Applying systems thinking to commissioning: remember Donella Meadows

What are the elements in your system of interest? Can you see them? Do you know what they are? In all likelihood, you can see them and you do know what they are. But, do you know how they are interconnected and what the purpose or function of your system is?

Donella Meadows, in her book Thinking in Systems, reminds us that a system must consist of three things: elements, interconnections and a function or purpose. We could say, then, that it is surprising that we can often see the elements more easily than we can identify the interconnections or define the function or purpose, for it is the purpose of the system that defines its behaviour and it is its behaviour that can often give us some cause for concern.

So, what about when we want to use different providers or different types of providers or different departments or teams etc. in our systems when we are commissioning? What happens then? Well, you can change the elements in a system quite easily and the system will remain the same. Just like the cells in the body are replaced on an ongoing basis but we still remain a human being, we don’t completely change. However, there is a BUT. The but is that the system will remain the same when elements are replaced IF the interconnections and purpose(s) remain the same.

This is something that I see being forgotten during times of change and transformation all the time. Elements – be they providers, services, teams, departments or any other element of the system – are changed and yet the interconnections and purpose of the system are not considered. This is especially true regarding interconnections. By interconnections I am talking about the relationships that hold the elements together. This can be anything from a chain of communication to a set of rules, a protocol or a timetable, for example. Imagine a football game. You can change the players (the elements) and it will still be a football game. Change the rules (interconnections) and you may have some sort of ball game, but it may not be football. Those rules might change the purpose or functions of the game and so you might no longer have a football game. You can completely change the elements and the ‘thing’ will remain the same, as long as the interconnections and purpose remains the same.

Donella also reminds us that, as systems practitioners, our focus is on stocks (accumulations of material or information that has built up in a system over time) and flows (material or information that enters or leaves a stock over time) and the operating unit of our system, which is the feedback loop (the mechanism that allows a change in stock to affect a flow into or out of that same stock). The dynamics of our stocks and flows gives us a picture of the behaviour over time of our system. This behaviour over time gives us clues about the underlying structure of our system, which can help us to identify what action we need to take to reinforce or change that behaviour. Yet, in commissioning, we are not always driven to taking action in response to how the system is structured and behaving as a result of that structure. I think this is partly due to pressures which force quick decisions to what is assumed to be an obvious cause and effect. This assumed cause and effect, as we know, is rarely a proven cause and effect and is exactly as described – as ‘assumed’ cause and effect. I also think it is down to there being a lack of general awareness of how systems, with their elements, interconnections and purposes actually work.

Do we always remember that ‘stock’ takes time to change because ‘flow’ takes time to flow? Even if a lot of money is available, it might still be difficult to change ‘stock’ instantly.

What is an example of stock? Well, Donella explains to us that the population can be considered a stock. It has a ‘reinforcing loop causing it to grow through its birth rate, and a balancing loop causing it to die off through its death rate. As long as fertility and mortality are constant (which in real systems they rarely are), this system has a simple behaviour. It grows exponentially or dies off, depending on whether its reinforcing feedback loop determining births is stronger than its balancing feedback loop determining deaths.’ Births and deaths do not usually happen at the same rate, so we need to be aware that there is a time lag when considering our stock. In commissioning,  we shouldn’t be giving up on our improvement or change efforts too soon, having thought they were a failure, when it might be that they just haven’t had the time they need to make a difference.

It might be useful to remember that inflows and outflows are independent and will, of course, happen at different rates. We tend to focus on stocks more than flows, and inflows more than outflows………….don’t just focus on hiring new staff (inflow) but also give some attention to preventing people from quitting or going elsewhere (outflow) – stem the outflow as well as increasing the inflow to increase the stock (number of staff).

This is but a brief snippet of the messages of Donella Meadows that we can apply to our commissioning practice – look for the history of the system, identify its long-term behaviour because this will provide clues about the system’s underlying structure. Identify the structure (the stocks, flows, feedback) which is determining the resulting behaviour. Try and identify your most important input – this is the one that is likely to be most limiting. Remember, overall, aim to enhance total systems properties like growth, stability, diversity, resilience and sustainability rather than focussing on short term ‘fixes that fail’ because they are implemented without knowledge of how the system works as a whole.

‘Systems of information-feedback control are fundamental to all life and human endeavour, from the slow pace of biological evolution to the launching of the latest space satellite….Everything we do as individuals, as an industry, or as a society is done in the context of an information-feedback system’ Jay W Forrester

(Donella H Meadows, Thinking in Systems, 2008)



Applying systems thinking to commissioning: are you seeing the Slinky or the hand?

