The Structure of Health and Social Care Services of the UK

The Structure of Health and Social Care Services UK

Health care team of five people wearing surgical masks and PPE talk together

A ‘Thought Piece’ – for discussion

by Gordon Stirrat1, David Blockley2, Kirsty Alexander3 & Sabrina Phillips4

Emeritus Professor of Obstetrics & Gynaecology, University of Bristol, UK.

Emeritus Professor of Civil Engineering, University of Bristol.

GP & Chair Bristol North and West Locality Leadership Group at Bristol, North Somerset and South Gloucestershire CCG, UK.

4 Alliance Director  (Interim)| Lambeth Living Well Network Alliance

Introduction

The United Kingdom’s National Health Service (NHS) was launched on 5 July 1948 with three underlying principles – the services were for everyone; healthcare was free; and provision of care was based on need rather than the ability to pay. In the intervening 72 years it has developed into an extremely complex organisation and one of the world’s largest employers. Because of its cost to the national exchequer, its organisation and funding have inevitably become matters of great political significance and debate. The general population has developed a great emotional attachment to ‘the NHS’ vividly expressed in, for example, Danny Boyle’s 2012 Olympic ceremony when, at one point, the floor of the stadium was occupied by a host of angelic nurses and 300 NHS beds filled with bouncing children. On the 60th anniversary of the foundation of the NHS Michael Rosen wrote his poem, ‘These are the Hands’, in praise of the mundane but vital contributions of healthcare workers. It has come back to prominence during our current tragic Covid-19 pandemic made even more poignant by the fact that Michael himself has been very seriously ill due to the virus. He has, thankfully survived and is gradually feeling better. Also, during the pandemic many of us have, along with our neighbours, gone out to clap on Thursday evenings as a sign of our support for ‘the NHS’ and the frontline workers coping with pandemic.

To many people in the UK, those working in GP surgeries and hospitals that deliver health (but not social) care are ‘the NHS’.  The reality is far more complex, and we suggest that the structure of Health and Social Care Services UK, including the NHS and social care, and how the system reports and is accountable to Government and the public are all unnecessarily complex and opaque.

A complex structure

The Department of Health and Social Care (DHSC) is the Government body responsible for implementing policy in England. It delegates the work to NHS England. It is accountable to the Cabinet, Parliament, and ultimately to the general public. Health policy and implementation is devolved to the Scottish and Welsh governments and the Northern Ireland assembly. England is the only one of the 4 UK administrations to have a quasi-market but all use performance targets.

The NHS is complex set of organizations which, for the most part, work quite well despite a myriad of sub systems. A number of authors have referred to this complexity (1, 2, 3, 4) and, for example Powell (4) says ‘The leadership of the NHS seems fractured……a system under siege where success isn’t celebrated but failure is catastrophised’ We need ‘to build the confidence of the people who hold the problem.’  Attempts to explain the complex systems are necessarily partial (5, 6, 7). Good people can make a poor system work well but when pressures overwhelm them failure can be catastrophic (8). The NHS England long term plan (9) recognises the issues and states that the NHS will move to a new service model with ‘properly joined-up care…..creating genuinely integrated teams….with Integrated Care Systems (ICSs) everywhere by April 2021. ICSs will ‘deliver the ‘triple integration’ of primary and specialist care, physical and mental health services, and health with social care………Breaking down traditional barriers between care institutions, teams and funding streams.’ The intention of the plan is that providers, commissioners, local authorities and others will together locally plan and integrate care to meet the needs of their population. This initiative has grown out of sustainability and transformation partnerships and is the latest in a long line of NHS organisational changes. Currently there are 18 ICSs but demonstrations of progress are sparse (10).

How will integration be successful?

What are the incentives that will make integration work? Why should the many providers take responsibility for the total care of the whole population for probably less resource – when they have very little control over all the parts?

Everyone in the NHS shares a strong common purpose of ‘caring for our patients’. But does that translate into more detailed shared purposes at the various levels of the sub-systems?

We suggest that the key to driving change should be ‘influencing from the bottom up’ and not more ineffective ‘top-down’ centralisation (11). When policy decisions for change make sense to those ‘at the coal face’ they will respond. However, that response is conditional on the need for change to evolve up and down through the entire system. Policy makers and those allocating resources should alter, and integrate, some of the factors that will incentivise the ‘coal face’ individuals and organisations to work differently. A particularly important aspect of that incentivisation is that adequate resource follows activity without waste through unforeseen issues. For example, hospitals may initiate medication for a patient for which they have a particular financial deal, but the primary carers are not part of the deal and the medication may become very expensive for them.

The various parties to Integrated Care must also be aware that their potential partners may be fearful of extra work and responsibility being ‘dumped’ onto them. Sometimes, for example, individual GPs may be reluctant to hold challenging risks that hospital staff, with their more collective responsibility, may not be exposed to. If a patient dies during hospital treatment after a late diagnosis of bowel cancer caused at least partly through unintended delays (in the systems and perhaps also by the behaviour of the patient) the GP may find himself/herself in the spot light of blame by relatives, for not diagnosing quickly enough.

Making integrated care work has been variously described as ‘pushing a boulder uphill’ or ‘swimming against the tide. For example, differing financial incentives may produce perverse consequences. The commissioner/provider split and ‘payment by results’ (where income is proportional to activity) sometimes leads to a tick-box culture when used for some parts of the system. Block contracts for others do not incentivise improvements. Payment models have to encourage closer working around the needs of patients by sharing ‘pain and gain’ in an agreed manner. Co-operating organisations in the public and private sectors may have different bureaucratic constraints and work to different priorities and time scales as they attempt to adjust with agility to rapid changes. Organisational culture (in simple terms, the way that things are done – including the unwritten rules that influence behaviour and attitudes) can often dominate strategic aims. Some of the factors that influence culture include: leadership, deployment of resources, clarity of structure and processes, values and traditions. Success rests on leadership that overcomes professional silos and tribalism with good IT and access to targeted data – to harmonise strategy and culture.

There is little evidence of an equivalent attention to the ‘joining-up’ the proliferation of higher level non-local fragmented organisations reporting to or sponsored by the DHSC. The drive for integration ‘at the coal face’ does not appear to be reflected at the top of the NHS. There seems to be no unifying concept around which the integration can coalesce nationally. Without that there is a significant risk of regional ad hoc solutions that may not join-up across geographical/national boundaries. 

Understanding the complexity through ‘systemic processes’

We suggest that the entirety of the health and social care system may be better understood by identifying its existing ‘systemic processes’. In saying this we do not imply the need for yet another total re-organisation. Rather we are suggesting an approach that could help the NHS system evolve into a more ‘joined-up’, less fractured and more integrated ‘whole’ across regional boundaries.

First, we need to describe the concept of a ‘systemic process’. This is not a sequence of events as in a flow chart (11). Neither it is simply a series of actions towards an end. Rather it is a reconceptualization of process as a potential that drives a flow of change – just as the volts of a battery drive an electrical current or water pressure drives the flow of water. A systemic process captures what people actually do and how change happens. In human systems the potential is contained in answers to questions ‘why’ – purpose, aims and objectives. The change is contained in answers to questions ‘who, what, where, when’. The transformation of the flow from one ‘state of affairs’ to another is contained in answers to questions ‘how’. The aim is to capture a systemic process as delivering the right information ‘what’ (data as performance indicators, success criteria and shared care records), for the right reasons ‘why’ (purpose), to the right person or organisation ‘who’ (role, stakeholder), in the right way ‘where’ (context) and at the right time ‘when’. Systemic processes are wholes and parts at the same time. They are ‘being things’ that change through natural forces – living or inanimate. You and I are ‘being’ wholes as individuals and yet also parts of family and social groups. As individuals ‘wholes’ we are made of parts such as our muscular skeleton structure and digestive systems. We are as we are because the parts collaborate to form the whole – in other words we show ‘emergent’ characteristics (12).

