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When we use systems to help us understand the busy, messy world of human activity, we are in effect drawing a boundary.  We identify some things that are ‘in’ our ‘system of interest’ and that means other things are outside it i.e. not a focal part of our interest.  We do this whether we realise it or not – the problem is, if we are not being explicit about our choice of boundaries then we blur them for ourselves and other people.  Then we get confused and conflicted.

Take for example, the NHS planning guidance published in December 2015.  The word system is used in it a lot – it is all about ‘the system’ but here are some insights into my thoughts as I read it…

Starting with the web-page linked above I see that the guidance is all about developing…

A local health and care system ‘Sustainability and Transformation Plan’, which will cover the period October 2016 to March 2021

so we’ve started with a “health and care system” to me that includes services in the NHS and also services like social care services commissioned or provided by local authorities.  As health services and care services work a lot together it seems sensible that there should be one plan.  Though in the document itself the introduction of the Plan requirement is that the NHS is being asked to develop these plans, not local authorities.

On the first main page of the guidance I then read we are talking about “local systems” and then “local NHS systems”.

Couple of things here – we’ve gone plural – does that mean that my city (Newcastle) has one or more of these systems or maybe we don’t even have a whole one, maybe we are part of a larger one.  The guidance does ask areas to submit ideas for the footprint that they feel appropriate for the plans but hint that ‘larger’ footprints likely to be better because of the work involved in planning.  So it seems system boundaries aren’t about what makes sense from the population’s point of view but what makes sense from a resources view.  The other thing is that different sets of services may operate at different footprints – so a ‘learning disability health and care system’ may be really different to a ‘stroke health and care system’ – but each plan only seems to be about one system on a particular footprint.

Second issue – rather than ‘health and care’ it is now ‘NHS’.  So local authorities are ‘out’ of the system – the same goes for other non-NHS organisations involved in health and care such as voluntary organisations – they too are now ‘out’.

but then I move onto the next page and we are back to ‘health and care system’ again

bit of a relief…maybe that NHS systems before was a bit of bad editing.  Local authorities seem to be back in there afterall.  But then I am not so sure….

System leadership is needed. Producing a STP is not just about writing a document, nor is it a job that can be outsourced or delegated. Instead it involves five things: (i) local leaders coming together as a team; (ii) developing a shared vision with the local community, which also involves local government as appropriate; (iii) programming a coherent set of activities to make it happen; (iv) execution against plan; and (v) learning and adapting….

[….]

Success also depends on having an open, engaging, and iterative process that harnesses the energies of clinicians, patients, carers, citizens, and local community partners including the independent and voluntary sectors, and local government through health and wellbeing boards.

So systems leaders need to come together and then both ‘involve’ and ‘harness the energies of’ local government – implying that local government aren’t in the category of systems leaders, which I would have thought they would be if we are talking about a ‘health and care system’.  They do afterall have the statutory leadership role for health improvement and provide not just social care but the vast majority of functions that are truly ‘preventative’ of poor health/disease.  Also interesting use of ‘through health and wellbeing boards’ – as if they are a route rather than an important part of systems leadership in their own right. (I would say that they are the place where systems leaders already come together, now it seems systems leaders are being asked to come together somewhere else)

Ah it just seems to go on and the more you try and think what boundaries are being drawn, the more you get confused……..

the strength and unity of local system leadership and partnerships, with clear governance structures to deliver them

What is the difference between ‘local system leadership’ and ‘partnerships’ – what is the distinction being made between the two so that it is worth mentioning them both?

a list of ‘national challenges’ to help local systems set out their ambitions for their populations.

now we are just a ‘local systems’ is that different or the same as ‘NHS system’ or ‘health system’ or ‘health and care system’?  And how does the idea of national challenges match with the fact that local authority areas already have health and wellbeing strategies based on local population needs assessments?

…and back to health systems (but still local)

Local health systems now need to develop their own system wide local financial sustainability plan as part of their STP

…and then two paras later we are back to health and care

The first critical task is for local health and care systems to consider their transformation footprint

okay I think I have given readers the idea.

So it is all very well critiquing this lack of clarity – but can I offer ways which help build the clarity.  The answer is yes – systems thinkers have developed ways of being able to develop clarity about the purpose of a system AND critiquing the boundary of the system in terms of motivation and legitimacy.  These are associated with system methodologies such as soft system methodology and critical system heuristics.

Now in giving examples, I am only making potential perspectives explicit.  But just imagine the quality of the discussion that would come if ‘systems leaders’ had a conversation to develop clarity about the purpose of the system(s) they are leading. (although of course someone would be drawing a rough boundary in the first place in order to get those ‘systems leaders’ chosen and in the room).

So here are my examples using a quick ‘snappy systems’ technique – which effectively is about “a system to do WHAT”

  • a system to improve wellbeing and health of people in xxx area
  • a system to prevent further deterioration or complications of people who have had a stroke in xxxx area
  • a system to improve the quality of life of people who have had a stroke in xxx area
  • a system to ensure children in xxx area develop well
  • a system to reduce A&E presentations at xxx hospital
  • a system to control tobacco in xxx area
  • a system to reduce prevalence of risky levels of drinking alcohol in xxx area
  • a system to reduce cost pressures on the NHS in xxxx area

These snappy systems can be built on.  One way of doing this is expanding it to also think about HOW something will be achieved and also WHY.  An example could be

a system to ensure children in xxx area develop well

by means of integrated family based and education services

in order to contribute to a healthier, happier population in xxx area

Critical system heuristics takes a little longer so I won’t expand it here.  But importantly it can be used in two ‘modes’ – the system as IS currently perspectived to be and the system as it OUGHT to be (in a normative sense).  Articulating the OUGHT gives a vision and a sense of direction, comparing IS with OUGHT helps you consider what you need to do.

I am currently co-authoring material on systems for health and the use of critical system heuristics with Dr Martin Reynolds of the Open University.  I’ll get to explore it more during this work and maybe blog again.


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