Commissioner

It can be hard, being a manager, balancing the needs of today with the possibilities and risks of tomorrow. Things can be stable for a while – but often not for long. And if it’s hard managing within a single legal entity, how much harder is it for managers to collaborate across a system which comprises many organisations and many service elements.

We run a management simulation, Commissioner, which was designed to provide a learning platform for managers to practice collaboration in managing across a set of public sector services to deliver the best outcomes with constrained resource, although the learning is applicable in many contexts. The case deals with the issues around managing Children and Adolescents Mental Health Services (CAMHS) and a team of delegates plays the management of the mental healthcare system. The task involves designing a performance measurement system that will make the working of CAMHS more transparent to different levels of management and using the information to decide on priorities and then manage the system by deciding on the allocation of resources. And of course, generically, that task of managing whole systems is increasingly common.

The simulation

The simulation has thirteen roles spread across those 3 organisations. Each role is taken by one or two delegates. They aren’t asked to role play, but they are given a very specific role description which includes the issues which that role is most concerned with, and the activities which that role need to deliver. The simulation covers a period of 10 years of service delivery – which provides scope for the management team to evaluate the impact of their policy decisions on service performance. The task for participants is to:

• Decide whether and where to collaborate with other services on both strategy and operational delivery
• Gain a holistic view by measuring performance across services
• Design a performance management framework with insightful and timely measures, providing the right information to take decisions
• Decide strategies for each service

The participants start to get a grip on the system when they can gather enough information to work that monthly demand exceeds the monthly capacity – and so the services as currently configured cannot possibly succeed and need to be redesigned. Through the simulation, they add effectiveness metrics to initial throughput metrics, and sometimes visualise performance information in support of both operational and strategic staff.

The learning is rich and fairly consistent, independent of the ‘day jobs’ held by participants. Learning is generally in five main areas:

1. Information / decision taking. Information ‘islands’ build up really quickly – not integrated, and so not useful. Those with good and relevant information (the operations staff) find it hard to get the strategists interested. When the strategists get outcome metrics, they tend to put them to one side and get on with what their strategizing. People take decisions based on the information they have – and as the information is poor / incomplete, then the decision will be correspondingly poor.
2. Strategy development. Those in strategy roles don’t know how to do’ strategy and issue motherhood-and-apple-pie statements to the operational roles. A tricky dynamic appears: strategists want the operational roles to “report their performance” (and request this in a very vague way) and the operational roles want the strategists to define the performance reporting they want.
3. Operations. Operational roles get vexed by the lack of direction and guidance, and the unstructured requests for information. Conversely, they are usually the quickest to spot how to ‘fix’ the system, but find it incredibly hard to be heard by the strategists. Operations staff report that it is uncomfortably easy to lose the connection to the purpose of the service (changing a mentally unwell child to a well or improved child) and instead get entrenched in the mechanics of the process, focusing on numbers, not children, parents, families. Operations staff feel the emotions of the role they have been allocated, and report feelings of being cut adrift, driven too hard, ignored, overlooked, having things demanded of them which aren’t well enough specified…
4. Strategy – operations interaction. When there is a strategy vacuum which results (the strategists aren’t doing it), the operational roles generally formulate strategy themselves (individually or collectively), as they are the front-line people who are being hit by the pain and who most want to make it better. Even if there is a strategy emerging, the operations staff will often self-organise and enact strategy as they see best, independent of the stated strategy coming from ‘above’. This sets up a reinforcing feedback loop – as the operations staff self-organise, the strategists get left even more in the dark. Their ‘strategic’ input becomes even less relevant so the operations staff take things even more into their own hands … Meantime, the middle managers can get disenfranchised – they can’t engage in the strategic debate (or the strategists won’t let them) and don’t engage in operations.
5. Testing and time lags. Some policy or strategy decisions take quite some elapsed time to demonstrate an impact, so they need to gather performance information for several months after each significant decision before they can assess what difference it has made (if at all). Making a large number of small, tinkering changes simultaneously makes it really hard to assess cause and effect, what decision drove what change.

Learning to manage whole systems

Overall, the participants say that it’s like their day jobs – and this makes simulations an incredibly useful form of management development. It recreates the tensions and challenges of delivering services and improving them at the same time. Participants learn through doing, and can try out ideas in a live but risk-free environment. They learn about piloting, and matching the scale of change to the scale of the challenge: in some situations, tweaking is not enough and just uses up all-too-valuable resource. They gain understanding of system dynamics, and the complexity of working in ‘organisations of organisations’ – multiple legal entities combining to deliver a service. From the point of view of the child or adolescent using the CAMHS service, and their family, the structure and its management should be invisible. What matters to the child and their family is that they get the right treatment in a timely way. But in a poorly designed system, it’s the child who carries the consequences.

In this simulation, participants can see the impact of their decisions on individual services, and see how to optimise a set of services to improve overall outcomes and social impacts. It helps them to understand the importance of the right performance information, so that they can commission the right services and then be able to manage them. It helps managers to work through the complex issues of collaborating to develop strategies for a set of services, as well as experiencing the interpersonal and inter-organisational dynamics that exist.

Systems-based simulations can make a huge contribution in developing management competence in managing whole systems beyond just their own organisations. And it’s learning which is really hard to get through any other training vehicle – the delegates learn different things, and learn to notice different things. Although the case uses CAMHS as an example, this learning is applicable across many systems leadership situations and therefore is really valuable.