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Dear Colleagues,

Many thanks for providing the opportunity to contribute to the CQC consultation onassessing commissioners and providers. Firstly, can I congratulate the CQC for

raising as a matter of priority the rights and entitlements of service recipients andthe CQC commitment to a dynamic approach to assessing both commissioners and

providers.

And, secondly for generating a very useful start point that acknowledges the

interdependencies between the whole and the parts.

Having worked with system dynamics for 20 odd years across both adult andchildren services in many of the settings both tertiary and primary across both health

and social care I agree with the broad aims set out in this consultation.

In making this response I have taken, what some may say is an abstract viewpoint;

nevertheless what follows has been influenced by the recent findings of the HealthCommittee Inquirys into Commissioning and Out of Hours GP cover.

A present an overarching SOSM (System of System Method) covering all the mainapproaches and concepts being used in health and social care planning does not

exist, and it is timely to collectively make sense of health and social care in the 21st

Century.

The key note message form the Health Committee Commissioning Inquiry is one of

failure. It could be argued that this is in part because there is no overarchingguidance to be found on where and when to use a particular approach.This makes it

extremely difficult for any commissioning, purchasing or procurement and deliveryfunction to be undertaken that meets with the many complex rule sets that apply to

meeting welfare, competition and public procurement rules. I will come back to thisissue later. Initially I have focused on the CQCs use of a dynamic approach what

reads as the adoption of a systems dynamic approach.

The CQC reference to dynamic approaches is to be welcomed. This said, I would askthat the CQC methodology team set out what precisely is meant by a dynamics

approach.

Methods like Systems Dynamics (SD) and most notably the work of EricWholstenholme, and Systems Engineering (SE), as developed by (INCOSE) do have

an important role to play. And, it would be useful if the CQC could build on this work

and differentiate between whether the CQC is intending to adopt a Detail Complexity

and/or Dynamic Complexity approach to assessing the parts and the whole. (seeSenge, Fifth Discipline, 2006)

Unfortunately this sort of high end systems dynamics assessment has been eroded

or is largely missing from health and social care planning. Although progress hasbeen made in assessing the detail complexity of the many public sector providers I

am mindful of the adage without conceptual frameworks [health and social careprofessionals] are likely to fail to understand the context within which they operate

(Preston-Shoot 1990)

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At this time it is becoming increasingly important to realize that the hard systemsapproaches such as TQM, Structured IT methods, Operations Management and lean

methods and lean systems thinking maybe useful from a Detail Complexityperspective when the problem definition/ solution is tame and the system of concern

is closed. However, when behavioural and dynamic complexity is more complexother approaches and perspectives are needed.

There are a number of ways of weighing these sorts of issues and they are shownbelow and over the page:

2009 Ado Consultancy or its affiliates. All rights reserved.

Where do we make the intervention?Clarifying The Problem?Where do we Start?

At what level do we start?How do we set scope and boundariesHow we identify airs of concern?'

Where do we make the intervention? At what level do we make the intervention? What is the systems of interest?

Systems Level, e.g.Viable System Model

-Supply Chain

Transactional levelA la lean thinking, e.g.

Order Entry

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2009 Ado Consultancy or its affiliates. All rights reserved.

Likeliest Intervention for

Performance Improvement

Rule SetComplex

Many Value Analysis tounderstand sources of

value, cost andperformance

Diagnosis to understandrelationship between

sources of value (context)and value chain;

determine and setboundaries.

Rule Set:Simple /Few

Simple Analysis tounderstand cost andperformance, e.g.

Six and Lean Sigma, BPR

More complex end-to-end Process Analysis

neededto construct value chainand understand, cost,value and performance

ProcessComplexity

Simple

ProcessComplexityComplex

Tame

Problems

Messy/Wicked Problems

Including special causes

Note; innovation often falls

into this area

Clarifying theProblem?

What is the systemsof interest?

Tame problems may be quite complex, but the lend themselves to analysis and solution by knowntechniques.

Complexbehaviour canbe based onsimple rules

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It will be crucial that the CQC helps commissioners to understand the differencebetween the respective problems and systems of interest; this is because some

problems can not, indeed most not be assessed through the lens of a closed systemwhere the problems are seen as tame when they are not. The use of closed systems

approaches (ie six and lean sigma or the more recent deployment of the oxymoronlean systems thinking), are as likely to add to the dynamic complexity and impact in

ways that may violate EC law and the NHS Constitutional pledge as they are toincrease process efficiency at the transactional level.

This does not mean that Detail Complexity should be abandoned it does mean thatthe CQC must not confuse the use for example, of systems dynamics, beit Detail

Dynamics or Dynamic Complexity with System Thinking and further Detail Dynamicswith the analysis of bounded systems of work. The latter is characterised by notions

of end to end linked process optimisation activities (transactional analysis sometimescalled lean systems thinking) that is suited to closed systems analysis only.

