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…..by 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)

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One thought on “Applying systems thinking to commissioning: are you seeing the Slinky or the hand?

  1. I’m reminded of the old saying, “If you make something idiot proof, someone only goes and invents a better idiot”.

    The mismatch between services offered at A&E and services requrested at A&E may be addressed by acknowledging the most control we have over the ‘system’ is with regard to those bits inside and not the complex (chaotic?) interaction at the boundary. Offering co-located, out of hours GP surgeries (as many departments do) seems a ridiculously simple (if not simple to implement) idea as a way to filter out (or at least deflecting) ‘undesirables’? Simply, if you don’t want ‘users’ to make the wrong choice, don’t offer them mutually exclusive choices, especially when they have a very high emotional stake.

    Like

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