Applying these ideas to the structure of organisations we see logically related layers of interacting and interdependent systemic processes. For the totality of health and social care services this should encompass all of the organisations in and related to the NHS, including local authority social care and private companies. The successful delivery of a systemic process emerges from the success of sets of processes in the next layer down. An important part of the identification of these lower processes is that their successes are jointly necessary and sufficient for the process above – there is an explicit logical relationship connecting defined success, in all of its manifestations, at every level. It is also important to note that the layers are not hierarchical power structures. Rather they are levels of abstraction from setting policy down to detailed implementation. The attributes of each and every systemic process can be grouped under the headings of why, how, who, what, where and when. At each level the attributes can be identified by multiple players in a common format and implemented on a secure intranet to be accessed by those given authority to do so. Each and every process should have one ‘process owner’ responsible for leading the players involved in that process in detecting and monitoring progress, identifying unintended consequences and agreeing the required actions to steer the process to success (i.e. meeting purpose/aims/objectives) and avoiding failure.

We see the NHS as an ecology of interdependent relations and interactions between systemic processes. Survival and continued success depend on being able to generate an internal ecology of adaptive decision-making at all levels. It may be helpful to imagine each systemic process as a jigsaw piece. The ‘process pieces’ are connected to other pieces not by their interlocking shape but by recording their ‘neighbouring’ connectivity as an attribute and by enacting that connectivity by sharing relevant authorised messages (composed by attributes why, how, who, what, where when).  Creating the ecology may then be achieved by identifying, at a particular level, neighbouring processes and building them into clusters – just as you might piece together areas of a jigsaw. Practically it is helpful to name each piece of the jigsaw, each systemic process, using the present participle or ‘ing’ form such as ‘Doing something’ – ‘Testing a blood sample’ or ‘Diagnosing a condition’. An advantage of the approach is that the essence of what people actually do and how change happens is being captured. Then by growing and connecting clusters of systemic processes eventually a ‘whole system’ of layered clusters emerges. What is more during this ‘piecing together’ or ‘cluster building process’ changes and improvements will suggest themselves. For example, points of strategic dissonance may become apparent. This happens when an organisation hangs on to the old ways of doing things for too long because of a disconnect between actions and intent or purpose at any given level. For more on the details of this approach see (13, 14) 

The organisations reporting to the DHSC seem to be contributing to seven high level systemic processes as shown in Table 1. There are, of course, many more organisations that cannot be included in the table.

Table 1: The 7 High Level Systemic Processes of Health and Social Care Services UK

ProcessExamplesRole/Comment
Commissioning care  NHS England, Scotland, Wales and Northern IrelandCommissions NHS services and is accountable to Ministers of Health 
Clinical Commissioning Groups (CCGs)Groups of GPs who purchase acute care on behalf of patients Accountable to NHS England.
Public Health England, Scotland, Wales & N IrelandArms-length Non-Departmental Public Bodies commissioning services to improve health & address inequalities Accountable to Ministers
Providing careGeneral Practitioners

Provision of primary care to patients under contract to Dept of Health & Social Care (DHSC)
NHS TrustsAcute Hospitals in England & Wales
NHS Foundation Trustsserving either a geographical area or a specialised function. (Do not yet have Foundation Trust status)
Supplying (including Special Health Authorities)NHS Business Services AuthoritySupplies business services  
NHS Blood and TransplantSupplies Blood and transplant organs.
NHS Digital
Supplies informatics 
NHS Resolution
Deals with legal claims  
NHS Counter Fraud AuthoritySpecial health authority fighting against fraud, bribery and corruption in the NHS.
RegulatingCare Quality CommissionRegulator for health and social care
Human Fertilisation and Embryology AuthorityRegulator of fertility treatment  
Human Tissue AuthorityRegulator of use of human tissue
+ 3 othersMedicines and Healthcare Products Regulatory Agency, Administration of Radioactive Substances Advisory Committee & National Data Guardian
AdvisingNational Institute for Health and Care ExcellencePurpose is to advise NHS on what constitutes good quality care.
Chief Medical OfficersReports to and advises Secretary State for DHSC plus other Government Departments
Chief Scientific OfficersEmployed by NHS England and leads healthcare science, advises all Government Departments & Chairs SAGE
Cabinet Office Briefing RoomsAdvises Cabinet on crisis and emergencies Accountable to Cabinet
Commission on Human MedicinesAdvises on safety & use of medical products
+ 18 others not identified here 
EducatingHealth Education England, Scotland, Wales & N IrelandPurpose is to support education and training An Arms-Length NDPB (Non-Departmental Public Body) Accountable to DHSC
Social Care Institute for ExcellenceIndependent agency that provides knowledge, evidence and accredited training for social care Accountable to Sponsors?
ResearchingNational Institute for Health ResearchReceives funds for research. Accountable to DHSC.

The success of each of these seven systemic processes depends on (and logically related to) the successes of many lower layers of systemic processesFor example, NHS England allocates budgets to Care Commissioning Groups (CCGs), and so a necessary but not sufficient condition for successful financial outcomes for NHS England depends on successful outcomes for the CCGs. Social care is shared between DHSC and the Ministry of Housing, Communities & Local Government. Advising is delegated to many disparate sources with the consequent risk of inconsistency. Educating is delegated to Health Education England and the Social Care Institute for Excellence which in turn relies on the Royal Colleges and Universities. Research is delegated to the National Institute for Health Research and the Medical Research Council and onto the Universities and research centres.  Clearly identifying all systemic sub-processes in the system is a considerable task. But it is a task that can and must be spread across all the players/actors involved in each and every process and captured on a national intranet.

We suggest that by structuring our thinking around these systemic interacting and interdependent processes we could achieve six objectives:

  1. Provide a simple overview of the whole organisational structure that everyone can understand and appreciate which can be traced right down to the detailed ‘caring for patient’ processes.
  2. Allow people to identify overlaps and interdependencies. For example, the 23 advisory organisations could possibly be streamlined to co-ordinate advice and avoid incongruity and inconsistency. Could the 8 regulating organisations be consolidated to avoid conflicting data and performance requirements?
  3. Enable caring for the sick, caring for public health and the vulnerable be under one ‘umbrella’ to avoid inconsistencies of policy over the longer time scales than politicians are typically in post.  
  4. Enable a common data structure for the why, how, who, what, where and when attributes of each systemic process – important to avoid different groups using different data structures that cannot easily be shared and for data exchange via an intranet, with appropriate permissions to sensitive data, and the monitoring of progress and interventions to steer processes towards success.
  5. Enable all those involved in delivering success for the NHS to identify how the necessary and sufficient conditions for the success of systemic processes at the ‘coal face’ feedback into success and deficiencies at higher policy levels
  6. Permit us to clarify 
    • pathways of precise terms of delegation and accountability – in particular;
    • how decision makers at all layers of the system delegate responsibilities down through the layers of processes – for example from government to NHS England and others to workers at the ‘coal face’ and ultimately to the patients;
    • how decision makers at all layers of the system are accountable up through the layers – for example from hospital ward care to Trust Boards, CCGs, NHS England and to government, parliament and ultimately to the public;
    • remove, reduce or ameliorate inconsistencies between policy and practice;
  7. improve adaptability of response to unintended consequences and future unknowns such as pandemics and potential impacts from climate change.