On a slow, sleepy kind of morning recently I found myself revisiting the writings of Donella H Meadows in the form of her book, Thinking in Systems. Only a few pages in, I was reminded of the power in the simplicity of her explanations of systems concepts. I was especially struck by the ease with which she explained one of the central insights of systems theory… using a slinky.

For those who haven’t come across this before, I’ve take the following wording from the beginning of her book,

‘Early on in teaching about systems, I often bring out a Slinky. In case you grew up without one, a Slinky is a toy – a long, loose spring that can be made to bounce up and down, or pour back and forth from hand to hand, or walk itself downstairs.

I perch the Slinky on one upturned palm. With the fingers of the other hand, I grasp it from the top, partway down its coils. Then I pull the bottom hand away. The lower end of the Slinky drops, bounces back up again, yo-yos up and down, suspended from my fingers above.

“What made the Slinky bounce up and down like that?” I ask students. “Your hand, you took away your hand,” they say.

So, I pick up the box the Slinky came in and hold it the same way, poised on a flattened palm, held from above by the fingers of the other hand. With as much dramatic flourish as I can muster, I pull the lower hand away. Nothing happens. The box just hangs there, of course.

“Now, once again. What made the Slinky bounce up and down?”

The answer clearly lies within the Slinky itself. The hand that manipulates it suppresses or releases some behaviour that is latent within the structure of the spring. That is the central insight of systems theory.’ (Donella H Meadows, Thinking in Systems, A Primer, 2008)

In commissioning, it is all too easy to focus on external agents, to believe that the cause of problems is ‘out there’ somewhere, to blame and to shift the responsibility from ourselves. We can all too easily forget that some of the problems we encounter are rooted in the complex structure of the ‘messes’ in which we are embedded. The danger in this, of course, is inappropriate commissioning decisions with ineffective outcomes and potentially creating a system that is even harder to navigate.

Take people turning up at A&E unnecessarily, for instance. I have spent years listening to complaints about how patients ‘just like to turn up at A&E.’ This is often followed by a flurry of activity to deflect the activity elsewhere – mainly in the form of communication campaigns, particularly telling the patient to ‘go away – you are in the wrong place!’

But, the problems we have are intrinsically systems problems – turning up at A&E can be seen as an undesirable behaviour which is characteristic of the system structures that produce it. Communications campaigns and the ‘go away’ messages merely focus on the hand and not the Slinky. For that reason, they may not bring about the results their instigators want to see – a reduction in people turning up at A&E. Instead, our energies could be more wisely used if we stop casting blame and see the system as the source of its own problem and find the courage and wisdom to restructure it appropriately to bring about different behaviour.

The ‘trap’ in our thinking that influences us to only see the ‘hand’ can also be a point of enlightenment, if we allow it to be. Wherever there is a trap, there may also be a potential opportunity – an opportunity to recognise the trap, apply systems thinking and transform our systems to produce more desirable behaviours….focussing on the Slinky, not just the hand. We can make the connection between structure and behaviour. We can move away from trying to analyse things in small segmented chunks and instead build an understanding of how our system works as a whole. We can choose to see differently and we can choose to think differently. We can choose to understand the nature of the relationships and we can ask different questions. We can widen our mindset to enable greater insight. Applying systems thinking to our commissioning in this way can help us not only to see the elements in the wider system but to understand the interconnections and commission so that our services ultimately fulfil the purpose for which they are designed.

‘Managers are not confronted with problems that are independent of each other, but with dynamic situations that consist of complex systems of changing problems that interact with each other. I call such situations messes…..Managers do not solve problems, they manage messes.’ Russell Ackoff (Donella H Meadows, Thinking in Systems, A Primer, 2008)

Applying systems thinking to commissioning: remember Barry Oshry!

If you aren’t using the wisdom of Barry Oshry in your commissioning practices, I’m not going to say you should be, but I am going to say you could be.

For those who can’t remember, or who haven’t come across, the basic pattern that Barry tells us develops with great regularity in the widest of organisations and institutions, it looks something like this:

‘There are conditions we all face in whatever organisational position we occupy. Sometimes we are a Top, having overall responsibility for some piece of action; in other interactions we are a Bottom, on the receiving end of initiatives over which we have no control. In other interactions we are Middle, caught between conflicting demands and priorities. In other interactions we are Customers, looking to some other person or group for a product or service we need. So, even in the most complex, multi-level, multifunctional organisations, we are all constantly moving in and out of Top/ Middle/ Bottom/ Customer conditions.’

