How Failure Demand Keeps Us Stuck with John Mortimer

In this episode, I sit down with John Mortimer, a specialist in systemic service design and founder of Impro, to tackle a concept that is silently draining the resources and morale of our health care system: Failure Demand. John explains that much of the "spinning" felt by practitioners today—the feeling of running faster while staying in the same place—is the result of a system designed to manage the consequences of its own failures rather than meeting the actual needs of the person.

If you have ever felt that you or your organization is only as helpful as the rules allow, this conversation offers ideas for finding traction in the spin and eliminating the invisible drain of failure demand.

Resources

John’s Videos on YouTube 

 Buurtzorg Model 

Human Learning Systems

Transcript

SPEAKER_03 0:11

Thanks for joining me today. In healthcare, many practitioners and leaders share a feeling that despite working harder and faster than ever, the system is simply staying in the same place. Our guest today, John Mortimer, is a specialist in systemic service design and human learning systems, and he helps organizations break out of this cycle of spin. As the founder of IMPRO, John helps organizations transition from traditional mechanistic management to an approach that prioritizes human connection over standardized processes and protocols. Originally trained as an engineer, John once viewed healthcare organizations like Repair Factory or Sausage Factories, as he likes to say. People go in broken, people come out fixed. However, a profound experience in 2003 led him to unlearn this machine metaphor and recognize that treating complex human needs with transactional tools often limits us in what we're able to do to keep people healthy. In this episode, we talk a lot about the Bertzorg model. Bertzorg meets neighborhood care in Dutch. This is a revolutionary approach to community nursing that started in the Netherlands in 2006 and serves as a real-world example of the approach we talk about in this episode. Unlike traditional healthcare organizations, with layers and layers of managers, Bertzorg is built on small, independent teams of about 12 nurses that are dedicated to a specific neighborhood or geographic area. These teams have full professional freedom and responsibility. They find their own office space, manage their own caseloads, and make decisions without any senior managers or rigid rules. They focus on what their people need and try to do it for them right away. The Bertzorg model recognizes that people often live in complex situations, and by trusting practitioners to use their professional judgment to adapt and flex to the need of the individual, family, or community, they get better results. The irony is that while many would consider it to be less efficient, it actually leads to significantly lower costs and better outcomes because it reduces the system demand that's generated from not meeting the needs of people the first time. This is referred to as failure demand. So let's get into it. This is my conversation with John. So it's Friday afternoon there, right?

SPEAKER_00 2:29

Mm-hmm.

SPEAKER_03 2:29

What are your plans for the weekend? What are you gonna do?

SPEAKER_00 2:33

As little as possible.

SPEAKER_03 2:34

Oh good. Sounds like me. Apparently, you don't have an 11-year-old and a 13-year-old to drive around.

SPEAKER_00 2:42

Not anymore.

SPEAKER_03 2:43

Oh good.

SPEAKER_00 2:44

They're a bit older than that now.

SPEAKER_03 2:46

Yeah. And where do you live in England?

SPEAKER_00 2:49

Um, not too far from Oxford.

SPEAKER_03 2:52

And how far is that from London?

SPEAKER_00 2:54

If I get on the train uh from the nearest town, it takes uh 40 minutes.

SPEAKER_03 3:00

Okay, oh that's nice. That's perfect. Then you can rip in for an event or a show and pop back out. The last time I went to London, I was like, I'm gonna move here. I love it here so much. This is like the best, and then about day three, I was like, holy smokes, I gotta get out of here.

SPEAKER_02 3:16

This place is crazy. Yeah, especially when you come from a small little town like me.

SPEAKER_00 3:21

So okay, yeah. And I used to have a job right in the center and I had to cycle in. Took me just under an hour.

SPEAKER_02 3:29

Whoa, that's a long bike ride in the city, like against all those cars driving on the side of the road.

SPEAKER_00 3:38

So it wasn't too bad in the end. But yeah, it was um, it was treacherous. You had to learn, you had to learn, you took your life in your own hands.