Conclusion

  1. The structure of Health and Social Care Services UK reporting to Government seems unhelpfully complex and opaque. We suggest a rationalisation using a ‘systems thinking bottom-up’ approach would be more likely to succeed than yet another top down reorganisation.
  2. Rethinking the interactions between existing organisations around ‘systemic processes’ could arguably bring considerable benefits including cost savings, better co-ordination, less ‘admin’ stress on staff at the ‘coal face’ and provide more organisational adaptability in an uncertain future. 
  3. Ultimately ‘systemic processes’ could help everyone deliver better patient care because that is the impelling purpose of the NHS.

References

  1. Timmins, N (2018) The World’s Biggest Quango: The first Five Years of NHS England, The King’s Fund & The Institute for Government, UK
  2. Hudson, A (2016) Simpler, Clearer, more Stable: Integrated accountability for integrated care, The Health Foundation, UK
  3. Powell, M (2016) Leadership in the NHS: Thoughts of a newcomer, The King’s Fund. https://www.kingsfund.org.uk/sites/default/files/field/field_publication_file/Thoughts_of_a_Newcomer.pdf (accessed June 2020)
  4. Dayan, M., Gardner, T., Kelly, E. & Ward, D. (2018) How good is the NHS? The Nuffield Trust. Available from: https://www.nuffieldtrust.org.uk/research/the-nhs-at-70-how-good-is-the-nhs (accessed June 2020)
  5. DHSC (2013) The Health and care systems explained. https://www.gov.uk/government/publications/the-health-and-care-system-explained/the-health-and-care-system-explained (accessed June 2020)
  6. NHS England (2019) Breaking down barriers to better health and care, March https://www.england.nhs.uk/wp-content/uploads/2019/04/breaking-down-barriers-to-better-health-and-care-march19.pdf (accessed June 2020)
  7. Bristol City Council (2018) Working with Us for Better Lives, https://www.bristol.gov.uk/documents/20182/2678414/Market+Position+Statement/bdd21e05-0a76-94ae-4094-246ad9eb5739 (accessed June 2020) 
  8. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry (2013), The Stationery Office, London https://webarchive.nationalarchives.gov.uk/20150407084949/http://www.midstaffspublicinquiry.com/sites/default/files/report/Executive%20summary.pdf (accessed August 2020)
  9. NHS England (2019) The NHS Long Term Plan https://www.longtermplan.nhs.uk/publication/nhs-long-term-plan/ (accessed June 2020)
  10. Goodwin N, Smith J (201) The Evidence Base for Integrated Care, The King’s Fund, Nuffield Trust, UK https://www.kingsfund.org.uk/sites/default/files/Evidence-base-integrated-care2.pdf  (accessed June 2020)
  11. NHS Institute for Innovation and Improvement (2005) Process mapping, analysis and redesign, Improvement Leaders Guide, UK https://www.england.nhs.uk/improvement-hub/wp-content/uploads/sites/44/2017/11/ILG-1.2-Process-Mapping-Analysis-and-Redesign.pdf (accessed June 2020)
  12. Wikipedia (2020), Emergence at https://en.wikipedia.org/wiki/Emergence
  13. Blockley D I, Godfrey P S (2018) Doing it Differently, ICE Publications, UK 
  14. Engineering Synergy at http://myengineeringsystems.co.uk/ 

Integrating Health and Social Care Services in NHS England

FIRST POSTED ON

Integrating Health and Social Care Services in NHS England

by Stirrat, GM1, Blockley D I2, Alexander K3, Phillips S4

Systems thinking helps us identify interconnected patterns so that we can anticipate and adapt to complex challenges.

1 Emeritus Professor of Obstetrics & Gynaecology, University of Bristol, UK.

2 Emeritus Professor of Civil Engineering, University of Bristol.

3 GP & Chair Bristol North and West Locality Leadership Group at Bristol, North Somerset and South Gloucestershire CCG, UK.

4 Alliance Director  (Interim)| Lambeth Living Well Network Alliance

Summary

A recent UK Government draft Heath White Paper follows the NHS England long term plan when it states that NHS England requires “a new framework that builds on changes already being made as well as building in the flexibility to support the system to tackle challenges of the future”. At present the structure of Health and Social Care Services UK reporting to Government seems unhelpfully complex and opaque. The purpose of this paper is to contribute to the building of a new framework by developing our previous suggestions that identifying and using ‘systemic processes’ can help facilitate the integration of England’s Health and Social Care services. We highlight some of the critical issues that are currently hindering integration and set out a new way of understanding the structure of NHS England through an ‘inside-out’ analysis of systemic processes. We describe and give three examples of existing systemic processes as ‘Consulting a patient’, ‘Enhancing a Single point of access’ -to mental health services and ‘Delivering health and social care services England’. Rethinking the interactions between existing organisations could arguably bring considerable benefits including cost savings, better co-ordination, less ‘admin’ stress on staff at the ‘coal face’ and provide more organisational adaptability in an uncertain future. Ultimately our suggestions are aimed at helping people to deliver better patient care – the impelling purpose of the NHS.

Purpose 

The purpose of this paper is to develop our suggestions made previously [4] that identifying and using ‘systemic processes’ can significantly facilitate the integration of NHS England Health and Social Care services. Specifically, our objectives are to:

  1. highlight some of the critical issues that are currently hindering integration,
  2. set out a new way of understanding the structure of NHS England and the way it works through an ‘inside-out’ analysis of systemic processes,
  3. describe and give examples of some NHS systemic processes,
  4. outline a strategy for identifying and improving them across the entire health and care community,
  5. reflect on the possible improved outcomes.

Issues that hinder integration

In a previous report [4] we have highlighted that the NHS is complex set of organizations which, for the most part, work quite well despite a myriad of sub systems. We noted that other authors have also referred to this complexity [5, 6, 7, 8] and, for example Powell [7] says “The leadership of the NHS seems fractured……a system under siege where success isn’t celebrated but failure is catastrophised”. We need “to build the confidence of the people who hold the problem.” Attempts to explain the complex systems are necessarily partial [9, 10, 11]. Good people can make a poor system work well but when pressures overwhelm them failure can be catastrophic [12].

In [4] we asked what are the incentives that will make integration work? Why should the many providers take responsibility for the total care of the whole population for probably less resource – when they have very little control over all the parts?

The pandemic has demonstrated to all that everyone in the NHS shares a strong common purpose of ‘caring for our patients’. But does that translate into more detailed shared purposes at the various levels of the sub-systems? We see at least 6 groups of issues that currently hinder integration.