‘Tops are burdened by what fells like unmanageable complexity; Bottoms are oppressed by what they see as distant and uncaring Tops; Middles are torn and confused between the conflicting demands and priorities coming at them from Tops and Bottoms; Customers feel done-to by non-responsive delivery systems.

Top ‘teams’ are caught up in destructive turf warfare; Middle peers are alienated from one another, noncooperative and competitive; Bottom group members are trapped in stifling pressures to conform.

Tops are fighting fires when they should be shaping the system’s future; Middles are isolated from one another when they should be working together to co-ordinate system processes; Bottoms’ negative feelings towards Tops and Middles distracts them from putting their creative energies into the delivery of products and services; Customers’ disgruntlement with the system keeps them from being active partners in helping the systems produce the products and services they need.

Throughout the system there is personal stress, relationship breakdowns and severe limitations in the system’s capacity to do what it intends to do.’

(Barry Oshry, Seeing Systems 2007)

Sound familiar? Is should do if you are in the changing environment of public services. I’ve seen this, to some extent, in nearly every area I’ve worked. The thing that makes me feel most pain is when it is being explained in terms of the character, motivation and abilities of individuals, just as Barry describes in his book, ‘Seeing Systems’. What follows is the inevitable moving round or dismissing of staff or alienating them to a point where they leave voluntarily. Alongside this comes reorganising and restructuring and then………… all happens again! As Barry tells us, that is because the problem is not the staff, nor is it specific to a particular organisation, it is systemic. He terms the inability to see that it is systemic as ‘system blindness.’ I fear we are all blind at least some of the time.

I’ve seen this particularly in times of great change. Let’s face it, that’s most of the time! As a systems practitioner, I tend to identify it when I am also identifying the pathological archetypes of the viable system model, which tends to widen my vision, helps me to ‘zoom out’ from the situation and look at things from a systemic viewpoint, rather than a personal one. For example, if I see failing change programmes where some parts of the organisation do not know why then need to change or who they need to work with, a lack of cohesion and stretched operations, resulting in questions to management around responsibility, staff unable to co-ordinate efforts and rifts throughout a number of levels in the organisation then I can potentially see the ‘identity crisis’ archetype. With this archetype, there may be some strategic issues or organisational design flaws that require attention. However, once it has happened, attention needs to turn to ensuring that people know what is intended, implementing effective co-ordination mechanisms and supporting staff to solve their own problems. Additionally, the potential management turf war, that is causing the mixed messages, also requires resolution. So, I can see the ‘identity crisis’ and I can also see the pattern of the ‘Tops’ being crushed by unmanageable complexity, the Middles becoming more isolated from one another in the confusion and the Bottoms feeling oppressed and disengaging in response to that.

When the Bottoms start to have negative feelings towards the Middles and Tops and when the Middle peers start to compete, I’ve also seen the ‘baronies’ archetype emerge, albeit not very strongly, but I believe it was there. I have seen a group break off and gain independence. They have remained in their own silo and stopped seeing the worth they can get from being part of the wider ‘whole’. I’ve seen competitiveness prevail and learning shielded from other teams. Fortunately, the group were persuaded to recognise the synergies of working as a whole and were able to re-integrate back into the wider system. I was able to recognise what was happening by applying systems thinking to the situation, which made things feel a lot less disturbing. I felt that I could understand it and then use that understanding to carefully start edging things back in the right direction.

Admittedly, it is difficult to actually see the system, if you are embedded in it. Believe you and me, systems practitioners engage in the patterns above all too often, even though they are aware of them and work to recognise them on virtually a daily basis, sometimes. But, you can try to ‘zoom out’ and see the wider system and the systemic nature of the situation you are in. Systems thinking is a model of thinking that can support you in doing that.

To leave you with another quote from Barry Oshry, ‘We humans are systems creatures. Our consciousness – how we experience ourselves, others, our systems, and other systems – is shaped by the structure and processes of the systems we are in.’ (Barry Oshry, Seeing Systems. 2007)

Applying systems thinking to commissioning: knowing what makes a system ‘sick’ can help you minimise the instances of ‘sickness’ in the future

In commissioning, it isn’t all about looking backwards, diagnosing weakness in services and trying to ‘put things right’. It’s quite the opposite. The focus is on creating whatever is required to give the right outcomes going forward. The focus, nowadays, is very much on things like integrating a number of suppliers into the whole system, taking an asset based approach and using levers to stimulate and shape the environment.  New kinds of systems are being created, with different boundaries and an extended repertoire of partners. This doesn’t come without its problems, of course, and a number of people, who are taking a commissioning approach in a new world of integrated public services, are often learning as they go along. That’s not a bad thing either. It’s great that people are learning their way forward together. It fosters a sense of community and encourages deeper thinking and enhanced learning as people deal with greater complexity together.

