through assessments. Standard discipline designed assessments prevent the real demand, and what matters to people from being uncovered.
- The way that we 'tell' people what they are going to get from the NHS is an example of 'power-over'. This attitude prevents collaborative solutions to emerge.
- The focus of many in the NHS is to apply a narrow specialism, and then refer on. This prevents wholistic solutions from being understood and emerging.
- Referrals make it almost impossible to make links and collaborate with others.
- The creation of eligibility criteria, drives up demand and costs by design, defeating its purpose.
- GDPR and specific rules drive huge amounts of waste and prevent collaboration, when they dont need to.
- Risk avoidance underpins the current ways of working and decision-making, and should be replaced by risk management.
- Leaders have no ability to develop this way of working because they are focused on meeting their short term financial targets.
- This approach to change and transformation is unknown in the NHS.
- What we currently record regarding patient records are not helpful in most cases.
The barriers are big ones, they might appear unsurmountable. BUT the team had solutions for all of them, and those are one of the key contributions the team makes in this approach.
What this is not
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 decision framework and the ability to make local decisions.
It was essential for senior managers to give the team permission to the team to liberate them from the current method:
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 decision framework and the ability to make local decisions.
It was essential for senior managers to give the team permission to the team to liberate them from the current method:
- 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
Learn these methods through workshops
Find this interesting? I design specific workshops to help organisations to learn and apply this
Practical steps you can take
From working with various ICS's and various service redesigns, we have learned a few practical activities and areas to focus on that make a significant impact on a health service. Use the button below to go to that list of practical steps.
Webinar of the ICS prototype
Here is a webinar with John Mortimer and member of the team, that describes this whole work. (YouTube 1 hour)
You can read another case study, about Bob whom we learned lots about how to do things right
Delving deeper into the methodology; Human Learning Systems, relational design and systems thinking
If you want to know more about the detail of the design and systems thinking methodology used, it is described in the section below
The approach that this piece of work took combined the Vanguard method principles and method, that combines systemic design, intervention theory, psychology, and Systems Thinking. Each is woven into the overall methodology in a method invented by John Seddon, 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, liberating the method of the team. 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 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 way that I used the Vanguard methodology
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.
Systemic design - 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 (developed by John Seddon). The team were stunned.
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.
Systemic design - 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 (developed by John Seddon). 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.
With a non-transactional workflow, so 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...
test and learn approach - 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.
Relational design - 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 think of solutions how to help people that they actually needed. Liberate those at the front line to do the right thing.
Learning - that we had to learn completely new ways of listening, evaluating, working collaboratively, and then assisting.
test and learn approach - 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.
Relational design - 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 think of solutions how to help people that they actually needed. Liberate those at the front line to do the right thing.
Learning - that we had to learn completely new ways of listening, evaluating, working collaboratively, and then assisting.
More about HLS here
Human
The main focus of the human aspect covered two main areas. The first was the staff in the team. How they worked together, and also their personal journey of developing a new working culture and relationships with each other. Of significance was psychological safety, the ability to bring their whole selves to work, individual strengths, and trust. The health service is delivered by people, not by technology or other mechanisms. This aspect of staff goes far deeper than simply taking about roles, but more the direction of how people work to their fullest. Dan Pink expresses that a human role should incorporate autonomy in the role, mastery of skills, and purpose with regard to achievement of purpose.
The other side of Human, was the design of a new approach that treated the citizens who needed help as whole people, and not as ‘service users.’ Service users and the focus of citizens in need in the past decades has moved towards people as customers. This means that citizens have to be understood as a totality, often including their relationships with friends and family. This is very different from health based episodic provision.
Human
The main focus of the human aspect covered two main areas. The first was the staff in the team. How they worked together, and also their personal journey of developing a new working culture and relationships with each other. Of significance was psychological safety, the ability to bring their whole selves to work, individual strengths, and trust. The health service is delivered by people, not by technology or other mechanisms. This aspect of staff goes far deeper than simply taking about roles, but more the direction of how people work to their fullest. Dan Pink expresses that a human role should incorporate autonomy in the role, mastery of skills, and purpose with regard to achievement of purpose.
The other side of Human, was the design of a new approach that treated the citizens who needed help as whole people, and not as ‘service users.’ Service users and the focus of citizens in need in the past decades has moved towards people as customers. This means that citizens have to be understood as a totality, often including their relationships with friends and family. This is very different from health based episodic provision.
Learning
The whole purpose of the prototype was to learn what worked and what does not work. It is designed to inform senior leaders, who can then make further informed decisions as to how they would like to take that learning forward. Those leaders themselves need to go through a learning process overt the life of the prototype. The team became adept at summarising the learning experience to a set of activities that occurs in a workshop situation, that takes leaders through journeys of learning. Under no circumstances would any outcomes be written up in the form of reports. And no reports were ever created for this work. Reports simply emphasise the current paradigm, as readers simply use the text to compare their current thinking with what they are reading. In addition, reports fail to convey complex narratives.
The primary mechanism to this progression of the prototype is learning – and learning that is directly experiential. This is required because the current paradigm of how our health services work, is framed in the principles of New Public Management. This design has been in place for so long, that it is very difficult to conceive of new ways of working within that frame. Therefore it is necessary to help leaders to enquire deeply into their mind-sets, to help them to understand a quite different paradigm.
The whole purpose of the prototype was to learn what worked and what does not work. It is designed to inform senior leaders, who can then make further informed decisions as to how they would like to take that learning forward. Those leaders themselves need to go through a learning process overt the life of the prototype. The team became adept at summarising the learning experience to a set of activities that occurs in a workshop situation, that takes leaders through journeys of learning. Under no circumstances would any outcomes be written up in the form of reports. And no reports were ever created for this work. Reports simply emphasise the current paradigm, as readers simply use the text to compare their current thinking with what they are reading. In addition, reports fail to convey complex narratives.
The primary mechanism to this progression of the prototype is learning – and learning that is directly experiential. This is required because the current paradigm of how our health services work, is framed in the principles of New Public Management. This design has been in place for so long, that it is very difficult to conceive of new ways of working within that frame. Therefore it is necessary to help leaders to enquire deeply into their mind-sets, to help them to understand a quite different paradigm.
Systems
The healthcare system is perhaps the complex that is possible to understand. It is both national and encased in legislation. The links that citizens often require cover a myriad of various specialisms and healthcare practice.
The systemic nature of this prototype is in contrast to the mechanistic and reductionist design that currently dominates the health services. This systemic perspective is the frame that the team must embrace, to then focus on the person in need in new ways.
The healthcare system is perhaps the complex that is possible to understand. It is both national and encased in legislation. The links that citizens often require cover a myriad of various specialisms and healthcare practice.
The systemic nature of this prototype is in contrast to the mechanistic and reductionist design that currently dominates the health services. This systemic perspective is the frame that the team must embrace, to then focus on the person in need in new ways.
This work was delivered by John Mortimer through Red Quadrant
