John Atkinson’s #NHSTform Transcript

On the 28th January 2016, John Atkinson took part in the NHSTformathon. John introduced The Big Five characteristics of Living Systems. Here you can read what he had to say, and you can watch the live video below. 

(Full transcript available at )

Helen Bevan

We are now going to hear a really informative talk from John Atkinson about changing the whole system.

John Atkinson

I have got some thinking on how systems work and therefore how we might change them. A system could be me it could be you it could be your team could be your ward, your hospital, it could be the whole health system. This was the basis of my thinking on the design of Total Place.

Let's launch straight into the slides and have a look at this. The key thing in all of this for me goes back to that old phrase, "Problems aren't solved from within the level of thinking that created them." So if we want to change thinking, we need to think differently about how the system works. Most times, where we sit in a system changes what we think about them and what it does.

This guy, Jackson, US Supreme Court judge, in 1949, referring to a question, why is it as a Supreme Court judge you view a matter of law – a hard, disciplined subject – differently than when you were a federal prosecutor? What he is saying, where you are in the system alters how you think about it.

When I started to work with places, asking how their systems work, explicitly, you get something that looks like this, we have all seen them. This is your standard organisational chart. There are all sorts of assumptions about how things work, that are not necessarily helpful, they are limited things.

One of the assumptions is that the people in the system are employees, patients and carers don't usually appear on these charts, other organisations don't appear on these charts and thousands judge organisations on how it works.

Another assumption is there is a hierarchy of information, the person at the top knows what is going on and they pass that down the chain so by the time it gets to the bottom everyone knows perfectly what to do.

That doesn't work, it divides us into little teams that lose connection with each other. Usually when I put that up and we start to explore it, people say that is not really how we get things done around here. If we tried to work our system like this, it works up to a point and then we find things go wrong.

This is something we did in Total Place and this is what happens when you try and run a small English county on a hierarchical tree. Defined money comes in from all sorts of different sources, that line of boxes at the top, there is a line a third of the way down, primary school, secondary school, all kinds of convoluted routes in the middle where we try and make things work

This is Obamacare and if you look closely, you will find the most important person is the Secretary for Health and Human Services, but you'll find the IRS, the tax agency, quicker than you find patients.

Trying to run them as big organisational charts doesn't work, it is a very mechanistic way of thinking. It has its roots in the industrial revolution where people sat on the end of a machine and serviced them to get a job done.

In an industrialised nation, when you deal with health on an industrial scale, we have industrialised it – not an ideal way to deal with human activity. If you say, well, that is just the Americans, this is the NHS here, this is still an organisational chart. The grey blob is the top, then it goes to a series of other bits, none of which are connected.

This is 2008 but the point remains the same. If you look at that chart and ask, does the money we invest in tackling childhood obesity give us the sort of return we should expect from it? There is no way we could answer that question.

The two green boxes at the top, local government and local communities, department of work and pensions, Department of Health have something to do with that, Ministry of Defence, culture, media, sport, all of these departments have an impact on the health of our young people.

We have no sense of how these things interact because we split them into constituent bits. We thought if we cut it into tiny bits, we could understand how it works and make it work more efficiently, but we lose the connectivity that makes things work.

This guy, James Phillips Kay, was a surgeon working in the slums of Manchester in the 1830s. He said, "The social body cannot be constructed like a machine on abstract principles, which merely include physical motions and their numerical results, in the production of wealth."

That is not the way to run a health service either. When I put this sort of picture up, people say, "Doesn't your organisation or team work like this?" It makes sense it should be.

This is a map of the internet, via ISP. It could be a transportation map, all sorts of things, but let us imagine it is the map of health and care in an English city. Let's imagine the green stuff is the acute provision, largely centred around a big hospital somewhere to the north of the city with a set of outreach to the south. Let's assume yellow is primary care, some bigger and smaller clusters, the red might be community health and social care.

What we see is it connects in all sorts of different ways, all sorts of different relationships at play, and identities at play, that all come together to get something done. If our mental frame that forms our thinking is one of an organogram, this feels more intuitively right and there will be a mismatch.


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