  1. Resources – where adequate resources do not follow activity without waste through unforeseen issues. For example, the cost of drugs from commercial pharmacies (and thus to the NHS overall) is considerably greater than the same drugs from hospital pharmacies Hospitals may initiate medication for a patient for which they have a particular financial deal, but the primary carers are not part of the deal and the medication may become very expensive for them. When payment models do not encourage closer working around the needs of patients by sharing ‘pain and gain’ in an agreed manner then integration will be harder to achieve.
  2. Organisations – the various parties to Integrated Care have to be aware that their potential partners may be fearful of extra work and responsibility being ‘dumped’ onto them. Sometimes, for example, individual GPs may be reluctant to hold challenging risks that hospital staff, with their more collective responsibility, may not be exposed to. If a patient dies during hospital treatment after a late diagnosis of bowel cancer caused at least partly through unintended delays (in the systems and perhaps also by the behaviour of the patient) the GP may find himself/herself in the spotlight of blame by relatives, for not diagnosing quickly enough. Co-operating organisations in the public and private sectors may have different bureaucratic constraints and work to different priorities and time scales as they attempt to adjust with agility to rapid changes. Organisational culture (in simple terms, the way that things are done – including the unwritten rules that influence behaviour and attitudes) can often dominate strategic aims. Some of the factors that influence culture include leadership, deployment of resources, clarity of structure and processes, values and traditions. Success rests on leadership that overcomes professional silos and tribalism with good IT and access to targeted data – to harmonise strategy and culture.
  3. Targets that are set top down without adequate consultation can lead to perverse behaviour. For example, waiting list targets resulted in requests for investigations and letters of referral being hidden from the doctors so that the patient was not put on an already “over target” waiting list. During the pandemic urgent cases were delayed because some doctors were not permitted to see the requests. Doctors and other staff were being told to use particular “pathways” and follow “guidelines”. Because the hospitals will not defend the staff if they stray from the guidelines then they effectively become directives. This leads to ossification of thought and procedure.
  4. Leadership – top-down control of the NHS is seen by many to be inefficient and has hindered much of its work – particularly during the pandemic. Nevertheless, it can be effective when the main task is relatively simple, for example immunisation (once all the vaccine is available). However, diagnosis and treatment processes for individual patients are not simple – they are beyond the abilities of top-down management to control. Leadership cannot come from managers who do not understand or who are not qualified to do the job. The old system of consultant firms in the hospitals worked because the person in charge knew what they were doing. Likewise, the sisters on the wards and the matron in the hospital were a good combination of knowledge and experience. During the pandemic doctors in the NHS were told not to use various drugs that they might have wished to repurpose – such as ivermectin, hydroxychloroquine and dexamethasone. Until double blind trials had been undertaken these drugs were forbidden from use. This was seen by many as an unhelpful interruption of clinical freedom with consequent harm to patients.
  5. Feedback and Learning – a consequence of top-down control is that staff are not encouraged to put their ideas forward. Some live-in-fear of their jobs if they blow the whistle to anybody other than their line manager – the very person that they often wish to report. Organisational learning requires more freedom of expression.
  6. Integrating at all levels – there is little evidence of an equivalent attention to ‘joining-up’ the proliferation of higher level non-local and fragmented organisations reporting to or sponsored by the DHSC. The drive for integration ‘at the coal face’ does not appear to be reflected at the top of the NHS. There seems to be no unifying concept around which the integration can coalesce nationally. Without that there is a significant risk of regional ad hoc solutions that may not join-up across geographical/national boundaries.

Systemic Processes

In [4] we suggested that the entirety of the health and social care system may be better understood by identifying its existing ‘systemic processes’. The purpose would be to evolve a more ‘joined-up’, less fractured and more integrated ‘whole’ across regional boundaries.

A systemic process [17] is not a sequence of events as in a flow chart [14]. Neither it is simply a series of actions towards an end. Rather it is a reconceptualization of process as a potential that drives a flow of change – just as the volts of a battery drive an electrical current or water pressure drives the flow of water. A systemic process captures why and what people actually do and how change happens.

The primary innovative characteristic of systemic processes is that they are structurally self-similar – just like the pieces of a jigsaw. Process ‘pieces’ form clusters and clusters of clusters which we can think of as layers of parts of the whole. The processes are, of course unlike a jigsaw, dynamic and ever changing. Systemic ‘jigsaw’ processes capture that change. Change derives from a potential that drives a flow (or dually from flow that creates potential). In classical physical systems potential is electromagnetic or gravitational and flow is movement. For example, voltage, current and velocity, force. In human affairs the potential is contained in answers to questions ‘why’ – purpose, aims and objectives. The change is contained in answers to questions ‘who, what, where, when’. The transformation of the flow from one ‘state of affairs’ to another is contained in answers to questions ‘how’. The aim is to model the right information ‘what’ (data as performance indicators, success criteria and shared care records), for the right reasons ‘why’ (purpose), to the right person or organisation ‘who’ (role, stakeholder), in the right way ‘where’ (context) and at the right time ‘when’.

Systemic processes are wholes and parts at the same time. They are ‘being things’ that change through natural forces – living or inanimate. You and I are ‘being’ wholes as individuals and yet also parts of family and social groups. As individuals ‘wholes’ we are made of parts such as our muscular skeleton structure and digestive systems. We are as we are because the parts collaborate to form the whole – in other words we show ‘emergent’ characteristics [15]. We see the NHS as an ecology of interdependent relations and interactions the behaviour and characteristics of which emerge from interactions between systemic processes – just as a whole jigsaw picture emerges from the interlocking pieces of a jigsaw

The successful delivery of a systemic process derives from the success of sets of processes in the adjacent layers. An important part of the identification of lower sub-system processes is that their successes are jointly necessary and sufficient for the process above – there is an explicit logical relationship connecting defined success, in all of its manifestations, at every level. It is also important to note that the layers are not hierarchical power structures. Rather they are levels of abstraction from setting policy down to detailed implementation. The attributes of each systemic process can be grouped under the headings of why, how, who, what, where and when. At each level the attributes can be identified (by multiple players) in a common format. These can then be implemented on a secure intranet to be accessed by those given authority to do so. Every process should have one ‘process owner’ responsible for leading the players involved in that process to detect and monitor progress, to identify potential unintended consequences and agree the required actions to steer the process to success. Success is defined as meeting purpose/aims/objectives and avoiding failure.

Practically we find it helpful to name a systemic process using the present participle or ‘ing’ form. For example, ‘Doing something’ – ‘Testing a blood sample’ or ‘Diagnosing a condition’. During the ‘piecing together’ or the ‘building of clusters’ systemic processes, changes and improvements will suggest themselves. For example, points of strategic dissonance may become apparent. This happens when an organisation hangs on to the old ways of doing things for too long because of a disconnect between actions and intent or purpose at any given level. For more on the details of this approach see [16, 17] 

A Possible Strategy

In [4] we suggest that the key to driving change should be ‘influencing from the bottom up’. Top-down centralisation has proven ineffective [1]. Ham [18] writes ‘The overcentralised management of the pandemic was undoubtedly a factor in the failure to learn more effectively. Boris Johnson, the UK prime minister, and a small number of Cabinet members were visible in their leadership and appeared reluctant to draw on the expertise and intelligence of the devolved administrations, regional, and local government leaders. Opportunities for learning were lost, contributing to the mistakes that were made’. Policy decisions for change have to make sense to those ‘on the front line’ if they are to respond positively. That response is also conditional on the need for change to evolve up and down through the entire system. Given that policy makers and staff need to see how their decisions spread or percolate through the organisation we now propose that rather than describing the change process as ‘bottom-up’ we should regard it as being ‘inside-out’. By that we mean that change should be initiated at all levels of the system. The first stage of that change process is to identify the systemic processes at that level. Then by discussing the overlaps and interactions with ‘neighbouring’ systemic processes the people involved (led by the process owners) can adjust or adapt the systemic processes to fit. It is as if we are reshaping our jigsaw pieces so that they fit and interlock. These kinds of adapting change processes would not be ‘one-off’ and static. Rather they are dynamic systemic learningprocesses and an integral part of an ongoing improvement model. Organisational adaptability through feedback and learning is a key to success as successful change is shared and spreads out from many different points across the clusters to the whole organisation.

A strategy such as this will require high level policy makers and those allocating resources to also adapt and integrate. That can be difficult for political leaders who may be criticised by media and public alike for changing their policies. There are two solutions to this dilemma. One is to declare that running the NHS is no longer a political matter. The other is to take the opportunity given to us by the pandemic to initiate a different approach to openness to change when faced with a future full of uncertainty – with many unknown unknowns. This would require considerable political skill to persuade everyone in an accountable democratic society that certainty is simply no longer available in complex systems. Changing one’s mind is currently seen as a weakness and not, as it should be, a strength when fully justified by dependable evidence. Leaders will need to learn and adapt to facilitate the changes that will incentivise all those affected by their decisions to work differently. The strategy has also to apply to the totality of health and social care services of the organisations in and related to NHS England, including local authority social care and private companies.

