How Can We Move From Demand Led Service In The ‘New Normal’?

In the early hours of Good Friday I found myself undergoing emergency surgery after a complication during an earlier test. Even in the midst of some pretty intense pain I was unwilling to go to hospital – a mixture of fear of contracting a certain virus and some overly optimistic thinking about my super human ability to recover without any professional intervention. It was probably Karen wilfully ignoring my instructions not to call an ambulance that saved my life.

Eleven days later I was discharged from hospital after major surgery and two COVID-19 tests. Family and friends were unable to visit so I had a lot of time for self reflection, and to observe from the inside how systems operate during periods of genuine crisis.

The term crisis is overused.  Every day the news is filled with stories about war, terrorism, crime, pollution, inequality, and oppression. There’s a health crisis, a housing crisis, a climate crisis , and a social care crisis. So many “crises” they have to jockey for position in order of seriousness.

What the COVID-19 crisis has done very effectively is to say “hold my beer” to the others – becoming the defining crisis of the moment.

One of the most interesting things about my experience of hospital was the apparent disconnect between the media reporting of what was happening on many wards, and my own actual experience.

Family expressed concern for the health workers without PPE at the same time as staff told me there wasn’t a problem. People told me the system was in meltdown when my observation was of staff continually adapting to new working practices based upon the evidence and experience of the previous day.  Even if the system was in ‘crisis’, at a local ward level people were pulling together and solving problems in new ways. Freed of some of the usual ‘rules’ people were succeeding despite the system rather than because of it.

The NHS is brilliant at coping with an emergency , both at scale and at the individual human level. I simply couldn’t fault my experience, from the operation to the recovery to the after care. The people ARE heroes. It’s not the time to pick fault with the system , but where it often falls down is in some of the basics. These are often things that are less urgent to professionals , but more important to us as citizens , such as communication and keeping us informed of progress.

This is not limited to the NHS , far from it. It’s a symptom of systems that are designed to be reactive rather than pre-emptive. They tend to be designed from a ‘service’ point of view – managing demand – rather than through person centred design, the principles of which are the opposite of service led design.

During my stay, staff noted how demand had dropped. People simply weren’t coming to Accident and Emergency anymore. The country had either stopped having heart attacks and strokes or were delaying reporting them.  This drop in demand isn’t limited to the NHS. Other social providers are seeing similar trends. The phenomenon has also occurred across the US and in parts of Asia.

So why has the system been able to manage demand, something that’s been a problem for decades, in just a matter of weeks?

Obviously , fear is playing a part. In a lockdown scenario people’s priorities have a major shift. Things that would once be major causes of anxiety get reordered in the face of a common enemy.

That said , there is something to learn from how the latent and underused power of community has been leveraged to protect our most precious resources.

People have begun supporting and caring for one another to an unprecedented extent, with community led groups popping up to address immediate needs in ways our organisations simply can’t. It is neighbours that have shown themselves to be the most useful support network in a physically distanced world.

YouGov have reported that only 9% of Britons want to return to life as normal after the end of the lockdown. 40% of people say they feel a stronger sense of community since the virus shut down normal life, while 39% said they had been more in touch with friends and family.

What this seems to indicate is that far from communities resenting a shift away from a passive provider-consumer relationship – they actually desire it. They want a greater say, they want more power to influence local decisions.

There’s a danger here of being overly optimistic as Simon Parker has warned. “Simply willing a better world is not enough. You have to dive into the complexity, dance with the system in its full, messy intractability”.

System change never comes easy. It means thinking beyond individual sectors and requires the whole system to work together, through health, housing, employment and social care. There’s opportunity here if we are brave enough. 

That said , a lesson so far from COVID-19 is that the best currency for change is local. People are discovering their neighbours for the first time, spending less time travelling to soulless business parks , and spending time and money where they live.

Powerful forces will resist any attempt to make this a new normal. It’s not how capitalism works.

However my recent experience has led me to believe that the organisations that emerge stronger from this crisis will be ones who have abandoned doing things to people, and moved to seeing themselves as equal partners with communities.

That requires making a move from telling to listening.

A move from obsessively managing demand to leveraging the skills in the community.

A move from filling the gaps with more services to closing the gaps through social connections.



Image by Queven from Pixabay 


8 thoughts on “How Can We Move From Demand Led Service In The ‘New Normal’?

