Reshaping Services at a Local Level - Understanding What Really Matters
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Vanguard Consulting Ltd
Reshaping Services at a Local Level - Understanding What
Really MattersSimon Pickthall - Vanguard Cymru
Vanguard Consulting Ltd
Purpose of This Session
• To discuss how organisations are traditionally designed and managed - and, therefore, why they find it hard to understand what matters.
• To explore counter-intuitive ways to design and manage organisations so they can understand what matters.
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Solving Problems
“We have more work than we can deal with”. “Morale is low”. “Costs are increasing”. !
How are these traditionally tackled?
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Thinking Governs Performance
Performance
System
Thinking
Single loop learning - Doing the Wrong Thing Righter
Double loop learning - Doing the Right Thing
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“Most people imagine that the present style of management has always existed, and is a fixture. Actually, it is a modern invention – a prison created by the way in which people interact.”W. Edwards Deming
1900 - 1993
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Results from Counter-Intuitive Thinking
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Stroke UnitDomain Before Now% stroke patients treated in Acute Stroke Unit (ASU)
60% 100%
Time to transfer to ASU 1.6 days 2 hours % patients spending at least 90% of their time on ASU
30% 80%
Average Length of Stay (LOS) 16 days 6 daysBed base 56 beds 39 bedsCost per patient (to Hospital Trust) £6k £3kProfit per patient (to Hospital Trust) (£2k) £1k
Domain Cost BenefitNet cost benefit released in Acute Stroke Unit
23% Neurology Budget 14% Total Hospital Budget
Cost reduction in externally commissioned rehab beds
17%
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Disabled Facilities Grants
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Housing Benefits
Before After
Mean 83 days 3 days
UCL 285 days 10 days
Before
Mean 83 days
UCL 285 days
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Counter-intuitive solutions
All demand is ‘work’
Value demand & Failure demand
If you feel uncomfortable - go study!
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• What Ruth said she wanted - what mattered to Ruth: • “I need help with housework and...” • “...gaining access to the upstairs of the property.” • “These two things would have such a profound effect on mine
and the children’s lives.”
• What Ruth received: • The same anger management course twice for two boys • The same parenting programme twice • Help cleaning one bedroom • Toilet frame, perching stool and bath board for a bath she
could not access • Family intervention programme
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• What Ruth said she wanted - what mattered to Ruth: • “I need help with housework and...” • “...gaining access to the upstairs of the property.” • “These two things would have such a profound effect on mine
and the children’s lives.”
• What Ruth received: • The same anger management course twice for two boys • The same parenting programme twice • Help cleaning one bedroom • Toilet frame, perching stool and bath board for a bath she
could not access • Family intervention programme
Cost of Doing What Matters to Ruth
!
Total - £20,760 !
Cost of Services to Date !
Total - £106,777 !
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• And it took this many people to deliver it... • 8 social workers • 22 support workers allocated • 30 referrals • 16 assessments • 36 teams/services
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• Between 1996 and 2012 Ruth had 129 different interactions with public-sector agencies. From running a successful business with her first husband she deteriorated to having ill health, her children removed and being entirely dependent on the public purse.
• Ruth was taken on by one of the new ‘Wellbeing’ teams piloting locality working; she is now in suitable accommodation with her children and her situation has stabilised.
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Counter-intuitive solutions
All demand is ‘work’
Value demand & Failure demand
StandardisationUnderstand What
Matters
If you feel uncomfortable - go study!
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Counter-intuitive solutions
Performance = people
Performance = 94% System Motivation = intrinsic
Specialisation Design against demand
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Check
PlanDo
Change must be based on knowledge, not opinion
Study
ExperimentMake normal
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The Long Weekend…
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What matters to people in these systems?!
• “Just talk about what matters to me” • “Understand my specific concerns, don’t use a
menu of services to solve problems you think I have.”
• “Feeling valued – feeling I contribute – social involvement”
• “Be transparent in your work” • “Wanting to be independent” • “A key person – one point of contact”
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Different Thinking - Different Solutions• We start from the demand in a locality, and
design public services to meet that demand. • This is not the same as changing local authority
boundaries. • This is not the same as ‘co-location’ - co-location is
necessary but not sufficient. • This is radical redesign of the entire public
service from first principles - restructure across existing organisations based on knowledge of local demand.
• Common Purpose, Common Measures, Common Principles
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Common Purpose
“Help Me Live a Good Life or Die a Good Death.”