In summary we suggest that the strategy to implement the laudable aims set out in the WP [1] should be to understand and motivate – not by imposing top-down targets but by ‘inside-out’ growing of clusters of understanding with commensurate motivation to ‘join up processes at multiple points and levels whether at the top, middle or on the front line.

Three Examples

We noted in [4] that the organisations reporting to the DHSC seem to be contributing to seven high level systemic processes. They are Commissioning Care, Providing Care, Supplying, Regulating, Advising, Educating and Researching. They will form our third example – see below. First, we present two lower level examples with a little detail (but still incomplete for space reasons) for illustration.

The method (a how question/attribute) we use to identify systemic processes begins with setting down, as a Mind Map [13] what people actually do. Figure 1a represents the systemic process of a GP ‘Consulting with a Patient’. Necessarily, as we have said, the diagram is incomplete. However, the main sub-processes shown are ‘Reviewing the patient record’, ‘Putting patient at ease’, ‘Diagnosing’ and ‘Managing further care’. The test for deciding on the nature of the sub-processes is to ask the question: ‘Would the successes of the sub-processes be jointly necessary and sufficient for the success of the process? Of course, each of these sub-processes has sub-sub-processes as shown. However, the sub -processes are self-similar in structure – they are each wholes and parts at the same time – which is why some people call them holons [16, 17]. A holon sub-process of ‘Diagnosing’ is ‘Requesting tests’ and a holon sub-process of that in turn is ‘Testing blood’ as highlighted in yellow. Each systemic process holon has a set of attributes gathered under the headings of why, how, who, what, where and when. In Figure 1a these are given in an abbreviated form. In a fully implemented Mind Map the attribute descriptions could be fuller and hold hypertext links to documents held on an intranet. For example, the (who) patient attribute could link to a Share Care Record or similar patient file. The {who) GP attribute could link to a GP Practice website of that GP. A link from the why attribute could link to present or previous symptoms. The Figure cannot show all attributes for all processes even as abbreviated. A further example shown in the diagram is that of ‘Prescribing’ with possible attributes also as shown. Figure 1b is a continuation of Figure 1a for the systemic process of

‘Testing Blood’. Subprocesses of ‘Making an appointment’, ‘Checking in’ etc. are shown again with abbreviated attributes. Of course, these processes are familiar and normally

well managed by GPs which is why we have given them as illustrative examples that relate to something familar.

Figure 2a is less familiar and more challenging. It shows an ongoing adjustment of systemic processes in the integrated Alliance Network of the fourth author. The process is ‘Enabling a Single Point of Access’ for mental health patients. Currently there are multiple points of access and these need to be integrated.

The processes highlighted in yellow of ‘Improving web access’ and Redesigning forms’ and Enhancing Teams are shown in Figure 2b. Clearly there are more processes and attributes to identify – for example ‘Consulting all involved’ and Checking fitness for purpose. Again a full description is not possible in this paper and work is ongoing.

A third example shown in Figure 3a is even more challenging. It is the top-level process of ‘Delivering Health and Social Care England’ and has the 7 sub-processes identified at the head of this section and in [4]. Sub-processes included are ‘Determining policy, ‘Allocating Resources’ and Integrating’ (highlighted in yellow). These are continued in Figure 3b together with ‘Regulating’, and ‘Advising’. Again, in each case we identify the attributes shown in abbreviated form for only some of the processes.

Clearly it is impossible here to capture the full richness of the processes and their attributes. That task can be made viable through adequate software operated by multiple players who ‘own’ each individual systemic process on multiple servers connected by an intranet. In the first instance only a simple mind Mapping tool is required but a full implementation will require adequate software with built in permissions and safeguards.

Improving Outcomes

The approach described could:

  1. provide an overview of the whole organisational structure that
  2. everyone can understand and appreciate which can be traced right down from the top level policy making down to the detailed ‘caring for patient’ processes;
  3. allow people to identify overlaps and interdependencies. For example, advisory organisations could possibly be streamlined to co-ordinate advice and avoid incongruity and inconsistency;
  4. enable caring for the sick, caring for public health and the vulnerable be under one ‘umbrella’ to avoid inconsistencies of policy over the longer time scales than politicians are typically in post;
  5. enable a common data structure for the why, how, who, what, where and when attributes of each systemic process – important to avoid different groups using different data structures that cannot easily be shared and for data exchange via an intranet, with appropriate permissions to sensitive data, and the monitoring of progress and interventions to steer processes towards success;
  6. enable all those involved in delivering success for the NHS to identify how the necessary and sufficient conditions for the success of systemic processes at the ‘coal face’ feedback into success and deficiencies at higher policy levels;
  7. :;permit us to clarify; 
    • pathways of precise terms of delegation and accountability – in particular;
    • how decision makers at all layers of the system delegate responsibilities down through the layers of processes – for example from government to NHS England and others to workers at the ‘coal face’ and ultimately to the patients;
    • how decision makers at all layers of the system are accountable up through the layers – for example from hospital ward care to Trust Boards, CCGs, NHS England and to government, parliament and ultimately to the public;
    • remove, reduce or ameliorate inconsistencies between policy and practice;
    • improve adaptability of response to unintended consequences and future unknowns such as pandemics and potential impacts from climate change.

Conclusions

  1. The structure of Health and Social Care Services UK reporting to Government seems unhelpfully complex and opaque. We suggest a rationalisation using a ‘systems thinking bottom-up’ approach would be more likely to succeed than yet another top-down reorganisation.
  2. Rethinking the interactions between existing organisations around ‘systemic processes’ could arguably bring considerable benefits including cost savings, better co-ordination, less ‘admin’ stress on staff at the ‘coal face’ and provide more organisational adaptability in an uncertain future. 
  3. Ultimately ‘systemic processes’ could help everyone deliver better patient care because that is the impelling purpose of the NHS.

References

  1. Integration and Innovation: working together to improve health and social care for all [working title]. The Department of Health and Social Care’s legislative proposals for a Health and Care Bill. (2021, accessed 24th May 2021) http://www.healthpolicyinsight.com/?q=node%2F1699
  2. NHS England (2019) The NHS Long Term Plan https://www.longtermplan.nhs.uk/publication/nhs-long-term-plan/  (accessed June 2020)
  3. O’Donnell G, Begg H (2020) Far From Well: The UK since Covid-19, and learning to follow the science, Fiscal Studies Vol 41 No 4, pp761-804 See https://onlinelibrary.wiley.com/doi/epdf/10.1111/1475-5890.12253 (last accessed Feb 2021)
  4. Stirrat, GM, Blockley, DI, Alexander K, Phillips S (2020 The Structure of Health and Social Care Services UK – A thought piece at http://myengineeringsystems.co.uk/blog/
  5. Timmins, N. The World’s Biggest Quango: The first Five Years of NHS England, (2018) The King’s Fund & The Institute for Government, UK
  6. Hudson, A. Simpler, Clearer, more Stable: Integrated accountability for integrated care, (2016) The Health Foundation, UK
  7. Powell, M. Leadership in the NHS: Thoughts of a newcomer, (2016) The King’s Fund. https://www.kingsfund.org.uk/sites/default/files/field/field_publication_file/Thoughts_of_a_Newcomer.pdf  (accessed June 2020)
  8. Dayan, M., Gardner, T., Kelly, E. & Ward, D. How good is the NHS? (2018) The Nuffield Trust. Available from: https://www.nuffieldtrust.org.uk/research/the-nhs-at-70-how-good-is-the-nhs  (accessed June 2020)
  9. DHSC (2013) The Health and care systems explained. https://www.gov.uk/government/publications/the-health-and-care-system-explained/the-health-and-care-system-explained  (accessed June 2020)
  10. NHS England (2019) Breaking down barriers to better health and care, March https://www.england.nhs.uk/wp-content/uploads/2019/04/breaking-down-barriers-to-better-health-and-care-march19.pdf  (accessed June 2020)
  11. Bristol City Council. Working with Us for Better Lives, (2018) https://www.bristol.gov.uk/documents/20182/2678414/Market+Position+Statement/bdd21e05-0a76-94ae-4094-246ad9eb5739  (accessed June 2020)
  12. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry (2013), The Stationery Office, London https://webarchive.nationalarchives.gov.uk/20150407084949/http://www.midstaffspublicinquiry.com/sites/default/files/report/Executive%20summary.pdf  (accessed August 2020)
  13. Buzan T. Mind Map Mastery, (2018 New Edition), Watkins Publishing Ltd, UK See also https://miro.com/mind-map/
  14. NHS Institute for Innovation and Improvement; Process mapping, analysis and redesign, (2005) Improvement Leaders Guide, UK https://www.england.nhs.uk/improvement-hub/wp-content/uploads/sites/44/2017/11/ILG-1.2-Process-Mapping-Analysis-and-Redesign.pdf  (accessed June 2020)
  15. Wikipedia. Emergence. https://en.wikipedia.org/wiki/Emergence (accessed May 2021)
  16. Blockley D I, Godfrey P S. Doing it Differently, (2018) ICE Publications, UK
  17. Engineering Synergy at http://myengineeringsystems.co.uk/  (accessed May 2021)
  18. Ham C. The UK’s poor record on covid-19 is a failure of policy learning, (2021) The BMJ Opinion Blog, Jan 26th See https://blogs.bmj.com/bmj/2021/01/26/chris-ham-the-united-kingdoms-poor-record-on-covid-19-is-a-failure-of-policy-learning/ (accessed Feb 2021)