The tool for handling complexity is organisation. But our belief about what organisation is and how it might work may still belong to a world which is perceived as far less complex. Today, we operate in a much more complex world that we would sometimes like to admit. It challenges us, it makes us uncomfortable, it makes us think differently, it questions our current perspectives. But, if we are really lucky, it stimulates us, excites us and encourages us to strive forward.

It does help, though, if, during times of change, we have some idea of what makes systems (be that an organisation, a service, a group of services or anything that works together as a whole) ‘sick’ so that we can either seek to reduce the level of ‘sickness’ in the first place or be aware of early signs of ‘sickness’ so that we can administer the right medicine to avoid it getting worse.

As different types of organisations become integrated we may well start to see signs of an entangled character as different cultures, which once had to adhere to different criteria, merge together and try to find common ground. There may be some challenges establishing common governance mechanisms/ procedures during this time. We might notice that clear boundaries of responsibility have not yet been established, or appropriate quality indicators and monitoring are not yet in place or that contingencies to reduce risk have not been fully considered. If we understand that this could happen as we are creating something new, then we increase the opportunities to put things in place to prevent any adverse effects. We may need to clarify mission and purpose and who it is we aim to serve and be consciously aware that a new identity could take a little while to establish itself.

It is easy for people to become confused during these times of change. Having moved through a period of potential denial that the change needs to happen they can easily enter a stage of indecision and hesitation as ambiguity prevails, before the bigger picture becomes clear. It is easy, during these times, to default to old job roles and habits, assumptions and expectations. I have seen many instances where operational elements of a previous job role have remained the default focus of people who have moved into different and more strategic roles. Strategic planning was not given the attention it required and instead of embracing the meta-perspective needed, the focus was on micro-managing operations. This caused the organisational focus to be internalised. As a result, changes generally took longer to embed and the risk of the organisation being unable to respond to its environment was significantly increased. Being aware that this might happen and realising the risk that it brings can help us to mitigate against that risk, thus minimising the ‘sickness’ and ensuring that both an internal and external focus are maintained as we move along our journey.

One of the most disruptive ‘sicknesses’ I have encountered during times of change has been in relation to what we call ‘co-ordination mechanisms’ – the things that are in place to prevent operations of the system from causing chaos for one another. For example, a timetable in a school. On the surface, it may be almost invisible. But, without it, the school would be in chaos. It is omission of these near invisible co-ordination mechanisms that can cause our systems to be terribly ‘sick’. It can cause oscillations in performance, turf wars, staff feeling like they are bobbing around in a small boat, all alone, in the middle of a crashing ocean, inter-team disputes and recurring problems and yet the scheduling, the co-ordination, the policies, the planning, the information systems etc. which are vital for maintaining stability are often overlooked, deemed unimportant, invisible, and are often the very last things to get any attention.

These short snapshots of a very few kinds of ‘sickness’ are not exclusive to any one group of people or any one organisation or group of organisations. They happen repeatedly in a number of situations. They can arise when elements of the system, which are required for viability, are not well implemented or are dysfunctional. The system may not be in a state of homeostatic equilibrium and as a result the ‘sickness’ emerges. Left unchecked this will, as best, hinder success and at worst, cause the system to die.

I believe that commissioners who understand organisation and can apply models of organisation, like the viable systems model, to their work have an increased chance of successfully transitioning into a new integrated environment. They gain an understanding of complexity and how it can be matched. They understand and recognise ‘sickness’ and attribute it to systemic failings, rather than blaming individuals – their character, motivation and abilities. They are able to see past the system blindness to which we so often succumb. To quote Barry Oshry,

‘With system sight we can become captains of our own ships as we understand the nature of the waters in which we sail.’

Applying systems thinking to commissioning

I’ve been applying systems thinking to my commissioning practice since about 2008 now, from when I first started on the systems thinking in practice undergraduate courses with the Open University.

