Understanding the work of healthcare

Questioning the work is pre-requisite to transformation

One of the traps organisations fall into when seeking to improve or transform is not taking time to understand the true nature of their work. Put simply, they fail to question their work (Anderson Wallace & Downham forthcoming).

The consequences of this are profound. They range from making the wrong work efficient, to re-enforcing current structures and models – locking in ways of working. This is a core reason truly transformational work is so uncommon. By not questioning the work, we make the current better, rather than do better things (Anderson-Wallace & Malby 2016).

Viewing the work differently

The other problem with much demand data is it tends to be based around labeled needs (Davis 2015). These labeled needs mirror the current system design, structures and response. In other words it, again, reinforces the current structures. If we truly want something different (transformational), we need to view the work differently. This is sometimes referred to as the difference between first order change (changes consistent with the already present schemata – the pattern of thoughts, logic and corresponding model and structure) and second order change (change the schemata itself) (Bartunek & Moch 1987).

A practical example of this would be to look at the front door of most healthcare systems – called Primary Care and specifically General Practice in the English NHS. Looking at this common first point of access can give us important insights beyond primary care and into the pressures more specialist secondary care hospital settings face.

Starting from the position of needing a new view, I am an advocate of keeping things simple. There are a large number of system archetypes to consider when trying to understand the work, but in healthcare two broad archetypes are particularly useful when beginning this journey.

Linear work:

A largely process driven bio-medical response to helping people. Examples are a test in secondary care, an onward referral to a clinical specialist or medical assessment. Other examples would be the diagnosis and treatment of a cancer or a surgical intervention.

This work can be highly technical in nature. Success is generally reliant on process steps coming together with high reliability (this is sometimes described as transactional work). It is generally highly specified in form and timing. Much commissioning of services assumes work is linear in nature.

Characteristics of linear work:

*Highly defined in process.

*Specified in nature, entry criteria and timing.

*Transactional relationships between the various parts of the process.

*High degree of certainty and reliability of interventions and timing define outcomes.

*Can be hugely technical in nature (such as a surgical intervention).

*Outcomes and standards can be easily defined.

*Pathways and processes are split amongst functionally specialized providers, teams and professionals.

*Market and financial incentives are used as management tools.

*The life context of the patient does not limit the outcomes of the intervention in the short and medium term.

*Delivered through hierarchical structures.

*Improved through Quality Improvement (QI) techniques (process mapping and waste identification).

Relational work:

A response that may include, but is largely concerned with factors outside the bio-medical. Such as the person’s environment and social circumstances (see my blog on social context in healthcare – Downham & Easton 2020). An example would be helping someone with type 2 diabetes, or trying to slow the disease progression of someone with COPD. This work centres on a person’s life and lifestyle – such as their network and wider determinants of health.  The work of Becky Malby (Malby 2019), Richard Davis (Davis 2016) and the late Julian Pratt (Pratt 1995) are good further reading in understanding this kind of work.

Characteristics of relational work:

*System designed to be able to iteratively help someone (to loop and try again multiple times).

*Adopt asset based (LSBU 2019) starting points with patients – what makes you well vs what makes you ill (The Health Foundation 2015).

*High degree of flexibility to help the patient ‘do what matters’ to them and help them take control of their lives (Marmot 2010).

*High degree of continuity avoiding deferring and referring where possible.

*Emphasis on helping the patient create a support network and sense of purpose.

*Time for professionals to create trust and relationships.

*Long term funding arrangements.

*Enabled through network based structures.

*Improved through systems thinking.

The important thing about these two archetypes is you need to organise and design services differently to achieve them.

The graphic below illustrates the split of these two work architypes as seen by a typical general practice over a week. This practice was in a relatively deprived urban area. Looking at the 262 consultations analysed, the green represents patients who required no further action, the blue represents patients who needed a linear response, and the purple represents patients who needed a relational response.

It shows that 29% of patients required no follow up at all. 50% required a classic bio-medical response (what the service is predominantly set up to do) and a very considerable 21% of people required a relational response.