In other words, the CQC must be able assess when a closed system approach toassessing the of work of a provider and when/where statistical tools such as

Statistical Process Control, run and control charts can be used. And, critically theinteraction with the wider open system it is said that at present there is no

Systems Thinking approach which can accommodate these two views although SoftSystems Modeling, System Dynamics and Viable System Models contain some

useful approaches.

The CQC may wish to give more attention to these approaches offering further

clarification and definition to what is meant by assessing the interdependencies

between the parts and the whole. This would enable the CQC to offer greatercertainty and guidance to both commissioners and providers when framing the

assessment process. For example, my own reading of Section 3, Our Aims forAssessment in the Consultation document would seem to have some similarity with

the European Foundation of Quality Management (EFQM), but unless this is spelt outcommissioners and providers alike will be left in the dark.

By comparison illustrations of a typical organisational circulatory system (Kleiner2009) and viable system model (Beer 1989) are shown below, I include them to

diagrammatically show the conceptual world views and interdependencies bothinternal and external to health and social care organisations. The first diagram,

drafted by Art kleiner, is work that has taken the iterative steps to show how systemdynamics show up in modern organisational behaviour. The second is known as

STEEPV (see below for description) and sets out to show how systems and subsystems interact. The relevance that these approaches is that when they are overlaid

conceptually they can map organisational effectiveness at a geographical level. This

sort of intervention will meet with the real world requirements of integrating thecommissioning agenda with the welfare principle, public procurement law andcompetition law. All diagrams have been reproduced here with the permission from

Art Kleiner and colleagues from Cranfield University.

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Hierarchy

(flow of authority)

Network

(flow of knowledge)

Clan (Core Group)

(flow of allegiance)

Market

(flow of work)

Seeks equilibrium; limbic system; source: King and God;

Transmits formal directives, requests, promises, rights, evaluations.

Seeks production; cardiovascular structure; source: Supplyand Demand; transmits value, goods, services, payment,

results, credit, nourishment, waste.

Seeks legitimacy; endocrine structure;

source: Family and Love; Transmits

behavior, emotion, loyalty, purpose,

commitment.

Leaders can affect at least four major circulatory systems.

Multiple PerspectivesA viable Systems View How does optimising processes at anoperational level help development of capability?

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Suffice to say these approaches are not for the novice but have been used withlimited success in work I have undertaken recently, and when layered and overlaid

with, say, the Kraljic Matrix will facilitate an approach that allows for the satisfactionand integration of the obligations that fall out of welfare duties with both competition

law and public procurement law. ( for a detailed explanation of the Kraljic Matrix seehttp://www.12manage.com).

In practice, my observation suggests that colleagues within health and social carehave a tacit knowledge of these approaches and that the introduction of such master

planning is already underway within Local Authorities; the information flows and datasets exist, and collaborative concordat between public authorities to undertake such

work already in place. It must, however, be noted that health and social care as asector is considered as being high risk in meeting with key value requirements, like

transparency, and is considered as lagging behind other public sector areas

The challenge, I would say, for the CQC, commissioners and provider organizations

(public and private) will be to show two things:

1. Apply Detail Complexity and Dynamic Complexity beyond the transactionallevel and into social, political and macro economic environment and

2. develop Viable Systems Models approach to deal with an open systems viewof world and develop current and future capabilities to enable them to match,

pace and lead their delivery partners.

Master planning, of this type, will enable public authorities to weigh the merit of

applying competition law against the efficiencies agenda and assess the impact onvulnerable populations.

In summary:

The advancement of a dynamics approach will depend on the guidance the CQC maybe called upon to address how effectively commissioners and providers engage in

master planning.

Techniques likes PDSA have and continue to be employed. However sometimes it will

be necessary to make the intervention above the transactional (Detail Complexity)level.

I think there are several challenges that face the CQC and it maybe helpful toassess:

whether appropriate intervention(s) are being made and at an appropriate

level

identify a proven closed systems approach for lean services

evidence ofboth convergent and divergent thinking

http://www.12manage.com/http://www.12manage.com/

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identify a proven open systems approach

evidence of an approach which allows for the co use of proven other

approaches, e.g. systems and requirements engineering (INCOSE) and SystemsDynamics (Sterman)

evidence which utilizes both hard and soft tools (e.g., run charts and conceptmodeling)

An approach which consider organizational maturity and commissionedexpectation.

An approach which recognizes the existence of a master planning framework

based on a layered architecture that integrates all of the above.

Here are some of practical identifiers of competence:

Systems mapping

Identifying and setting boundaries Concept modeling

Context modelling Multiple perspectives analysis

Emergent properties Cognitive mapping

Influence diagramming dialogue mapping

The constraints the CQC may face are:

There is a range of System Thinking approaches, some useful and some

academic Very little guidance on when and when not to use them A nonexistent SOSM

Confusion around what is an open and closed systems model Uncertainly about where to start.