Five axioms for systems thinking

AXIOM: A1 of impelling purpose

WHAT: A system, discriminated from its surroundings, is a set of models of our reality created by people for reasons which give meaning to and determine the purpose of the system

WHY: We identify a system because we are curious and want to understand (science), or wish to modify the world around us to improve the human condition (engineering, medicine) or express our emotions (art, religion). Our purpose in identifying the system is our highest goal. That goal provides us with meaning and motivates us to put in effort to add value. Identifying purpose draws on our emotional intelligence to help us reflect on and understand WHY we think and act, what we value and how we can improve how we work together.

Axiom: A2 of appropriate layers

WHAT: Systems models are holons i.e. they are both parts and wholes and hence are layered according to levels of detail and abstraction.

WHY: Thinking of a system in layers helps us cope with size, scale and dimensionality. Models of holons at different levels can be different but still be inter- dependent.

AXIOM: A3 of complex interdependency

WHAT: Holons are connected to certain other holons with which they exchange messages.

WHY: In a complex world everything seems to be interconnected and hence inter- dependent. Outcomes are often unintended. We can simplify by focussing on local connections in a manner similar to the internet of connected computers.

WHAT: A4 of the ubiquity of change

WHAT: Systems models change at varying rates but none are permanent and invariable. Some changes may be unforeseen. Some changes may be small but some may be ‘revolutionary paradigm shifts’ involving new ways of thinking.

WHY: Most of us think of matter or substance as the permanent stuff of which something is composed and form as the way that stuff is put together. Interestingly eastern traditions emphasise flow and change as things come into being and cease to be. This view ties in with the spontaneous random fluctuations of energy in a quantum space.

AXIOM: A5 of evolutionary learning

WHAT: Complex systems often cannot be ‘solved’ rather they have to be managed to desirable outcomes.

WHY: Learning reduces uncertainty. Learning is too often seen as rote learning of facts and techniques and ‘how to do something’. Learning to learn or ‘learning power’ has much to offer in finding our way through uncertainty.

Corollaries to axioms

Corollary: C1 regarding reality

What: Reality is actual but only accessible through human cognition

Why: We need to make explicit the notion that models are a representation of reality not the reality itself.

Corollary: C2 regarding worldviews

What: Systems models are created through the ‘spectacles’ of a set of worldviews.

Why: If models are a representation of our reality and not the reality itself we can think of the models as filters or spectacles through which we must look to see our reality.

Corollary: C3 regarding understanding

What: We can only control effectively what we understand.

Why: Perhaps this is self-evident but each of us understands in a different way. That is why we need to collaborate in teams to share understanding in different ways.

Corollary: C4 regarding embedment

What: Physical natural or artificial systems are ‘hard’ systems. Both are embedded in ‘soft’ people and social systems. Hard systems are objective whereas soft systems are subjective and intersubjective.

Why: This aspect of rigour sounds unduly ‘academic’ esoteric and remote from practice. However it underpins our understanding of uncertainty and the way we learn our way through it and so is important.

Corollary: C5 regarding functions

What: The purpose of a hard system is a function. The function of an artificial system is decided by us – it is man-made. A model of a natural system helps us understand the behaviour of a part of a reality. As a consequence we may ascribe a function to it.

Why: The function of man-made artefacts is a familiar concept to most of us. However the function of a natural system can be a source of confusion if we do not explicitly recognise that that function is ascribed by us through our models.

Corollary: C6 regarding fitness for purpose.

What: Hard systems are not universally true i.e. true in all contexts and circumstances. Rather they are dependably fit for purpose to a degree in a context. Dependability corresponds to our common-sense notion of truth or fact. Statements deduced from dependable models correspond to reality in a particular context or situation.

Why: Models, by their very nature are partial representations of our reality. Consequently they are incomplete and are only dependable in the context to which they are relevant.

Corollary: C7 regarding duty of care

What: The dependability of a systems model requires those people involved to exercise a proper duty of care, to test the model to an appropriately dependable level based on evidence, to demonstrate sufficient competence and integrity and to be transparent about their values.

Why: Dependability has to be judged based on the testing of a model. The tests have to be as searching and rigorous as appropriate for the problem. Practical rigour requires diligence and duty of care that leaves no stone unturned with no sloppy or slip-shod thinking.

Corollary: C8 regarding subsidiarity

What: The Principle of Subsidiarity (as set out in the Treaty of Lisbon 2007 [Eur-Lex 2016] is that systems models should be created at the lowest practical level consistent with delivering their purpose.

Why: The idea here is that decisions should be as local as possible because that is where the problems are best understood.

Corollary: C9 regarding emergence

What: Holons have emergent properties. These are attributes that apply at only one or more layers as a result of interactions between holons at lower levels that do not exhibit these attributes.

Why: Emergent properties arise or come forth from inter- dependencies at more detailed layers. They are more common than many people realise. For example the pressure of a gas is the result of the buzzing around of gas molecules at a lower level of description. The human ability to walk and talk emerges from the co-operation our many subsystems.

Corollary: C10 regarding connectivity

What: Connections create relationships and patterns of relationships.

Why: In Chinese thought all things are interconnected. The internet is a web of interconnected computers. The brain is a network of highly interconnected neurones. Our infrastructure is an interconnected network of facilities.

Corollary: C11 regarding stakeholder interests

What: There is an increased chance of success if stakeholder interests are aligned.

Why: Common sense tells us that we are more likely to be successful if we ‘pull together’ as oarsmen do in a boat race. We are more likely to pull together if we have a common purpose.

Corollary: C12 regarding processes

What: Systems models are processes.

Why: If we accept that change is ubiquitous then everything is a process. Why is this helpful? Because it shifts our focus and leads to a new understanding of change. It provides us with a means of integrating many ideas and enables us to create simplicity in complexity. Unsurprisingly perhaps many people find it hard to think of a table as a process since they cannot reject the idea that it is a thing composed of ‘stuff’ – such as wood. It may help to think about the life cycle of the table from raw material, through design and making to usage, maintenance and disposal to see the table is constantly being and becoming. Everything exists in the process of time.