SPEAKER_03 3:45

Yeah, right. Yeah, yeah, for sure. Okay, so uh we'll get started here. Thank you so much for doing this with me. I've had such a good response from people from England when I asked. The bro was like, yeah, sure. I've had Andy Wilkins, I've had Dennis Vernier, who I'm sure you're familiar with, both of those gentlemen. Um, and now you. So thanks so much. So we crossed paths probably, I don't know, I feel like it was maybe two years ago, three years ago, um, when I had discovered the Systems Innovation Hub, which you were already a member. And as a nurse, my whole thinking and training was around assess, diagnose, plan, implement, evaluate. And then when I became a quality improvement person, it was plan, do, study, act. Um, and then, you know, even with lean, there was like a start and a finish to all the work that we were going to do. And then I came across this complexity thinking concept and healthcare is a complex adaptive system. And it completely changed, it was like a paradigm shifting experience for me. And like my friend Tanya says, my brain expanded like an elastic, and now it cannot go back to what it was before. It cannot go back to the shape that it was before. Um, and so I was quite new to this thinking, but you had been around and doing this work for a long time. You were one of the first people I actually reached out to personally to be like, can you like help me like figure out what how do you do this in healthcare? And we've had subsequent conversations since then. And I really appreciate how you've always been generous with your time and your thoughts and your feedback and helping me kind of sort this stuff out. But what I really appreciate about you is that you've taken some of these concepts that seem kind of like difficult in a lot of ways to implement and you've implemented them and you've worked with a lot of healthcare systems. And I'm assuming you were like me, where you were sort of introduced to the linear logistical methods, and then at some point you switched. So I was wondering if you could kind of give me your background on your journey and how you kind of came to the work that you do today.

SPEAKER_00 6:05

Yeah, thank you for that. So I used to work in the private sector in a large multinational uh and my background is engineering, so I was working in engineering, and of course, I had a very logical mind, and I thought that everything could be understood, um, made into little packs of data and knowledge that you could then transfer and make into graphs. And for me, an organization worked just like a machine, and I spent a lot of my time making it work more like a machine. I'd heard about different ways of working and all this kind of thing, and I looked at them and I was quite skeptical, to tell you the truth. I thought it was a bit pink and fluffy. I thought it was like, oh yeah, that looks nice, but it's not really appropriate when you get to the hard-nosed side of doing real business. And um, I happened to get a chance to work with a consultancy that worked very differently, and in the first few weeks and months, I was actually a bit skeptical as to what they did until I spent three days with somebody actually doing it and working with people. So they had a three-day course where they we took a group of people through this in their workplace, and I was absolutely shocked as to what this actually was. I had to experience it. I'd read about it and it didn't make much difference. I had to experience it, and um, I suddenly realized that there was a whole avenue of thinking about how organizations work that I hadn't come across and that was different to how I previously believed. So that was it. Uh, it was in 2003.

SPEAKER_01 7:55

Oh wow, that was a long time ago.

SPEAKER_00 7:59

Yeah, was that when that helped me? And I remember it, I remember the whole thing. Wow, and I remember the impact of people in that group. I was kind of not part of the group, I was watching, and I remember the impact uh it had on them. It was profound, and it was then profound on me. And from that, I started to look at the model, simple models that explained the concepts behind this. Uh, and and there were things like um the blind men in the elephant, for instance. When I saw that as a picture, I thought, wow, yeah, that represents what I've just, you know, how I was like, and and I then started to study um organizations like Toyota. But this was all through someone called John Sedden who helped me to see this. It wasn't me doing this on my own, so I was guided through this myself. So uh, and that was very helpful. And I kind of needed that guidance, I needed that mentoring um because it was it was a world that was uncertain to me as well. It was it was uncomfortable, so I needed the reassurance that this was a path that was worth going down.

SPEAKER_03 9:10

Yeah, there is a lot of comfort in that illusion of control that you have in changing a system, right? Like I had that um all the time when I worked it with nursing units, and I thought, well, yeah, you guys, you just do this, this, this, this. And we would do something. And then the first time I realized it didn't work was when we totally screwed up all the stock supply people because we had changed something and it had all these domino effects. And I'm like, oh, this just isn't as simple as I thought this was gonna be. We're gonna have to think more broadly about the changes that we make here. But of course, I didn't have any tools or theoretical background or anything to know how to figure that out. Um, yeah, so can you tell me more about John Sedden's work? I find him so fascinating, uh, or what his theory is about the organizations as complex systems.

SPEAKER_00 10:08

So he is a psychologist uh by training, and he started working in organizations and realized that what he was doing didn't work. And he found out that it wasn't the people that needed changing, it was the whole system around the people that employed the people. The way of working, the culture, the way leadership works, the way management works, the measures, motivation, all of this actually defines how people work. So he designed over time a methodology where people unlearn what they've learned, which is kind of what I had to go through, and then learn to new way of working. So he developed that methodology, and I kind of learned that uh during that time that I was working with him. And since I've left him quite some time ago, I've been developing that, but not just me developing that, it's not unique to one person, it's kind of it came from other places, it came from organizations like Toyota. Uh and a lot of people work this way, even though they haven't heard of John Seddon or Toyota.

