Dear Colleagues, Many thanks for providing the opportunity to contribute to the CQC consultation on assessing commissioners and

providers. Firstly, can I congratulate the CQC for raising as a matter of priority the rights and entitlements of service recipients and the 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 and children 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 Health Committee Inquirys into Commissioning and Out of Hours GP cover. A present an overarching SOSM (System of System Method) covering all the main approaches 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 overarching guidance to be found on where and when to use a particular approach.This makes it extremely difficult for any commissioning, purchasing or procurement and delivery function 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 this issue 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 ask that 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 Eric Wholstenholme, 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. (see Senge, 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 has been made in assessing the detail complexity of the many public sector providers I am mindful of the adage without conceptual frameworks [health and social care professionals] are likely to fail to understand the context within which they operate (Preston-Shoot 1990)

At this time it is becoming increasingly important to realize that the hard systems approaches such as TQM, Structured IT methods, Operations Management and lean methods and lean systems thinking maybe useful from a Detail Complexity perspective when the problem definition/ solution is tame and the system of concern is closed. However, when behavioural and dynamic complexity is more complex other approaches and perspectives are needed. There are a number of ways of weighing these sorts of issues and they are shown below and over the page:

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 boundaries How we identify airs of concern?'

Systems Level, e.g. Viable System Model -Supply Chain

Transactional level A la lean thinking, e.g. Order Entry

Where do we make the intervention? At what level do we make the intervention? What is the systems of interest?
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Likeliest Intervention for Performance Improvement

Rule Set Complex Many
Diagnosis to understand relationship between sources of value (context) and value chain; determ ine and set boundaries.

Messy/Wicked Problems Including special causes Note; innovation often falls into this area

Value Analysis to understand sources of value, cost and perform ance Sim ple Analysis to understand cost and perform ance, e.g. Six and Lean Sigma, BPR

Clarifying the Problem? What is the system s of interest? Complex behaviour can be based on simple rules

Rule Set: Simple /Few

More com plex end-toend Process Analysis needed to construct value chain and understand, cost, value and perform ance

Tame Problems

Process Complexity Simple

Process Complexity Complex

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

techniques.
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It will be crucial that the CQC helps commissioners to understand the difference between 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 system where 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 oxymoron lean 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 to increase process efficiency at the transactional level. This does not mean that Detail Complexity should be abandoned it does mean that the CQC must not confuse the use for example, of systems dynamics, beit Detail Dynamics or Dynamic Complexity with System Thinking and further Detail Dynamics with the analysis of bounded systems of work. The latter is characterised by notions of end to end linked process optimisation activities (transactional analysis sometimes called 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 to assessing 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 the interaction with the wider open system it is said that at present there is no Systems Thinking approach which can accommodate these two views although Soft Systems 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 greater certainty and guidance to both commissioners and providers when framing the assessment process. For example, my own reading of Section 3, Our Aims for Assessment in the Consultation document would seem to have some similarity with the European Foundation of Quality Management (EFQM), but unless this is spelt out commissioners and providers alike will be left in the dark. By comparison illustrations of a typical organisational circulatory system (Kleiner 2009) and viable system model (Beer 1989) are shown below, I include them to diagrammatically show the conceptual world views and interdependencies both internal 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 system dynamics show up in modern organisational behaviour. The second is known as STEEPV (see below for description) and sets out to show how systems and sub systems 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 the commissioning agenda with the welfare principle, public procurement law and competition law. All diagrams have been reproduced here with the permission from Art Kleiner and colleagues from Cranfield University.

Leaders can affect at least four major circulatory systems.

Seeks equilibrium; limbic system; source: King and God; Transmits formal directives, requests, promises, rights, evaluations.

Hierarchy (flow of authority) Network (flow of knowledge) Clan (Core Group) (flow of allegiance)
Seeks legitimacy; endocrine structure; source: Family and Love; Transmits behavior, emotion, loyalty, purpose, commitment.

Market (flow of work)

Seeks production; cardiovascular structure; source: Supply and Demand; transmits value, goods, services, payment, results, credit, nourishment, waste.

Multiple Perspectives
A viable Systems View How does optimising processes at an operational level help development of capability?

Suffice to say these approaches are not for the novice but have been used with limited 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 satisfaction and 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 see http://www.12manage.com ). In practice, my observation suggests that colleagues within health and social care have a tacit knowledge of these approaches and that the introduction of such master planning is already underway within Local Authorities; the information flows and data sets 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 a sector 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 transactional level and into social, political and macro economic environment and

2. develop Viable Systems Models approach to deal with an open systems view of 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 on vulnerable populations. In summary: The advancement of a dynamics approach will depend on the guidance the CQC may be 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 to assess: level whether appropriate intervention(s) are being made and at an appropriate identify a proven closed systems approach for lean services evidence of both convergent and divergent thinking

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 Systems Dynamics (Sterman) evidence which utilizes both hard and soft tools (e.g., run charts and concept modeling) An approach which consider organizational maturity and commissioned expectation. 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, Systems Dynamics approaches have little to say about this. And, in health and social care the interaction between competition law, public procurement law, contract law and welfare law is largely unchartered waters. Article 226 infringements of the TEU are increasing in number, and recent EU decisions are having an increasingly bigger impact at a national level than first thought possible. This is new ground for many public authorities and national governments. And just as 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 Employment Rights, the Rights of Establishment, Effective Remedies and Fundamental Human Rights will start to gather a pace.

The risks bing mitigated here are an Article 226 complaint and judicial review. The former 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 the TEU) 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 UN Convention of the Rights of the Disabled Person and EU Charter of Fundamental Rights, hence the vulnerability to judicial review. And, by derogation with Art 48, at the level of the independent service provider who must 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 service obligation and/or welfare duty. This later condition, is unchartered water, when applied to personalisation and individual budgets, nevertheless the risks is not so remote 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, and national courts and public authorities are obliged under EU law to resolve any discrepancies. It would be useful to ask commissioners, both LAs and PCTs, about how 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 without public 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 promotion of 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 like shifting the burden eroding goals, fix to fail and tragedy of the commons are assessed against the systems requirements and that this dimension of the CQC assessment schedule looks for evidence of both master planning and a requirements management approach, to ensure compliance with both domestic and EU law.

This will show up at the commissioner and provider level by looking at health inequality at health speciality level by measuring the RTT access to services of those most likely to experience discrimination. I would suggest that the CQC include homelessness, depression, drug related deaths (including alcohol), sexual health for 16-25 year olds, asylum seekers (especially unaccompanied children), ethnic monitoring 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 the additive 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, how these considerations address health inequality at the level of the total population served and fourthly, the ability of providers and commissioners to demonstrate robust and effective demand management to address unmet need. The extent to which there is any generic understanding of these approaches to systems dynamics, but also systems thinking and system requirements remains unclear and I would ask that the CQC make explicit the approaches it is using as embedded 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 embedded part 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 care modernisation 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 and systems requirements and cover comprehensively all that has been mentioned above. Other open source learning material is available at systems thinking world at http://www.systemswiki/resources and the Open University has recently started an OU programme for systems thinking. Alec Fraher