Corollary: C13 regarding feedback

What: Processes may be loopy involving feedback and feedforward.

Why: Most engineers are familiar with the ideas of feedback and feedforward in hard systems. They apply equally in soft systems where they are often called loops of influence.

Corollary: C14 regarding leadership

What: Managing a process to a desirable outcome requires appropriate leadership and collaborative learning.

Why: Traditional learning is something we do to acquire knowledge that may be useful to us in some way. We tend to think via a prescribed framework which promotes a strong distinction between the academic and the vocational which devalues practical wisdom. To change, people need vision. Leadership is about engaging with that vision then building and coaching teams to achieve it – and it applies at all layers.

Corollary: C15 regarding outcomes

What: Unexpected and unintended changes may result in future consequences that may be opportunities to create benefit or hazards that threaten damage.

Why: We must protect ourselves from the harmful effects of unintended consequences that is why we need to be alert to the possibility of ‘incubating failure’. Just as importantly we must take advantage of possible benefits from unintended consequences – they lead to new opportunities and genuine innovation.

Corollary: C16 regarding the six ‘honest serving men’

What: Attributes of processes can be classified into the categories of why, how, who, what, where and when. ‘Why’ expresses the purpose which drives the ‘how’ of the methods, transformations and procedures of change in the descriptors and measures of people (who), performance indicators and systems variables including impedance (what), contextual influences (where) and measures of time (when). One way of expressing this is ‘why = how (who, what, where, when)’.

Why: Rudyard Kipling’s six good men are generic. They provide the means to capture, model, control and improve processes in systems.

Corollary: C17 regarding ‘trade-offs’

What: Trade-off decisions may be required when two or more output variables are negatively related. For example the trade-off between lower NOx and lower CO2 pollution in exhaust gas recirculation of a diesel engine. A balance of disadvantages may have to be struck. For complex systems, the balance between the multiplicities of variables becomes even more difficult.

Why: Axiom 5 states that complex systems often cannot be ‘solved’ rather they have to be managed to desirable outcomes. One of the means of managing trade-offs is through evolutionary learning recognising that many trade-offs are non-linear and step changes may be created by innovation.

Seven Principles

Principle: P1 of fitness for purpose

The systems models should be of appropriate quality as to be fit for purpose. But check that the purposes include all purposes i.e. not just function but risk, safety, affordability, sustainability, resilience etc.

Principle: P2 of proper duty of care

A duty of care is a legal obligation to act to a reasonable standard. Not to do so is negligent. All players should have clearly defined appropriate responsibilities and be clearly accountable. Are the players competent to carry out their roles and functions?

Principle: P3 of integrating people, purposes, products, old processes to create better performances

Do the processes include:
a) Firming the foundations FF by:
FF Design – being curious, open minded, identifying issues,
FF Build – developing the vision, clarifying values,
FF Operation – reflecting, learning, understanding the models,
b) Strengthening the structures by:
SS Design – collaborating, creating relationships, defining responsibilities,
SS Build – building networks, getting advice, solving problems,
SS Operation – improving relationships, adapting,
c) Working well by:
WW Design – learning from evidence,
WW Build – being resourceful & resilient in making decisions,
WW Operation – creating and enhancing quality?

Principle: P4 of sufficient structure

Are the systems model processes:
sufficiently discriminatory – all terms are as distinct and as clear as required,
sufficiently consistent – the content of the model are compatible and not self-contradictory,
sufficiently cohesive – the content of the model are integrated so that it all hangs together,
sufficiently concordant – conflicts and differences of all kinds are identified with procedures to resolve or manage them?

Principle: P5 of sufficient content

Are the systems models:
balanced between contrasting pairs such as detail and overview, risk and opportunity etc.,
sufficient for the stated purposes i.e. contain the requisite detail,
necessary – i.e. do they contain all that must be contained;
locally important,
of requisite variety – content is widely applicable and appropriately diverse?

Principle: P6 of control

Are the processes:
being guided towards desirable outcomes
such that risks are being managed
from the uncertainties being identified and monitored
and the lessons being learned?

Principle: P7 of evidence

Evidence is an attribute of the ‘what’ of a process:
evidence is gathered both quantitatively and qualitatively such that timely decisions and interventions are made to keep processes on track towards purposeful outcomes

Systemic Processes

Systemic processes are central to my approach to systems thinking.

Everything – every object – exists in time. Therefore every object has a life cycle and is a process. But the process is set in the context of a system containing other connected processes – some at higher and some at lower levels of definition. We capture those processes using mind maps to create a processs model.

All processes have attributes that we characterise using why, how, who, what, where, when.

 

Why attributes include all expressions of sucess as purpose including vision, mission, objectives and targets.

How attributes include all models of transformations of inputs to outputs, including physical systems (scientific) models, method statements, systems models, resources requirements

Who attributes include all of the people involved – the players or actors- and their roles and functions. In particular the process owner is the leader responsible for the delivery of success to the client(s) and keeping all stakeholders informed of progress.

What attributes include all expressions (models) of structure and form, state variables, performance indicators, inputs and outputs as well as Italian Flags or any other summary measures of progress or performance.

Where attributes include definitions of systems boundaries, contextual assumptions as well as physical site or place as location.

When attributes include durations and times such as earliest/latest start, earliest/latest finish, float from e.g. a critical path network analysis.

These variables manifest tyemselves in physical hard systems as in the table below.

Physical hard System Potential

(Why)

Flow

(What)

Impedance

(What)

Electricity Volts Amps Resistance, capacitance, inductance
Mechanics Velocity Force Damping, mass, flexibility
Water pipes Pressure head Flow Drag, open tanks/reservoirs, closed tank?
Traffic Need Flow On-street parking, off-street parking, route changes
‘Soft’ Why – (Who, Ambiguity/conflict,
creative What, capacity to perform,
tension Where,

When)

capacity to adapt/innovate

We can compare some hard system derivatives with speculative soft ones as in table below

Concept Hard – e.g. Mechanics Soft – suggested equivalent
Across Variable: Potential V

(Why)

Velocity Motivation: The rate of change of willpower (self-control): volition for purposeful effective action
Through Variable: Flow q

(Who, What)

Force Rate of external change through action
Integrated V: x = ∫Vdt Displacement Will: strength of purpose
Differentiated V: y = dV/dt Acceleration Increasing motivation
Integrated q: z = ∫qdt Momentum Change
Power P = Vq Power The capacity to influence change: authority, means, competence, capability, proficiency
Work W = ∫qdx Effort Effort
Energy E = ∫Pdt Capacity for work Capacity for work
Capacitance Mass, inertia Ambition, aspiration, resoluteness as stored willpower
Inductance Flexibility Adaptability to change
Resistance Damping Prevarication and wasted effort

To most people a handbag is an object with ‘substance’ (the materials with which it was made) and form with some sense of permanence.  To a systems thinker of the type we are describing here a handbag is a process that plays a role in other processes.  Put at its simplest, the handbag has a life cycle in which it was conceived, designed, made and used and eventually disposed of.  Whatever it was designed to do (function) and whatever form it takes (e.g. as a fashion item) it is unlikely that it was designed to carry an abandoned baby as in the play ‘The Importance of Being Ernest’ by Oscar Wilde premiered in 1895 .  Nevertheless in that role or function the handbag played a crucial part in keeping the infant Jack safe and, as revealed as the play unfolds. The handbag was important in his being abandoned, found and rescued and taken into a good family upbringing.

To understand what we mean here when we refer to a process we need to reject all existing preconceptions of what constitutes a process and to create a new and all encompassing definition.  So a new process is not just the how of doing as it is often used. It is not just an input being transformed to an output, or a Gantt bar chart, a recipe, a flowchart, a network of an IDEF0 diagram – it is all of these and more.

