Applying systems thinking to commissioning: the story of the stray lamb

At this time of year, nearing Easter, lambs are on many people’s minds but not this type of lamb. The stray lamb I’m referring to is one of the pathological archetypes that I learnt to see when applying systems thinking to my commissioning practice. I’ve only seen it once, I think. Although, I’ve probably seem it many more times but been focussed on much more worrying problems within my system of interest at the time.

This lamb was all on its own, nested in a cosy corner of an A&E department. Of course, I’m not talking about a white fluffy thing with four legs but a primary activity within a hospital pathway that seemed to have been ‘missed out’ of any formal organisational structure. It was a specialist nurse led clinic, the exact nature of which I won’t go into. They had previously been part of a different department but had been recently physically re-located to a corner of the A&E department. As a result, their previous management structure disowned them, believing they were now part of A&E and A&E didn’t have them in their management structure because yes, you guessed it, they weren’t really part of A&E.

So, how and why did I see them? Well, as a commissioner at the time, I had been asked to consider taking part of a pathway out of an acute setting to ‘bring it closer to the patient’ i.e. into primary care. The clinic was part of that pathway. One of their activities was to work with other hospital departments to get leg scans performed on patients (as part of a particular investigation), but only a half leg scan, and only for those patients who had positive results from two other types of tests first. The hospital had been shouting at commissioners to commission more staffing to perform scans, to meet what they perceived to be high demand. After all, the department was always full and people were waiting far too long for their leg scans. It had to be about demand, didn’t it? Well, no. Not strictly speaking. But, recognising the associated clinic as a stray lamb, I decided to investigate if that was having any impact on the pathway, demand, the inability to cope and the subsequent request to take part of the pathway out into primary care.

Well, you can probably imagine how the people in this clinic had been feeling. Moved around, left out, disowned and probably scared that their department was going to be the next one to be cut. So, what were they doing? Yep, you guessed it – they were ‘proving why they needed to exist.’ By that, I mean they were sending every patient who came through their door for a leg scan. Not only that, they were requesting a full leg scan, at twice the time and twice the cost of the required half leg scan. On top of that they were bringing patients back and requesting repeated scans. This was allowed of course, and part of standard practice but only up to approx. 3 return visits. So, when I unearthed that 31% of patients should not have had a scan at all and that some patients had been brought back to the clinic in excess of ten times (some in excess of 30 times) a whole new picture started to emerge. The quest for survival was causing some serious consequences to this system.

The purpose driving the need wasn’t really the right purpose. The need driving the demand was unnecessary and the real demand, once I had stripped out all of the unnecessary activity (i.e. removed 1000+ unnecessary attendances and re-attendances) amounted to nothing more than around 300 patients a year for that area.

Without applying systems thinking I may just have taken action to respond to what I was originally told was the demand for that clinic. It was only after recognising the stray lamb archetype and digging deeper (by that I mean battling really hard to get some accurate data and facts about how things worked) that I unearthed much more than we ever expected to find. This system wasn’t just dealing with complexity, but was attempting to create value by carrying out a greater volume of tasks than it ever needed to. Systems thinking helped guide my decisions about what to do next. I didn’t commission more sonographers (they didn’t need them). I didn’t commission more hours of clinic time to respond to unnecessary demand (it wasn’t required). Did I bring the part of the pathway out from the acute setting into primary care? Well, yes, I did, but only to the extent to respond to genuine patient demand and to no detriment of the clinic involved.

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