My days in pharmacy and their relevance to my systems practice of today

Linking with my old colleague, Alison Hemsworth, lately really prompted me to think about my career journey and the value that every job I have had has brought to my current systems thinking practice. I started life as a pharmacy technician. It wasn’t my chosen career path, I kind of fell into it. But I can say that it taught me some valuable skills that I carry with me today. It highlighted that my progress has been a long and steady journey, with incremental learning and challenging of mental models along the way. Systems thinking, for me, isn’t today’s best thing, but a product of a long, exciting and challenging career. I should tell you first, what it was like way back when……

Working in a pharmaceutical specials lab was just the best. Imagine semi-sterile environment, gowned and masked in blue overalls with hair in a net and absolutely no make-up, rather like a giant smurf. If you were really lucky, you got to use the respiratory hood and play spaceman all day. Ermmm…we had a really serious job to do, making bespoke medicines by hand…..suppository anyone? A suspension maybe? How about some pastilles? I can even make lollipops! I know what flavourings NOT to mix with quinine sulphate…..some make your mixture kind of resemble the magic porridge pot…..just keeps bubbling over…and bubbling over….and bubbling over…..

I remember with great fondness the day I accidently set a Hobart mixer on full speed with over 20kg of liquid paraffin and white soft paraffin in the bowl. For those non-pharmaceutical people out there, think giant food mixer with 20kg of warm, molten Vaseline in it mixed with warm greasy liquid paraffin, think not putting the mixer arm down far enough and not noticing, think hitting the fastest mix speed, instead of slowest. Yeah, that! And think of me and the guy I was working with ending up looking like two giant candles……….then the 4 hour room clean up that came afterwards….. But I tell you, I still laugh out loud about it today.

Then, think firemen…..glucose burns really easily, you know…and gives off quite a lot of smoke. Think stabbing your finger with a syringe containing controlled drug and having to make an ointment with cade oil on a Friday, before a night out! Ermm…scrap that, anyone making cade oil ointment just didn’t go out that night. Why? Because it stinks of rotten fish……and so do you….for ages….and it takes around 4 washes before your clothes smell pleasant again. Yeuck!

Then there were the times I was able to fine tune my management skills. Particularly memorable was the volatile incident where two staff members were at spatulas at 20 paces in the middle of a semi-sterile cleanroom. (They were big spatulas too!) If I couldn’t allocate one of them work in the high confinement room (aka solitary confinement) we had to draw an imaginary line down the middle of the lab that neither was allowed to cross. All in good fun of course, they were like brother and sister really……just having a right good scrap at the time.

Then into the land of patient care, home visits and being chased by what seemed like every dog in the damn street, so that I could be assured that my patients could take their medicines as prescribed when they were discharged from hospital. I didn’t realise that being chased by dogs was a vital part of health care transformation….but, hey, I’ll try anything once.
The dramas and delights of pharmacy………

But those days were an amazing grounding for my chosen career of today – a systems practitioner. I will never do health and social care transformation without considering multiple perspectives, particularly the patients, their family/ carers and friends. I know what the interface issues are, I’ve lived them and tried to manoeuvre them. I’ve struggled with them at 7pm on a Friday night, over a weekend and on a Bank Holiday.

I would never fail to consider the complex systems dynamics involved in hospital discharge because I’ve seen the adverse effects on patients and tried to guide them through the process. I’ve experienced the communication breakdowns and felt the excruciating frustration of trying to get very simple things done.

I will never re-design a pathway without the input of a clinician or allied health professional. To do so would be to potentially jeopardise patient safety in an inexcusably negligent way. But, the combination of clinician/ allied health professional and systems thinker is extremely powerful. The insight from both sides allows us to navigate through the unbounded complexity with tenacity and without fear.

Nowadays, when doing quality improvements I will apply my learning from Barry Oshry, who tells us about how staff in the situation of tops, middles and bottoms feel and react in organisations, but I always bring into it my memories of having been in those places, having lived it from the perspective of the person embroiled in the complex mess of health and social care.

I will never commission without ‘zooming out’ and considering the wider picture. Having felt, as a technician, what it was like to become embroiled in the politics and policy constraints, I now act with a hugely greater insight into things like managing entropy and emergence.

And then there’s the networking. This is a key skill for anyone moving forward. Nothing gets done without great networks and communications. Working in pharmacy all those years ago, I couldn’t get anything done if I didn’t have the right network connections to enact change quickly. Sometimes, good communication has been the only thing required to make a massive difference to patients. They want processes that work. They shouldn’t be embroiled in the politics and policy constraints.

Nowadays, the focus is very much on the wider community, which makes me consider breathing a sigh of relief. That said, whilst everyone knows it makes perfect sense, it is still very difficult to pull things together on a wide enough scale to make a real difference for everyone. It is heartening, though, that there is recognition that things like patients, families, carers, friends, health, social care, education, community, employment, justice etc can no longer be effective if the interconnectivity and inter-relatedness is not understood and harnessed and the collective power recognised and used in a different way.

I thank my days in pharmacy for the grounding and years of experience it gave me. I learnt so much about risk, quality, patient safety, human factors, improvement, multiple perspectives, emergence, unintended consequences etc. Some people ask if systems thinking is a fad of today. I would say, ‘no, definitely not’. I think more people than you imagine are systems thinkers and just because they may not have the power, alone, to make massive change, does not mean that it cannot be done.



Are you riding the waves of change or drowning in the turbulent seas? What can we learn from Gareth Morgan?