SPEAKER_04 11:21

Right.

SPEAKER_00 11:21

So it is actually a natural way of working once we are able to unlearn some of the things that we've kind of learned. And I think that's the trick, really, is that unlearning. Uh, and it took me a long time to understand that that's what actually I had to do, which was it's a bit like what you're saying. I had to remove my comfort blanket.

SPEAKER_04 11:44

Yeah.

SPEAKER_00 11:45

And the a lot of people I meet have been influenced by him, and a lot of work that we currently do today has been influenced by people like him and and where his principles came from. And one of the other key areas that he focused on was uh the discipline of systems thinking. And systems thinking has become very popular recently in terms of helping people to look at different ways of thinking and understanding.

SPEAKER_03 12:14

And so is his model the Vanguard method? Is that his method? Okay, and that's the one you've learned and developed for the way you do work.

SPEAKER_00 12:23

Yes, and then when after I left Vanguard, I found that there were other people doing similar things. We all got together and we came together and called ourselves human learning systems.

SPEAKER_01 12:34

Okay, okay.

SPEAKER_00 12:36

So that's kind of and and that's all open technology, it's all there. You know, there's a guidebook there. There are 80 case studies, they're all public sector-related case studies. Some of them are to do with health. And so that's what we're trying to do. We're trying to really promote this way of understanding because it doesn't belong to anybody or any one method. Right. It is um it is for all of us to understand and apply it in the way that we think. But in more importantly, it's about us learning from each other.

SPEAKER_03 13:08

Let's start with how you started working in the healthcare system.

SPEAKER_00 13:13

Okay, so I'm gonna answer that question probably slightly differently to how you expect me to.

SPEAKER_01 13:18

Okay.

SPEAKER_00 13:19

I think that where I started was when I worked with local government, because for anyone that understands health from a systems thinking perspective, you realize that there are two parts to that. The first part is the clinical part of health, which are the doctors, the nurses, the specialists, the hospitals, etc. And then there is the aspects that determine health. And the majority of health lies outside of the clinical, formal, statutory processes of health. So that normally occurs in local government and in our communities. So at least 70% of the determinants of health lie outside formal health structures. So that's the first thing I learned when I started to work with local government is that what we were doing in local government was affecting people's health and their lives, because health is about living well, not about just fixing broken bones, it's about living well, it's about having a good life. That's what real health is. Uh, and that's what uh Andy Wilkins will have been talking about as well. So that's when I first got exposed to understanding health as a whole system, and then realizing that actually within local government, you can make huge differences to people's lives and to their health. But the fact that that was disconnected with the more formal health system, completely disconnected. So then I started working in the formal health system, and um, that was interesting because it was um very fragmented, it was highly specialized, and I I watched as the people working within it were working in a very mechanistic way that caused a lot of both further health problems, but also problems to them when they're trying to do this work. So I didn't come across a health system that was working very well, so I started to help them to see if we can explore different ways of working. Now that was um, gosh, that was 15 years ago. And I realized then that that was that was a huge task. And at the at the time we found that the whole health system wasn't designed to work differently, so it's very difficult to change one part of it when the whole of the health system was was working in the let's call it a mechanistic way.

SPEAKER_01 15:55

Yeah.

SPEAKER_00 15:56

And um then after that, I started to get to know uh the types of working like Bertzorg, for instance, which is a Netherlands-based uh model of nursing care. Um that was a very different approach to how we do that in the UK and how many countries do that around the world. And I was quite fascinated when in the UK they tried to implement Bertsaug and failed miserably.

SPEAKER_01 16:28

Oh wow.

SPEAKER_00 16:30

And what interests me is not just the method of Bertsaug, and that's just one example, um, but the fact that they couldn't make it work. Uh, and and that's now going to the deeper aspects of health and the way that we understand health, which we don't normally discuss these things. These things are not well understood for a start. If I talk to senior leaders in in health in this country, it's not a topic that they talk about. So part of this is actually starting to widen the conversation to ask ourselves, why do we work this way? And for a lot of leaders, they just follow the instructions that they have been told that they have to work this way. And of course, I come along and I challenge all that.

