Commissioning for Value

A Systems Thinking Approach to

Designing and Commissioning Advice

Services

Simon Johnson

AdviceUKLondon Advice Conference

3 July 2012

Thinking governs performance

... if we asked different questions we could do better things

… we work on doing things better ...

When we want to improve performance...Performance

System

Thinking

Systems ThinkingSystems

• Where and how do people come to our service?

• Why do people come to us and what matters to them?

• Do we do what matters?• How do we know?• How does work flow

through the organisation?• Why is it how it is?

Thinking

• What are our underlying assumptions about how work should be organised?

• What do we think our purpose is?

• Who decides and how?• What do managers pay

attention to?• How do they spend their

time?

We treat all demand as though it is useful work and manage it through rationing

Understand what demand is preventable (failure) and design it out

Pay attention to costs and costs will fallUnderstand that cost is in how work flows.

Identify the causes of waste and design only to do value work

Standardisation improves performanceUse scripts, procedures etc.

Design against demandDesign the system to absorb variety

Control work using targets and activity measures Understand and improve based on measures derived from purpose and what matters

We have a people problem – find ways of managing their performance

95% of the causes of ineffectiveness are in the system. Paying attention to individual

performance is focusing on the 5%

Managers make decisions, workers implement them

Decision-making is integrated with the work

Traditional Thinking Systems Thinking

Unlearning how we think

We have a contractual relationship with people. We provide a service and they choose to use it

We work alongside people to understand their problem and what matters to them

We have a contractual relationship with commissioners. They procure and monitor:

we deliver and report

We have a partnership that uses measures data to continuously improve the service and outcomes

It’s the System Stupid!

●30 – 40% of the demand for advice shouldn’t be there. It’s caused by the failure of public services to get it right for their customers

●The way advice services are commissioned typically drives the wrong behaviour

●Pressure to hit targets causes cherry-picking of easier cases and a revolving door – if clients don’t get their problems fixed, they keep coming back

Look at work a bit differently...

“The performance of anyone is largely governed by the system he works in.”

If we set targets and make people’s jobs depend on meeting them...

“...they will likely meet the targets – even if they have to destroy the enterprise to do it.”

Dr W Edwards Deming1900 – 1993

What we learned about demand in

PortsmouthNot all demand is the same:• 56% ‘value work’ – what we’re here to do• 41% preventable, generated by other

agenciesAgency % Preventable

% of Demand on Advice Services

Job Centre Plus 25% 8%

Pension Service 10% 3%

Disability & Carers Service 5% 1.5%

Social Fund 10% 3%

HMRC 10% 3%

Other 25% 8%

Purpose

“Help citizens to pay their rent and council tax by making a decision and paying benefit

quickly”

Portsmouth Approach:Background

• Portsmouth CLAC opened on 1 April 2008• PCC felt that LSC contract inflexibility meant

service not meeting residents’ needs• CLAC partnership dissolved and interim 1-year

contract let while commissioners learned about the service

“What gets us into trouble is not what we don’t know…

It’s what we know for sure ... that just ain’t so.”Mark Twain

1835 - 1910

What are we here for?

How well do we do it?

How do we know?

Why is our performance like this?

Get Knowledge and Understanding (Check)

• How the work works

• What gets in the way?• Thinking

• Purpose• What matters?

• Demand

• Measures• Capability

?

Understanding demand: ‘getting in the work’

Understanding purpose as commissioners:• Listening to customers at front desk• Sitting in on interviews• Finding out what matters – really matters – to customers• Understanding the system• Realisation that the system was driving the work, not vice versa

56% Value 44% Failure

205 - 345 per week

Take ticket from

machine Take a

seat

Called to reception &

handed green form

Take a seat

and fill in form

Hand in form to

reception

Take a seat

Form details entered on IT, ticket number on form, board

in back office updated and form placed in tray

Advisor picks up oldest form from

tray and calls client number

Advisor and client go to interview

room

Advice givenClient leaves

Average 69 minutes : could take 2 hrs 39

mins

Client enters centre

Avg 33% of clients leave

before adviser is free

Purpose: Give me the right advice and appropriate level of support to help me resolve my

problem

On 56% of days we are open for less than 50%

of advertised hours

What we learned

Waste Steps

Waste = Spending time doing things again which have not been done right the first time

Waste = Duplication of effort

Waste = Doing things which add no value to the client

Capacity = Value Work + WasteCapacity = Value Work + Waste

Levels of Need

I need something done on my behalf

31%

I need advice about something

51%

I need some guidance /

information then I can sort it out

myself18%

Type of help requested

Defining purpose

Better understood our customers’ needs Defined purpose in customers’ terms Purpose supported by underlying principles Learning then drove the commissioning

process:

Invitation to TenderPurpose:To provide an advice service that supports the people of Portsmouth to solve their problems.

Principles:•Responsive•Enabling •High quality•Professional•Flexible•Collaborative

Working with The Wider System Preventable Demand (Failure)

Advice Portsmouth

PCC

People

Other Agencies

egDWP

‘The Wider World’

If we did something different in Advice

Portsmouth we could prevent this demand

coming in

If PCC did something different we could

prevent this demand coming in

If other agencies did something different

we could prevent this demand coming in If the wider world did

something different we could prevent this demand coming in

Commissioning:• Learning drove the commissioning and tender

specification• Purpose, principles and measures are specified –

method is free• Applicants required to demonstrate, against each

principle:– understanding of the continuous improvement approach– evidence of where they have designed and delivered

services in a similar customer-focused manner– how they would apply the learning to the Portsmouth

model

Commissioning:

How did the process feel?•Looked very different to previous tender specifications•Needed to get procurement ‘on board’•Element of risk

– would organisations ‘get it’?– would commissioners be able to assess objectively?

•Changes the relationship from commissioner / provider to a partnership approach, with learning and improvement at the heart

Commissioning:Did it work? Yes!The framework demonstrated clearly how far: •bidding organisations understood the approach;•they could relate it to ways they had worked previously; and – most importantly...•they could think about the work in a new way, building the service around what matters to clients

Measuring success• Number of people trying to access the service by type and

frequency of demand• Number of people successfully accessing the service by type

and frequency of demand• Number of people who abandon trying to access the service by

type and frequency of demand• Number of repeat visits• ‘End to end’ measures i.e. length of time taken for customer to

receive service, total time taken for customer to resolve their problem

• % value and failure demand• % of people referred to other agencies

Redesign Principles

• We are open when we say we are open and we never turn anyone away

• We stop doing things that create queues• We have expertise on the front line• The people who use our service define what matters• We have conversations with people that help us to

understand their problem and what matters• We only do things that create value for the people who

use the service• Minimise hand-offs – pull expertise when required• We design the service based on knowledge. If we don’t

have data we go and find out• Everyone has two jobs: do the work and improve the

work

Just the beginning• New transformed service launched beginning April • Steering Group using measures data to have meaningful

conversations about continuous improvement• But still lots of work to do:

• Deeper understanding of root causes to inform response• Exploring common areas of failure demand across the

wider advice services in order to switch it off• Building on the measures• Building on the partnership – shared Risk Register,

monitoring meetings ‘in the work’, understanding external failure demand

• Working with partners to switch off external failure demand