‘Imagine a long, open Hawaiian beach. The surf is rolling in, and the waves are speckled with surfers and surf-boards. Some surfers are riding the waves with flowing determination. Others are flying high into the air and plunging deep into the foam. The image provides a metaphor for management in turbulent times. For like surfers, managers and their organisations have to ride on a sea of change that can twist and turn with all the power of the ocean.’ (Gareth Morgan, 1988)

What are you doing right now? Are you surfing, swimming or drowning? Are you surrounded by beautiful fish or man-eating sharks? Today, in public services, it is all too easy to feel like the surf is spinning you around, dragging you under and then crashing you against the rocks. But, back in 1988, Gareth Morgan gave us some great insights into the management competencies that would be required moving forward, to help us surf like a professional.

Morgan reminds us that, ‘many organisations and their managers drive toward the future while looking through the rear-view mirror. They manage in relation to events that have already occurred, rather than anticipate and confront the challenges of the future.’ He is clear in highlighting that organisations are becoming flatter and more decentralised. Self-organisation is occurring where autonomy is given to remote staff groups who are controlled from a distance.

With these changes comes the undeniable need to think and work differently. Possessing specific skills and abilities and combining technical, human and conceptual skills to create efficiency is no longer enough. To date, many organisations have tended to be successful because of very tight centralised control. Direct control can often feel like an attractive and comfortable way to manage. It suits those at the top who often can’t let go because their concept of being organised is linked to controlling and monitoring their constituent teams/ services. There is also some fear that the people at the bottom will not be driven to the same excellence in decision making as those at the top. But what can replace this direct control and how do people need to work to make it happen?

Moving forward, control will look more like management of relationships across a network, rather than management of discreet activities. ‘A network must be managed as a system of interdependent stakeholders, with collective identity and management philosophies that recognise the importance of mutual dependence and collaboration and a collective sense of accountability and control.’ ‘Collective identity’ itself will be a particular challenge, in my opinion. It is all too often that teams/ services/ organisations cling on to their identity for dear life and even after years of restructuring/ integrating/ changing, being dragged under the water over and over again, they still emerge flustered, gasping and adamantly refusing to let their old identity go.

Morgan tells us that, ‘Increasingly, the leadership process will become identified with an ability to mobilise the energies and commitments of people through the creation of shared values and shared understandings’. Development of operational skills will be only one part of the story. Developing attitudes, values and the mindset to allow teams to confront, understand and deal with forces inside and outside of the organisation will be the other side of the coin and the two must work in harmony together. Navigating the forthcoming waves with foresight and flexibility will be imperative to survival.

Management competencies will look and feel much different to those of today and will include:

  • Developing contextual competencies – building bridges and alliances, reframing problems to open up new possibilities, acting nationally and locally, developing a new approach to social responsibility;
  • Reading the environment – scanning and intelligence functions, forecasting, scenario planning and identifying major occurrences that could shape the future environment;
  • Proactive management – developing proactive mindsets, managing from the outside in (keeping in close contact with the evolving environment and enhancing capacity to rise to challenges and opportunities in an ongoing way) positioning and repositioning skills (the ability to manage tension between present and future so that you can position for the future whilst avoiding collapse in existing operations);
  • Promoting creativity, learning and innovation;
  • Skills of remote management (helicoptering, managing through an umbilical cord, promoting self-organisation, managing ambiguity and managing the balance between chaos and control);
  • Using I.T. to drive improvements;
  • Managing complexity (many things at once, transitions and multiple stakeholders)

The manager may no longer be able to function as a technical specialist who is also responsible for managing people, as is so often the case today. He or she will have to be become much more of an all-round generalist. Traditional supervisory roles are likely to disappear and the important competency may then lie in the ability to get employees enthused and fully absorbed with the new corporate philosophy, rather than to follow instructions in a mechanical way.

Innovation will be essential and with it comes the need to improve lateral interactions. Team managers will need to be able to:

  • Talk to and work with one another, embedding really successful interactions;
  • Develop a sense of common purpose;
  • Engage in effective conflict management and be able to read and handle hidden tensions;
  • Be a general resource to teams, a trouble shooter, a networker between self-organising teams, linking those teams to the wider organisation;
  • Take a more hands-off approach to management so that the initiative and control is passed to others;
  • Feel comfortable dealing with loosely structured situations and only intervene when necessary and in ways that empower;
  • Be aware of feedback systems that keep them informed without giving direct operational control.

In addition, organisations will need to adopt a risk taking ‘see if this works’ attitude, developing a supportive culture to experimentation. They will need to give parameters within which to operate, monitor on the basis of results and give teams the autonomy to operate quickly and flexibly to the changing environment. Planning can be bottom up, with management ensuring that plans fit with the organisation’s overarching vision. However, early warning systems should be built in to let managers know when intervention is required. Those mechanisms should seek to maintain the autonomy of the teams.

To deal with accountability, organisations and their managers should create systems of values, so employees can share and understand the mission and general parameters that guide action, rather than developing a set of rules as bureaucratic organisations do now. This, in itself, will require a mind-set shift from current day. Future managers will have to become as skilled in the art of empowerment as traditional managers are skilled in exercising direction and control.

Anticipating, communicating, sharing, inspiring, empowering, facilitating, networking, motivating are all words which are likely to become more and more common place in relation to management competencies.

As Morgan tells us,
‘You must have a remote type of management facility – the Europeans call it the helicopter principle – where you hover like a helicopter over the scene. If something goes wrong, you can come down and resolve it, but essentially you operate at a distance, and let the operation go.’

Which, I dare say, will be easier said than done for most organisations……

(Riding the waves of change, Gareth Morgan 1988)