SPEAKER_03 17:15

Right. It's interesting. We had a health action plan released for our province this week. And um, I did an episode, just a little comment on it, because it was so disappointing how old the ideas were. And the Minister of Health in a in a press conference said, we're done standing still or we're not standing still anymore. And I was like, I don't think anybody's standing still. I feel like everybody's running, like spinning, like everybody's working really hard, but you can't get any traction to move anything forward. And I'm really interested in what causes the spin, what causes us to do so much work yet not get anywhere meaningfully. Um, so that's why I'm interested in different approaches. Like, how do we get unstuck? How do we stop spinning? Do you have a sense of why the Bertzog model didn't work in the UK?

SPEAKER_00 18:14

So in the UK, we have we used to have nurses that used to have end-to-end care, uh, let's say in the community. So a nurse would get to know somebody, they would uh take ownership of that person, and they would work with them over time. Maybe they visited them every day to do something, or whatever it was that they had to go in. So during the 1980s, a new model of working came in that was deemed to be more efficient and effective. And what that did, and this is exactly what happened in the Netherlands where Bertzall came from, that role of a nurse, end-to-end role of a nurse, got cut up into about 11 or 12 separate activities, which were then dished out to different nurses. Okay, so a nurse would go out there and was were given 30 minutes to do particular activity with Mrs. Miggins, then she'd get in a car and go and do something else to somebody else. That was all documented down in a nice list for for what that nurse had to do that day. That was deemed to be more efficient. And someone else would go and see Mrs. Miggins for something else.

SPEAKER_04 19:26

Right.

SPEAKER_00 19:27

That completely destroyed the whole idea of end-to-end care. So all Bertsaug did, so I'm gonna use Bertzorg as an example for any part of health. This is this is transferable to anything. Um so Bertzorg came along and said, no, we're gonna join that up again. And so what happened in the UK is that they go, oh, that's good, let's put that in. But oh, hang on a minute. We we have to plan what our nurses do in advance and who's gonna do it and how long they're gonna take. So suddenly that way of working clashed because in Bertsorg, you go and see Mrs. Miggins and you stay there for as long as is appropriate. If it's 20 minutes, it's 20 minutes. If it's two hours, it's two hours. And you work together with other nurses and other healthcare professionals to decide best how you are going to deal with Mrs. Miggins. And that that those decisions aren't made by a senior manager or by a set of rules that have been predefined, which is what happens today. It's actually made by the people on the ground, the frontline people on the ground that are helping Mrs. Miggins. They have the flexibility to do that because they're not there to do single activities. They're to there to look at Mrs. Miggins, understand what matters to her, understand the complex nature of her life, understand those around her and the support that she gets already or could get, and work in that way. It's a totally different approach. The NHS tried to bring in Bertzorg and stick that on top of their current way of working, which wasn't going to last very long.

SPEAKER_03 21:04

Yeah, because there's an element of letting go that people are just like they will cling to that old way. Like their life depends on it. The risk that they feel or perceive with letting go of old ways of working is really holding us back. I think that's really causing that spin kind of motion. And within this model, there's also this idea of value demand and failure demand. Can you speak to that a little bit?

SPEAKER_00 21:33

So, one of the things I learned early on was uh the concept of value. I hadn't really come across this before. I mean, it's a simple word, and you think value, well, yeah, that's good, but what exactly is it? And I learned from John Seddon to identify and to focus on value, but from a position of the citizen, the person we're actually trying to help. The user, I don't know what to call them, but the the people we are there for. What is the value to them? And when you look at that, you realize that we do these this huge amount of activity over here, this running about, as you say, uh, to stay in the same place, when in fact the value to them is kind of minimal sometimes.

SPEAKER_01 22:22

Yeah.