The pledge the CQC makes to Put People First and Champion their Rights will be

seen from a systems requirements management perspective. Unfortunately, SystemsDynamics approaches have little to say about this. And, in health and social care the

interaction between competition law, public procurement law, contract law andwelfare law is largely unchartered waters. Article 226 infringements of the TEU are

increasing in number, and recent EU decisions are having an increasingly biggerimpact at a national level than first thought possible.

This is new ground for many public authorities and national governments. And justas we start to familiarise ourselves with the details of recent case law for a breech of

public procurement law, other associative issues, such as Acquired EmploymentRights, the Rights of Establishment, Effective Remedies and Fundamental Human

Rights will start to gather a pace.

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The risks bing mitigated here are an Article 226 complaint and judicial review. Theformer is a competency challenge, that links with other associative EC requirements

that are relevant risks, namely, the rights of establishment (as per Article 48 of theTEU) and the associative rights that fall out of Article 47 or effective remedies.

These two conditions have a direct bearing on the satisfaction of Art 6 and 13 of the

ECHR at the level of the individual and are manifest requirements of the UNConvention of the Rights of the Disabled Person and EU Charter of FundamentalRights, hence the vulnerability to judicial review.

And, by derogation with Art 48, at the level of the independent service provider whomust be afford the same TUPE style protection to those employed directly by the

state where these services are required as a condition of the universal serviceobligation and/or welfare duty. This later condition, is unchartered water, when

applied to personalisation and individual budgets, nevertheless the risks is not soremote that it can be ignored.

Needless to say this is a dense and complicated legal and policy matter suffice to say

that in legal theory EU legislation, once agreed, has primacy over national law, andnational courts and public authorities are obliged under EU law to resolve any

discrepancies. It would be useful to ask commissioners, both LAs and PCTs, abouthow they intend to meet with their obligations to both Art 152 (the promotion and

protection of health) and Art 95 (harmonisation).

In addressing these issues in the round the CQC will have to ensure that both LAs

and PCT commissioners know how to apply these considerations when a third party

partnership may be considered to have behaved in a concerted way, with or withoutpublic authority backing and/or when the rights of redress at the level of the

individual are fettered by contract level agreements and/or the rights to consultation

and opportunity to be heard have not been upheld. The CQC can weigh these

matters by asking public authorities:

to produce Commissioning and Procurement Concordat and review their S11

Health and Social Care Act procedures, making clear issues of subsidiarity,decision making derogation between welfare, procurement and competitive

process and decision making rights, and rights of representation and redress.

to use Prior Information Notices to publicise their commissioning intentions

to make full use of OJEU Part A procedures and where appropriate make the

case for efficiency exemptions

to show how service standardisation (Article 95 of the TEU) satisfies both

local welfare duties and the EU requirements for the protection and promotionof health ( Article 152 of the TEU) and the social protection of vulnerable

adults and children.

Further risk mitigation in this scenario can be developed by ensuring the behavioural

attributes of commissioners and providers set against systems archetypes likeshifting the burden eroding goals, fix to fail and tragedy of the commons are

assessed against the systems requirements and that this dimension of the CQCassessment schedule looks for evidence of both master planning and a requirements

management approach, to ensure compliance with both domestic and EU law.

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This will show up at the commissioner and provider level by looking at healthinequality at health speciality level by measuring the RTT access to services of those

most likely to experience discrimination. I would suggest that the CQC includehomelessness, depression, drug related deaths (including alcohol), sexual health for

16-25 year olds, asylum seekers (especially unaccompanied children), ethnicmonitoring and the pathway between primary and tertiary are for disabled people as

areas for special review at Q2 and Q4.

Further to this I would ask that the CQC looks at the cumulative additive value of

RTT data for third party provision in these areas at 4 levels, firstly, weighing theadditive contribution made to the quality of life a the level of the target population;

secondly, the extent to which choice exists at the level of the individual; thirdly, howthese considerations address health inequality at the level of the total population

served and fourthly, the ability of providers and commissioners to demonstraterobust and effective demand management to address unmet need.

The extent to which there is any generic understanding of these approaches tosystems dynamics, but also systems thinking and system requirements remains

unclear and I would ask that the CQC make explicit the approaches it is using asembedded aspects of the assessment approach. And, I would go further and suggest

that the current metrics that are formulated using how many of a kind (fractions)do not provide a robust mathematical basis for the determination of ratings or

performance judgements.

In conclusion, the CQC has used the language of systems dynamics as an embeddedpart of the assessment process and this is to be welcomed.

This said, spelling out what the CQC mean by system dynamics, systems thinking

and system requirements will go along way to re-invigorate health and social caremodernisation adding a motivating pull to all stakeholders - public, patients and

professionals alike.

In the absence of a bespoke competency assessment framework INCOSE have

produced a generic model incorporating systems thinking, systems dynamics andsystems requirements and cover comprehensively all that has been mentioned

above. Other open source learning material is available at systems thinking world athttp://www.systemswiki/resources and the Open University has recently started an

OU programme for systems thinking.

Alec Fraher

http://www.systemswiki/resourceshttp://www.systemswiki/resources