Commissioning to me, back then, seemed a logical approach to achieving the health outcomes aspired to by the NHS and yet the turbulent journey through multi disciplines and across organisational relationships rarely made it an easy job. So, I welcomed with open arms the Systems Dynamics which allowed me to unpick the complex areas of hospital discharge and urgent care. It supported me in examining the potential consequences of different configurations of the wider system and thus vastly informed my commissioning decisions. I can tell you this, no matter how bad the problem seemed at first glance it rarely needed a huge commissioning exercise to make improvements. It just required a different perspective and an understanding of how things work as a whole system. I welcomed learning about Donella Meadows places to intervene in a system to increase effectiveness. I especially welcomed the Viable Systems Modelling, which I use virtually every day in my practice and in my personal life now. It taught me how to explore organisational arrangements and governance and how to spot variety imbalances that were preventing systems from operating to their maximum effect. More often than not, a number of strategic tweaks, informed by rigorous examination of the system before hand was all it took to make a difference. By difference, I mean maintaining delayed discharge figures at below national and regional average for over three years, gaining sign up from three major regional hospitals to a Transfer of Care Protocol, reducing high prescribing costs in over 50% of GP practices in the area, understanding and preventing the reasons for high care home admissions to hospitals, building effective and efficient escalation systems that people actually respond to, reducing frequent callers to the ambulance service, to name but a few things.

The key thing that my systems thinking taught me in the early days was that examining the thinking behind some of the faulty decision making in my complex world was essential to making a difference. To allow me to enable the multi-organisational relationships I firstly needed to understand the prevalent patterns of thinking in each stakeholder group so that I could facilitate a joint understanding. Critical Systems Heuristics helped me here, as well as Soft Systems Methodology. Again, welcoming them in with open arms I was able to encourage meaningful conversations and understand the different reference systems at play. Sources of motivation became visible, as did value systems and sources of legitimacy in appreciating the consequences of any changes.

Unbeknown to me at the time, the methods, concepts, tools and techniques that I was learning back then were forming a solid bedrock that I would use time and time again to examine and deal with complex, dynamic and diverse problematic situations. Common sense approaches sometimes just aren’t good enough for improving situations and creating better outcomes. But, a more highly sophisticated commissioning approach, incorporating systems thinking, has proven to me time and time again to be powerful, effective and believe it or not….quick!

After all, Mary Catherine Bateson once reminded us that systems approaches continue to serve as a continually creative endeavour, ‘It’s confusing, but we have a right to be confused. Perhaps even a need. The trick is to enjoy it: to savour complexity and resist the east answers; to let diversity flower into creativity.’ (M.C. Bateson, 2004)

The Power of Peer Support in Developing and Devolving Systems Practice

It is easy to confine systems thinking to the comfort of the academic forum where exciting concepts tantalise the mind and modelling constructs the solid foundations for thought. But, failing to link this to how people actually think, behave and work in the real world can be a recipe for disaster for systems practitioners. Separating academic concepts and models from behavioural insights, psychology, social neuroscience, but to name a few areas, can be a recipe for at best a failed attempt at applying systems thinking to your situation and at worst, a disaster in the form of a failed piece of work and alienating the very people you are trying to get on board.

So, what do we do if, and when, the transition from academic insight to real world application becomes overwhelming? Who do we turn to and from where do we get our support?

Well, my suggestion would be peer support. It isn’t the one and only thing we can do to get support as systems practitioners but it is immensely valuable. I, for one, certainly wouldn’t want to be a practitioner going it alone without the input from my valued friends and colleagues. Using, sharing and disseminating our practice in the real world in addition to understanding the concepts and modelling techniques in the academic world is vital, not only to our personal success but for the success and development of the discipline.

Our choices for peer support are wide and varied, from using an unstructured medium, such as social media, through to engaging in formal mentoring schemes. There is something out there for each and every one of us.

Personally, I find social media a solid platform from which to give and receive peer support. It minimises feelings of isolation, supports constructive challenge, enables us to share models, concepts and ideas and thus creates inclusion and mutual advancement. Strong relationships can emerge, increasing capacity for personal, relational and community change and growth. It goes one step further than argumentatively challenging the views of those we don’t agree with. It allows us to share our experiences and knowledge and provides mutually beneficial motivation when energy levels are low or challenges seem overwhelming. It is ongoing, accessible, and flexible. There’s no pressure – you can come and go as you please – and engaging across geographical, social and cultural boundaries becomes effortless.

There are many other ways to engage in peer support, of course, so if one way doesn’t suit you, don’t give up but try something else instead. Peer support helps us learn and grow. It helps us support one another and disseminate our thinking to others. It supports us in being successful, which, in turn, helps a whole host of other people also.  

Let’s help one another in the practical world. Let’s get systems thinking out there. The only way we can do this is to help and support one another. Don’t keep your practical success under wraps. Get it out there and share how you did it. Encourage newcomers, constructively challenge the experienced and most of all….enjoy it! Systems thinking and practice really doesn’t have to be dry and dull. It can be as exciting, creative and innovative as you want it to be. Share yours widely and most of all… proud of it!