SPEAKER_00 22:23

So why don't we just leave that bit alone for a moment and focus on the value to them? The first thing you have to do to do that is to understand them. And when we look at what happens to them when they come to us as a bunch of different health services, they get bounced around like a snooker ball because many of them have complex needs. Not for someone like me who might have broken my leg and I need it sorted out, and then I can go back to work. But a lot of people have different levels of issues that apply all at the same time when they come to the health service. And what they end up doing is going to the different front doors and getting treated differently at each of those front doors. And no one is there to look at me as a whole person and to understand what actually should happen to me as a person. So uh it's very fragmented, and because it's fragmented, there's a huge amount of bureaucracy that happens to try and make that fragmentation work, and actually, it doesn't work very well. There has to be a heck of a lot of activity for that to happen. So there's a lot of failure demand, and failure demand is all those things that happen because we haven't created a system that works for Mrs. Miggins, we've created a system that we think works for the auditors. Uh I don't know who's designed it, but it wasn't people that were focused on what matters to Mrs. Miggins. It was a very different focus. And so that's why you get that clash. So value and failure demand is a way of beginning to understand what are the barriers that people face when they come to health and need support from health. What matters to them, not just what is their demand, but actually what matters to that person uh as a whole. And from that, we can derive what's the purpose of why we are here. And our purpose of why we're here is not just to fix broken legs, it's to help people have good, healthy lives. That's a totally different purpose. And if you look at the NHS in the UK at the moment and you ask the question, who is it here that's really focused on that overarching purpose? Um, you can't really find them. With failure demand, for instance, we find that when you've got people that need health services that are in some ways complex, they also need services from local government. Housing is often a problem. Um, they might have issues where they live, they might have issues with finding enough money to feed their families, they may have dysfunctional families, they may have mental health problems, um, they may not be able to work because of some of these problems. Now, that's the reality of a lot of people in this country, and of any country, in fact. And that's actually the issue to solve. You have to understand and put all that together before we can really approach this. So that's what understanding value and failure demand helps us to highlight.

SPEAKER_03 25:39

Yeah, it really speaks to me as well because I've supported a lot of refugee families that have come. And holy smokes, you want to see a fragmented system try and help a refugee family set up their new life. Like this was hours and hours and hours and hours, week upon week upon week, trying to get one system to talk to another system, right? To find out where to go, how to get this support, how to get that support. And you know, everywhere we went was like, well, that's not me, or I don't do that, or you gotta go here, you gotta go there. And you know, as an educated white Canadian, I don't experience, I mean, I experience it a little bit, but I don't think anybody understands what that's like until you are with a family that's in a in a position of trying to get all these services set up.

SPEAKER_00 26:27

What a systems thinking approach and value and failure demand helps us to see is that actually health goes across horizontally.

SPEAKER_01 26:35

Uh-huh.

SPEAKER_00 26:36

It doesn't go vertically, it goes horizontally. And the current health services that we have in in the UK at the moment make that almost impossible.

SPEAKER_02 26:43

Yeah.

SPEAKER_00 26:44

The way that you have to do that is through referrals. And referrals is a terrible way to join up services. It does not work.

SPEAKER_03 26:51

Yeah. Okay. How do you start engaging with people to think differently about the project or the idea that they want to pursue?

SPEAKER_00 27:02

So at the end of March, I'm going to start with a new team, brand new team. And the reason we're starting with this team is because the senior people in health, firstly, they've got an NHS 10-year plan, which talks about reforming the NHS region. They go, what the hell is reforming? But they also know that the current system is broken. So they don't just want something to be improved, they want real change. So the way that we're going to do that is we're going to get a group of frontline people and we're going to put them in a room, and they're going to get permission to apply a set of new principles to bypass the policies, the procedures, and the frameworks of the current organization. And they're going to take real people and they're going to deal with real people in a locality, and we're going to test out different ways of working, and we're going to learn from those which are the best ways of working. That's it, that's it in a nutshell. And from those ways and the learning, those senior leaders will then be able to understand how we can then go and change the other parts that large organizations that they've actually come from in the first place. So from that, they should be able to realize now that we've understood from this team, we now know how to go and change how we work together, how we have to manage differently, what are the different measures that we should be using that motivate people? What are the ways that we could change roles so that they become wider and more valuable to both the person in the health service but also the person we're trying to help? How can we develop real end-to-end understanding and real end-to-end care? Because one of the things that the team will find is that by working this way, costs reduce and demand reduces. And at the moment in the UK, those are one of our biggest problems. Costs are increasing and demand is increasing. It's because of the way of working that we have. So when we experiment and test a different way of working, we find that those things change. And the only way that we can prove that is by doing it. So I've done this more than once in different parts of the country. So I know roughly what we're going to find. And other people have done it as well. And Bertsaug is an example. The costs in Bertsaug are now far lower than someone that does a traditional way of doing care. So we're going to have a social worker, we're going to have occupational therapist, mental health person, a housing person from a local authority, drug and alcohol person. And they're going to be in one room and they're going to form one team.

SPEAKER_03 29:53

And are they going to look at a certain type of patient?