  1. Hi Paul, great to hear that you seem to have come through a very scary time okay. It will be interesting to see how many lessons we are able to learn from the current situation. We’ve had a lot of contact with the NHS as a family over the last several years and our experience has been (almost always) excellent. Communication and social care are the two areas where things are not so good. Communication is also extremely wasteful; we received an average of two identical letters for each appointment and often more. No-one seems to have heard of email. We get text reminders of appointments but never details of that appointment electronically.
    Keep well

    1. Thanks Russell – I’m getting there! Yes you’re right and it’s also interesting how the pandemic may have accelerated some local progression. For instance my GP has suddenly switched to email to save me going into surgery. It has definitely prompted a sense of urgency that I hope continues.

  2. Hi Paul, and interesting to hear your experiences. The write up touches on so many points, and I thought I would respond to only one.

    The NHS is make up a myriad of ‘services’, just to simplify something so complicated. Each service in itself, will have its own waste and issues, but may work quite well never the less. In particular, the surgical part of the NHS has been designed to effectively get patients into and out of surgery well, and this is achieved because the flow to achieve this is relatively transactional, but not always complex.

    If you then superimpose that surgery, with an elderly person, or someone who has mental health issues, the surgery might go well, but their recovery at home may push them into untold trouble. Their reduction of wages might push that family, who are already in debt, to an impossible situation for them.

    We have taken demands from community health and social care and each case was complex, and required a flow to be designed around the demand and what matters to that person.

    It is interesting how you demonstrate that the NHS is itself only an organisational construct, the workflows that delivers what it is there for, are widely varied and a huge list.

    Interesting to think of the staff that give the wonderful service, and how they do that. Nurses and many others in hospitals work 12 hour shifts as standard. Can you imagine the stress and condition of those staff after one year, and can you imagine the potential for error when nurses work like this? And despite all that they do such amazing work.

    1. Thanks John – I was reading some of your posts as I formed my thoughts and you’re spot on. I think the fact that we sometimes think of the NHS conceptually as one organisation is part of the problem (also the same when applied to much smaller but no less complex organisations). Clearly any complex structure is going to have parts that work quite efficiently in isolation the problem coming when things go beyond the transactional. I actually had direct experience of this a couple of weeks before my operation when the system worked efficiently UNTIL I made a request for a second opinion. It seemed the system that was in place wasn’t set up to adapt to a person centred workflow. I think this is quite common in many organisations. But yes, you’re right to point out the amazing work that goes on despite this. It shows how great people can still do amazing things despite working in complex systems

  3. Hi Paul, great post. Your search for realism and authenticity knows no bounds! Glad you’ve survived to tell the tale. Fascinating at the moment to try to grasp what the future will look like, the only certainty, to quote the old joke, is that ‘the future ain’t what it used to be’. Your first hand view bears out the testimony of a close friend of mine who I go to the match with – and we usually have another medic or two on his spare tickets. He’s a senior anaesthetist at a large hospital so he manages the Intensive Care Unit (ICU) including use of ventilators. Each time we’ve communicated I’ve had the impression of people on the ground coping very well with the changing scenarios, yet it’s at odds with the general overview we’re given in the media. If communication at a local organisational level needs to improve so indeed it must at national level, particularly Govt. As a board member these days I’m interested to see how we can provide a human contact, face-to-face service safely in the future for those that need it. The current position may serve to convince people, even if only through fear of illness, that they can manage with Digital only, but over time there will be a balancing out I would guess as some will struggle. What I’m also finding baffling is how unprepared we’ve been as a nation, especially given that at times we seem overrun by risk consultants. This pandemic only seems to have been foreseen by filmmakers (Contagion, 2011, see Netflix – so accurate!) and writers (Lockdown, 2005, Peter May – they even build a hospital next to the Thames to cope with numbers). Yet we describe it as a ‘black swan’ event, something we coudn’t predict but with hindsight we may well have seen coming. Stay well!

    1. Thanks Paul – a great comment. You’re right – I heard former Home Sec Jacqui Smith saying that a pandemic had been top of the national risk register ever since the nuclear threat receded so it’s remarkable that the west was unprepared. In the circumstances I think people have responded brilliantly and that’s largely because they’ve adopted a ‘what works locally’ mentality.

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