It is our contention that we can capture everything that we know (model) in processes.  A handbag, a kettle, a building, an aeroplane, a power station, an airport terminal and all living things, including human beings, can all be represented as processes.  In this way a systems thinker recognises from the start that everything has life cycle. But it is a life cycle that is set in the context of a system containing other processes – some at higher and some at lower levels of definition.

Why do we need holons?

WHY do we need holons?

The moon is a whole but also part of the solar system. Moonlight is an emergent property of the relationship between it, the sun and the earth

(more…)

Start with a Mind Map

Tony Buzan invented mind maps as a simple tool for thinking through the issues relevant to a problem.

We use them to develop our process models. The technique is actually very simple. Let’s illustrate it here by writing a mind map for becoming a systems thinker based on our axioms. Our top level process –  the process we want to execute is Becoming a systems thinker. So we write that proposition at the centre of the diagram. If we think that our axioms are together logically necessary and sufficient for success in the process then they can be added to the diagram as below.

Notice that in every case we use the ‘ing’ form  – the present participle to give a sense of process and not just simply a statement or proposition.

Next we show an example of a mind map to develop the processes around the maintenance of a physical system like a highway.

 

 

The diagram is for illustration only and is not comprehensive as would be required in practice. Next for each process in the mind map we begin to write down the six important parameters of a process – why, how, who, what, where and when as illustrated above in the table.

To help you begin to see how mind map can be used quite generally across a range of systems below is an illustration of a hierarchy of layers of self-similar process loops as described on our process pages. They are Designing (D), Building (B) and Operating (O).

 

 

But these engineering terms (designing, building and operating) can be interpreted more generally and within different contexts. For example in the scientific method we see the conceptual equivalent to designing as conjecturing i.e. creating ideas. In engineering design is creating a new product/system whereas in science creating is conjecturing a new hypothesis or theory. In engineering building is the making of the idea into a physical reality that will be tested as it is developed and then used in practice. In science a hypothesis is tested in an experiment or against some specific criteria to see if it has some confirmation in reality. In engineering operating is using the product/system and finding out if it workd well. In science operating is the wider testing by many people together with its use in practice to find out how well it confirms explanations or predicts new results. Here the theory is evaluated and confirming or falsified. In both engineering and science much is learned from all three phases.

So thinking of the process of engineering designing much more generally we can suggest that in other contexts it is equivalent to sensing, perceiving, specifying, planning, conjecturing or wondering.

Likewise building is equivalent to manufacturing, thinking, reflecting, establishing, making, writing and testing.

And operating is equivalent to acting, using, doing, running, evaluating, experiencing or learning.

In this way we can begin to see how to integrate ideas and systems by synthesising similarities rather than analysing differences.

Practical wisdom and why we need to value it

“Some people who do not possess theoretical knowledge are more effective in action (especially if they are experienced) than others who do possess it.”

Aristotle was referring, in his Nicomachean Ethics, to an attribute called practical wisdom – a quality that many modern engineers have – but our western intellectual tradition has completely lost sight of. I will describe briefly what Aristotle wrote about practical wisdom, argue for its recognition and celebration and state that we need consciously to utilise it as we face up to the uncertainties inherent in the engineering challenges of climate change.

Necessarily what follows is a simplified account of complex and profound ideas. Aristotle saw five ways of arriving at the truth – he called them art (ars, techne), science (episteme), intuition (nous), wisdom (sophia), and practical wisdom – sometimes translated as prudence (phronesis). Ars or techne (from which we get the words art and technical, technique and technology) was concerned with production but not action. Art had a productive state, truly reasoned, with an end (i.e. a product) other than itself (e.g. a building). It was not just a set of activities and skills of craftsman but included the arts of the mind and what we would now call the fine arts. The Greeks did not distinguish the fine arts as the work of an inspired individual – that came only after the Renaissance. So techne as the modern idea of mere technique or rule-following was only one part of what Aristotle was referring to.

Episteme (from which we get the word epistemology or knowledge) was of necessity and eternal; it is knowledge that cannot come into being or cease to be; it is demonstrable and teachable and depends on first principles. Later, when combined with Christianity, episteme as eternal, universal, context-free knowledge has profoundly influenced western thought and is at the heart of debates between science and religion. Intuition or nous was a state of mind that apprehends these first principles and we could think of it as our modern notion of intelligence or intellect. Wisdom or sophia was the most finished form of knowledge – a combination of nous and episteme.

Aristotle thought there were two kinds of virtues, the intellectual and the moral. Practical wisdom or phronesis was an intellectual virtue of perceiving and understanding in effective ways and acting benevolently and beneficently. It was not an art and necessarily involved ethics, not static but always changing, individual but also social and cultural. As an illustration of the quotation at the head of this article, Aristotle even referred to people who thought Anaxagoras and Thales were examples of men with exceptional, marvelous, profound but useless knowledge because their search was not for human goods.

Aristotle thought of human activity in three categories praxis, poeisis (from which we get the word poetry), and theoria (contemplation – from which we get the word theory). The intellectual faculties required were phronesis for praxistechne for poiesis, and sophia and nous for theoria.

Sculpture of Aristotle at the Louvre Museum, Eric Gaba, CC-BY-SA-2.5 via Wikimedia Commons
Sculpture of Aristotle at the Louvre Museum. Photo by Eric Gaba, CC-BY-SA-2.5 via Wikimedia Commons

It is important to understand that theoria had total priority because sophia and nous were considered to be universal, necessary and eternal but the others are variable, finite, contingent and hence uncertain and thus inferior.

What did Aristotle actually mean when he referred to phronesis? As I see it phronesis is a means towards an end arrived at through moral virtue. It is concerned with “the capacity for determining what is good for both the individual and the community”. It is a virtue and a competence, an ability to deliberate rightly about what is good in general, about discerning and judging what is true and right but it excludes specific competences (like deliberating about how to build a bridge or how to make a person healthy). It is purposeful, contextual but not rule-following. It is not routine or even well-trained behaviour but rather intentional conduct based on tacit knowledge and experience, using longer time horizons than usual, and considering more aspects, more ways of knowing, more viewpoints, coupled with an ability to generalise beyond narrow subject areas. Phronesis was not considered a science by Aristotle because it is variable and context dependent. It was not an art because it is about action and generically different from production. Art is production that aims at an end other than itself. Action is a continuous process of doing well and an end in itself in so far as being well done it contributes to the good life.

Christopher Long argues that an ontology (the philosophy of being or nature of existence) directed by phronesis rather than sophia (as it currently is) would be ethical; would question normative values; would not seek refuge in the eternal but be embedded in the world and be capable of critically considering the historico-ethical-political conditions under which it is deployed. Its goal would not be eternal context-free truth but finite context-dependent truth. Phronesis is an excellence (arête) and capable of determining the ends. The difference between phronesis and techne echoes that between sophia and episteme. Just as sophia must not just understand things that follow from first principles but also things that must be true, so phronesis must not just determine itself towards the ends but as arête must determine the ends as good. Whereas sophia knows the truth through nous, phronesis must rely on moral virtues from lived experience.

In the 20th century quantum mechanics required sophia to change and to recognise that we cannot escape uncertainty. Derek Sellman writes that a phronimo will recognise not knowing our competencies, i.e. not knowing what we know, and not knowing our uncompetencies, i.e. not knowing what we do not know. He states that a longing for phronesis “is really a longing for a world in which people honestly and capably strive to act rightly and to avoid harm,” and he thinks it is a longing for praxis.

In summary I think that one way (and perhaps the only way) of dealing with the ‘wicked’ uncertainties we face in the future, such as the effects of climate change, is through collaborative ‘learning together’ informed by the recognition, appreciation, and exercise of practical wisdom.

 

Practical wisdom and why we need to value it