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Cost%Analysis%Comparison
PoliceSocial%Services Health%ServiceLocal%Authority Education
£2k
£6k
£10k
Historic%Approach
Principles@Based%Approach
£%%83,649%
£%%824
£%%3,379£4k
£8k
£12k
£14k
£80k
£%%646
£%%2,859
£%%214
£%%3,818
£%%33 £%%493
Principles.based2Approach£%2,210%
2%
£££99%
£££81%
£££93%
£££99%
£%106,777%Historic2Approach
Multi@agency%Mtngs
0
2
4
6
8
10
I%am%listened%to%and%heard
I%have%more%confidence%
My%financial%problems%are%
sorted
My%children%can%sleep%in%their%own%room
My%children%have%space%to%
play
I%have%some%space%of%my%
own
I%am%able%to%manage%my%home%better
Our%sleeping%arrangements%do%not%affect%�
Start
29.06.12
24.09.12
I22need2serious2help(multiple2complex2needs)
I2could2go2either2way2(multiple2problems)2
I2am2in2balance2but2need2a2little2help
5%
31%
(64%)
Tier2212�2In
dividu
al2
Outcomes/2Econ
omics2
Tier2222.2Geo
grap
hy2
Capa
city2/Scalab
ility2
Tier2232�2Strategic2
Deman
d2Re
duction2&2
Cost2Rem
oval2
Street2number Street2name PoctcodeCYP2Referral
CYP2Re.referral
CYP2asst.2to2service
Rent2Arrears YAMH ASB VA Crime
Count2of2Flags
A CARSON% ROAD ST%6%7BG Y N N Y N N N Y 3B CROSSLEY% ROAD ST%6%7AJ Y N N Y N N N N 2C BARNETT% GROVE ST%6%6NA Y N N N y N N N 2D CROSSLEY% ROAD ST%6%7AJ Y Y Y N N N N Y 4E CROSSLEY% ROAD ST%6%7AJ Y N N N N N N Y 2F CROUCH%AVENUE ST%6%7HT Y N N N N N N N 1G GALLIMORE% CLOSE ST%6%4DZ Y N N N N N N N 1H GREENBANK% ROAD ST%6%7EY Y N N N N N N Y 2I HUNTILEE% ROAD ST%6%6EP Y N N N N N N N 1J IRENE%AVENUE ST%6%7HB Y N N N N N N N 1K IRENE%AVENUE ST%6%7HB Y Y N N N N N N 2L NORRIS%ROAD ST%6%7AS Y N N N N N N Y 2
Common Measures
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Common Principles• We will retain ownership and only pull in other
expertise when absolutely essential • We will listen to understand you in your context • The focus of our intervention will be to help you
achieve what matters to you • We will build on your strengths and encourage
you to find your own solutions through your community wherever possible
• We will only capture information once which is appropriate and relevant to our purpose
• We will solve problems that stop the front line help people live their good lives
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Adult Social CareSample Size 250+: • 24.1% of referrals previously led to statutory funded packages
of care - now down to 10.9%. • 28% reduction in residential and nursing care placements. • Average domicillary care packages reduced from 12 hours to
9.7 hours per week. • 46% reduction in contacts into Social Services. • Underspent community care budget (cost avoidance of £1.5
million in 2013-2014). • 30% reduction in assessments. • Re-referrals reduced from 46% to 10%. • "In 20 years, you're the first ones who've really listened to me". • "If I had not known about this service, I would have admitted
this person into hospital" (GP).
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0
20
40
60
80
100
120
140
160
180
200
Criminal.Justice.System DWP Fire.Service Local.Authority Multiple NHS Police Society./.Economic
7 0 0
197
0
96
192
160 0 0
108
0 08
28
Economic'Outcomes,'Number'of'Pre'and'Post5Interventions'by'Agency:'All'Cases'
PreHIntervention.Activity PostHIntervention.Activity
Criminal.
Justice.
System
�������
DWP
no.change
Fire.Service
no.change
Local.
Authority
�������
Multiple
no.change
NHS
������
Police
������
Society./.
Economic
�����
Criminal.
Justice.
System
1%DWP
0%
Fire.Service
0%
Local.Authority
39%
Multiple
0%
NHS
19%
Police
38%
Society./.
Economic
3%
Pre5Intervention'ActivityCriminal.
Justice.
System
0%DWP
0%
Fire.Service
0%
Local.Authority
75%
Multiple
0%
NHS
0%
Police
6%
Society./.
Economic
19%
Post5Intervention'Activity
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Localities Reporthttp://locality.org.uk/wp-content/uploads/Locality-Report-Diseconomies-web-version.pdf
http://www.triarchypress.net/the-whitehall-effect.html
The Whitehall Effect
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Book Your Long Weekend…
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Reshaping Services at a Local Level - Understanding What
Really MattersSimon Pickthall
- Vanguard Cymru Simon.pickthall@vanguardwales.co.uk
07951 481878
Vanguard Consulting Ltd
Some further readingThe Toyota Production System
‣ Taiichi Ohno The New Economics
‣ W. Edwards Deming I Want You to Cheat Freedom from Command & Control; a Better Way to Make the Work Work Systems Thinking in the Public Sector
‣ John Seddon (Vanguard) Punished by Rewards
‣ Alfie Kohn The Machine That Changed the World
‣ Womack, Roos & Jones Understanding Variation
‣ Donald Wheeler Tracking Medicine
‣ Jack Wennberg
www.vanguard-method.com wellbeing.vanguard-method.com
‣ Vanguard Websites – lots of content
www.livesthroughfriends.org
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