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)

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