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.



What is a Systems Practitioner?

SmallLogo A systems practitioner is someone who is able to put systems concepts into action. This might be in their work, everyday personal life, or both. Systems practitioners often use systems ideas to investigate, evaluate, and make changes in complex situations. Some people think that systems practitioners “look at our systems.” To some degree we do. However, what we mainly do is to take the concepts of how a system works and apply them to situation so that we can work out what is happening in that situation and how we might improve or change it.

But what is a system? Well, a system can be defined as anything consisting of two or more parts which work together as a whole to give a property/ properties that do not exist in one of the parts alone.

For example, a car car  can be classed as a system. It consists of a number of parts which, together, give a mode of transport. Transport is the emergent property of the system. It emerges when all of the parts work together. Singularly the engine is not a mode of transport, nor are the wheels or the seats etc. Without the rest of the car they are not a mode of transport.

Systems have various properties. Here are a few of them:

  1. they have emergent properties (i.e. being a mode of transport is the emergent property of the car)
  2. they self-organise (i.e. they are dynamic, they change)
  3. they exhibit “feedback” (i.e. they consist of information flows or loops of causes and effects)

Systems practitioners tend to focus the connectedness between the component parts in a system. These parts can be: people, departments, services, organisations or sometimes whole societies. A system is however big or small you want it to be. Our intention is to understand the system, as a whole, so that we can predict its behaviour. We tend to do this because if we reduce the situation into smaller “bits” and tweak or change only one bit and not the others we will have more chance of failure. But, if we look at it as a whole then we usually have more chance of success. It is not an “ivory tower” academic discipline. It is very pragmatic and practical. Systems practitioners consider the impacts and unintended consequences of actions as well as the actions themselves.