Making it better for children and mothers

Complexity science in the NHS

Leila Williams and Peter Miles

Complexity in the NHS

We all understand that the world is becoming more complex and inter-related, and nowhere is this more evident than in today’s NHS. We also know that there are limits to the complexity that people can manage without specialist tools and techniques, yet in most cases we continue to attempt to muddle through. However, learning from the emerging set of sciences labelled as ‘complexity’ is beginning to point the way with the emergence of pragmatic tools and techniques for managers faced with otherwise intractable challenges. This is the story of the application of the Complexity Solutions Synplex process to the kind of complex transformation that is becoming increasingly prevalent in the NHS and beyond.

Making it Better

‘Making it Better’ represents a transformation of maternity, children’s and neonatal services across Greater Manchester, and as a first key step in implementation, the Children's, Young People and Families’ Network decided to apply the Synplex process from Complexity Solutions to help with the challenge of implementation.

The objectives for Making it Better are higher quality, more child-oriented services closer to home with increased choice for mothers, all backed up by centres of excellence with a concentration of highly skilled and experienced staff. It has taken more than five years, and the biggest public consultation in the history of the NHS, to reach a decision to go ahead. The change involves twelve primary care trusts, eight acute and foundation trusts and a wide range of other organisations, including local authorities, the voluntary sector, the ambulance service and public transport services.

Where do we start?

With any complex situation, some initial discussion is required on where to start. It soon became clear that the biggest barrier to success was that the trusts were going to have to work together in a coherent way as a network rather than a set of ‘silos’. Any problems in implementation could trigger a natural reversion to focusing on the needs of an individual trust to the detriment of the whole network. The chief executives and their senior teams naturally had real concerns about the transition and there needed to be a process whereby these could be addressed.

The decision was taken to invite the chief executives themselves to a Synplex workshop at which they could raise their concerns in a structured way and start to see the patterns of concerns that emerged on the principle that, once these concerns were clearly visible they could be managed.

A trigger question was sent to all participants, who then responded over the next few weeks with answers to the question. All responses were captured in the Synplex software tool and Complexity Solutions spent some time prior to the workshops analysing the responses.

What are we facing?

The first workshop

Starting with a list of 160 factors, all responses to the trigger question, participants then selected those factors which concerned them most.

The main part of this process is called influence mapping. This involves comparing pairs of responses to the trigger question and voting on whether people see an influence from one to the other (everyone has a yes/no card). This part of the process may seem trivial, but in fact this is where the ‘magic’ happens. People vote differently because they have different things in their heads. Sometimes the factors have to be re-worded along the way or one factor has to be split into two or three new ones. Differences of understanding and opinion are discussed until there is a strong majority voting one way or the other. By this time, there is reasonable confidence that the participants are now using the same words to mean the same things. This may sound simple and obvious but it is the key to mutual understanding. No time is wasted when people agree, but when they disagree, as much time as necessary is taken to clarify what people are thinking and to make sure the words match the ideas. A very wide range of discussion topics can be covered in a few hours, each of them very focused. Step by step the collective understanding of the group is increasing, with the results represented on the influence map generated by the Synplex software.

The influence map is built up, step by step, as more factors are selected for analysis. This two-day workshop concluded with an influence map with 27 factors displayed, agreed by all of the participants.

Now, what are we going to do about it?

The second workshop

The group reconvened several weeks later for this two-day workshop, focused on developing and agreeing a set of clear actions to break through the complexity of the original situation.

The group examined the influence map and chose a set of issues which they decided needed to be resolved to enable the implementation of Making it Better. These are called the critical factors and the group selected nine of them.

Focusing on these critical factors, the group then developed eleven objectives to address them. The Synplex tool was then used to check for timing dependencies between these objectives-this is vital to understanding how they interact. The group made initial time estimates and an owner was appointed to each objective. Much of this workshop was spent with small groups working in tables, then reconvening as a plenary group.

The result of this workshop was a breakthrough plan designed to ‘clear the decks’ for Making it Better. This has provided a solid basis for the full implementation plan that is now being developed.

Future opportunities

The continuing transition to an NHS which is ‘patient-centred, clinically-led and locally accountable’ will require stakeholders of many different kinds-including service users- to work together to co-develop the joined up, integrated, coherent services that will be demanded.

Making it Better is one of the first major reconfigurations of its kind in the UK, so people across the NHS are looking to see how it is implemented and learn from it. This initial NHS application of Synplex has been seen as a very positive learning experience and has already generated significant interest by other NHS groups facing complex multi-stakeholder situations.

“The process works so well as it is immediately engaging and involving. Collectively we quickly gained insight into the significant issues that we needed to resolve to ensure successful implementation of a major service change”

Sue Assar, former project director, NHS North West

"The Complexity Solutions' approach is disciplined and rigorous and genuinely does provide a means to see a clear way through even the most challengingly complex projects and programmes"

Chris O’Gorman, associate director of Joint Commissioning, Manchester PCT

“I found both the process and the delivery of the workshops high quality with tangible outcomes. I would, and have, recommended the methodology to colleagues faced with resolving complex problems with multiple stakeholders”

Ann Barnes, deputy chief executive, Stockport Foundation Trust

“I found the approach especially helpful because it stimulated an intelligent debate between people coming at the issues from different perspectives, but was successful at distilling a consensus on ‘what really matters’

Ann Schenk, director of Service Development, Bolton Hospitals NHS Trust

Synplex and ‘lean’

Whilst lean is generally focused on efficiency-doing things right, Synplex is focused on effectiveness-doing the right things. As such they complement each other, with Synplex being a great place to start. A Synplex workshop can ensure that a deep understanding of the current ‘as-is’ situation is developed amongst the appropriate stakeholders along with a clear alignment of priorities. It ensures that participants have coherent mental models of the situation and that they use language in consistent ways, avoiding misunderstandings which can lead to distrust. All of this provides a solid foundation for the subsequent application of other techniques including lean and traditional programme management.

The complexity sciences

‘Complexity’ provides a theoretical framework for understanding organisational change and re-design. The “complexity sciences” cover a wide range of disciplines, spanning physics, maths, social systems, management, and even art and music. There was a multidisciplinary conference in Liverpool in 2005 covering all of these areas and more but perhaps the greatest single area of interest was health. For a number of very good reasons, many key thinkers in the UK health service are interested in this area. Complexity was a particular theme of the Modernisation Agency and the ideas continue to be developed.

Making it Better is the first application of Synplex in the NHS. Synplex has been used in the USA to develop contingency plans for bio-terrorism in the US hospital network.

Peter Miles

T: 0161 209 3800

E: peter.miles@complexitysolutions.com