Steve Allder: Systems Thinking in Health Services

Seddon introduces Steve by saying he’s done Systems Thinking without Vanguard. The only difference between having Vanguard consultants, versus doing itself, is that it may take longer and you may make more mistakes, but Vanguard’s purpose is to change management thinking, so they are happy for others to use their method.

Steve Allder is a consultant neurologist at Pymouth NHS hospital Trusts.  They had the worst stroke mortality in their region.  Strokes showed very consistent demand, but the length of stay in the stroke unit was incredibly variable. They were spending £6k on each patient, but being funded only £4k.  There was lots of debates about how to solve the problem. The government implemented targets, but no-one in the discussions at the local trust had any data, it was only folklore and opinion.  The two CEOs knew they didn’t have anything to spend on this, so Steve promised to get something without needing to spend.

If you come in with a stroke, you now go (within 2 hours on average) to the Stroke unit straight away. 100% of stroke patients go to the unit (previously 60%). The length of stay has dropped from 16 to 6 days. They are the only unit in the country to get near the government target of 90% (currently up to 80%).  They now ‘save’ £1K a stroke patient, with improved care. 

What has this got to do with Systems Thinking?

Steve was going to get a t-shirt saying “Peter Senge Change My Life” due to the pain of trying to create change. He liked Senge’s limiting conditions work.  You need to balance working on improvements with working on the limiting conditions, which was helpful for Steve.  He then read Seddon’s “Freedom from Command and Control” and got ideas like “true knowledge can easily be missed by the prevailing group, but the prevailing book has the power”.

For Steve, the words were “Purpose, Value, Demand, End to End and Capability”. It’s best to go in with an open mind and go back to first principles.  The value of Systems Thinking is that once you’ve learnt something it’s not possible to ‘unlearn’ – e.g. a point like ‘get knowledge’

The key to Steve’s intervention was an understanding of the six different groups within stroke patients (took 4 years of iterating to find this). Most patients were frail before they had a stroke, and had a huge stroke, which averaged a 50 day stay. The patients and the relatives just wanted to keep them comfortable, but we kept putting feeders into them.  Now we’ve recognised the patient group and talk about what might happen and they say “just keep them comfortable [rather than doing everything medically possible]”.  That group has radically improved.

If you were well before a big stroke, then you have to go to rehab, but the rehab unit would say “they are not well enough”, but for frail elderly patients they may not be up to rehab, they may just need time with nursing care.  Now they use that end-to-end lens, it’s liberated how they manage patients.  This has lead to all of the benefits they’ve got.

It wont work without a cast iron mandate

It is difficult to explain Systems Thinking to others. Steve has had this with most of the NHS. Steve talks about Flatland from “The Happiness Hypothesis” about a sphere visiting ‘flatland’ and everyone sees the sphere as a circle, getting bigger and smaller, but the two-dimensional square can’t understand the third dimension (“thickness as well as height, you say?”). The sphere yanks the square out of flatland into the third dimension and feels sickened and unnerved. When the square returns to flatland he can’t ‘preach the gospel’ to the other two-dimensional shapes.

Everyone in health agrees high quality and low cost, but don’t know how to get there. Steve says you need to work on the thinking.

What could this mean for the NHS?

As well as meeting the financial challenge it will help give patients what they need and allow employees to connect to their internal motivation and serve the wider society. You don’t know when you’ll need the NHS, but when you do, you’ll need it fast.

Questions and Answers

Why did it take so long to find out the different types of customers?

Because I wasn’t expecting it, it took me a while to understand what the data was telling me because I wasn’t expecting to see it.  The first thing I did was to do the capability chart without trying to guess what the answer would be.  Now, in health, frailty and multiple issues are current topics, so this might make it easier next time.

Seddon: The purpose of time-series data is to ask better question.  You might have to look at the data for a while, then get an inspiration and run more data.

The NHS has an issues of the revolving door with substance abuse. We’d like to engage with people earlier and get at the social issues at the cause of substance abuse. Do you have an idea about how to get through the medical arguments that doctors don’t want 3rd parties on the wards. Any advice?

We need a psycho-social model of health combined with a Systems Thinking approach.  Try and find the right advocate – a doctor outside the Trust with links inside and empower them to find someone credible in the NHS who has influence. It’s difficult to get traction.

Is there a way of extending what you’ve done to the rest of the hospital without getting managers to agree to it?

65% of beds are used by people who are stuck. The clinicians are unable to fix that. The managers, who work in the PCT / Local Authority, need to understand this, and they behave very badly.

Seddon: There’s a designed-in problem between clinicians and managers [not sure I got this right].  A bed manager is an absurd idea for a Systems Thinker.

Can you use Systems Thinking to help the community earlier in the health pathway?

GPs are paid to get blood pressure. Where we are, we have great GPs and blood pressure treatment is great.  Treatment of blood thining was not so good, but the demand data said there are only 4 patients per practice. Instead of an ‘education program’ they now ring the patients.  Now I look for the data, quantify the demand, and there’s somebody in the system that should already be doing it, and just need a little nudge.

Seddon: Isn’t it amazing we have a health service that doesn’t understand demand.

Steve: my aha moment was when the waiting time to see me or have a test was two years.  I was thinking ‘what value can I be adding?’. At that time, I thought ‘there’s not enough money and demand is increasing’ but that wasn’t correct. Demand is predictable and stable, the problem is the way we’ve designed the work.

How do I persuade my clinical colleagues that Systems Thinking will help them?

I am in management, but use the same approach to management that I used as a clinician. I have a framework, I gather data.  The problem is not the clinicians, the problem is getting their management to free up some time and support so that they might change things. Clinicians say they want to change, they just want someone to facilitate it. Find like-minded colleagues and look for easy starting points.

Seddon: Vanguard have found clinicians lap it up because they like to ‘get knowledge’.  The problem is that managers and the Dept of Health and they have been created in the last 20 years, and they believe they are doing “God’s Work”.  You need to get them out to study the system, and their thinking changes.

Why do clinicians change when they become managers?

I don’t think they do. McKinsey have found a correlation between improved productivity and percentage of clinicians in management roles.  If you show them the data they will respond to you. My experience hasn’t been that clinical managers change when they become managers.  There is a problem when managers don’t have a framework.

People who understand Systems Thinking feel liberated, so they often sound like they are talking about the spiritual and the divine.

Seddon: A clinician CEO ‘got it’, but the appointed non-clinical staff