Reshaping Services at a Local Level - Understanding What Really Matters

Vanguard Consulting Ltd

Reshaping Services at a Local Level - Understanding What

Really MattersSimon Pickthall - Vanguard Cymru


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.


Solving Problems

“We have more work than we can deal with”. “Morale is low”. “Costs are increasing”. !

How are these traditionally tackled?


Thinking Governs Performance

Performance

System

Thinking

Single loop learning - Doing the Wrong Thing Righter

Double loop learning - Doing the Right Thing


“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


Results from Counter-Intuitive Thinking


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%


Disabled Facilities Grants


Housing Benefits

Before After

Mean 83 days 3 days

UCL 285 days 10 days

Before

Mean 83 days

UCL 285 days


Counter-intuitive solutions

All demand is ‘work’

Value demand & Failure demand

If you feel uncomfortable - go study!


• 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


• 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 !


• And it took this many people to deliver it... • 8 social workers • 22 support workers allocated • 30 referrals • 16 assessments • 36 teams/services


• 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.



All demand is ‘work’

Value demand & Failure demand

StandardisationUnderstand What

Matters

If you feel uncomfortable - go study!



Performance = people

Performance = 94% System Motivation = intrinsic

Specialisation Design against demand


Check

PlanDo

Change must be based on knowledge, not opinion

Study

ExperimentMake normal


The Long Weekend…


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”


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


Common Purpose

“Help Me Live a Good Life or Die a Good Death.”


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


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


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).


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


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

http://locality.org.uk/wp-content/uploads/Locality-Report-Diseconomies-web-version.pdf

http://www.triarchypress.net/the-whitehall-effect.html


Book Your Long Weekend…


Reshaping Services at a Local Level - Understanding What

Really MattersSimon Pickthall

- Vanguard Cymru [email protected]

07951 481878

mailto:[email protected]


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

http://www.systemsthinking.com/

http://www.livesthroughfriends.org

Reshaping Services at a Local Level - Understanding What Really Matters

Government & Nonprofit

vanguard consulting

bath board

stroke patients

hospital trust

cost of services

anger management course

acute stroke unit23

counterintuitive ways