SPEAKER_00 29:57

And then we're going to go out into the community and go, right, let's look for people, not that have just got a broken leg and it needs fixing, but actually people that have complex needs. And we're going to take one of those people, we're going to bring them into the team, and we're going to first do something which they've never done before, which is let me understand you.

SPEAKER_02 30:18

Yeah.

SPEAKER_00 30:19

We're going to understand that person. And then that team is going to decide how, together with the person, what they're going to do next and how they're going to do it. And we're going to be focusing on people that are beginning that journey of increasing care. Maybe they've lost their job and they've got some low-level mental health issues or they're having some certain difficulties in their lives. But we're also going to deal with those people that have significant issues. One of the things that we're going to really find is that actually for those people that are in significant need right now, if we had dealt with them when they first came to us, it would have been a lot easier and a lot less costly if we had dealt with them properly and worked with them in the right way at that time, instead of waiting three years before they've got to where they've got to now, where they've now lost their job, they've got a divorce, they've lost their house, uh, et cetera, et cetera. That's really the key. And a big part of the NHS 10-year plan is prevention. And prevention has isn't like a bolt-on, it's not something new that we have to just do as like an initiative. It's a thing that happens within the core of health itself. It's the core of how health has to be designed. And when someone when someone says they need help and stick their hands up, the quicker and the better that we engage with them, that is prevention.

SPEAKER_03 31:52

Yeah, and that was my main critique of this recent health plan that was released was that it was all about once you're broken, this is the money we're gonna invest in fixing you. And there was nothing about here's how we're gonna keep you healthy. Like the best way to do this work is to make sure you don't become a patient at all. That's the cheapest, most efficient, most effective way to run a healthcare system. But there was like nothing in there about that. Like it was all about we're gonna build more urgent care centers, we're gonna build more hospitals, we're gonna add more beds, we're gonna do more surgeries. And it's just the entirely wrong focus for 2026.

SPEAKER_00 32:31

You're gonna you're gonna be running faster while staying in the same place. Exactly. You're going backwards.

SPEAKER_03 32:36

Spin deeper and go backwards, 100%.

SPEAKER_00 32:38

And the only the only reason I can say that uh with clarity is that that's what happened to us. That's what happens. It's not uh, you know, that's we we could see this starting 15 years ago when we decided to do something called austerity, yeah, which is basically start to reduce funding to the determinants of health.

SPEAKER_03 32:59

Yeah. Yeah. So when you are working with these teams, what are their aha moments as they start to change things or build different processes with their collaboration?

SPEAKER_00 33:11

I think probably the most interesting one is when they have to go out and instead of reading a document about somebody or a referral, they have to actually go out and understand somebody without an assessment.

SPEAKER_03 33:28

Like without a paper form. Okay.

SPEAKER_00 33:32

When I last did that, they were terrified. They didn't know what to ask, they didn't know if they were going to miss something, they had to go in pairs so that one of them could observe and make sure they hadn't missed anything. And that team, it took two weeks of doing that before they began to feel comfortable. But just simply doing that, so that wasn't just an exercise. It was an exercise, but it was much more than that. They started to realize that the issues that Mrs. Miggins had, firstly, were very individual to each person. So you it's very difficult to, very dangerous to categorize people as, oh, that person is like one of these or one of those. They're all different. But secondly, they understood that by really listening and understanding that they got a very different picture to what they would have had if they just read the referral document. But that picture that they now got was accurate, and they could now deal with Mrs. Miggins in a way that they wouldn't have done before. So that was a fundamental thing. And as soon as they did that, they started to realize they were starting to do very different things with Mrs. Miggins. And those different things, some of them were new, some of them they had to go and get other colleagues from different parts of the public sector or the or the voluntary sector to work with them. And they suddenly realized that Mrs. Miggins was getting better and was actually being supported by her family, by the community around her, and Mrs. Miggins was getting more positive and getting more motivated to sort out the problems herself. So it changed not just the way of working from the people there, but it changed the response and the situation that was in front of them, which was very dynamic, it was very highly complex. You couldn't predict, and I think this is a key part of this. You can't predict in a real health setting what's going to happen. So you have to be very nimble as a frontline professional. You have to be very open to changing your strategy or changing what happens. And that's not possible when you have a highly structured, highly formalized healthcare system. You need that flexibility at the front line, you need those decisions to be made close to where the work happens.

SPEAKER_03 35:53

There's this concept I've heard called no wrong front door. Like it's that you can go into any sort of public service and they can't say, I don't know, that's not what we do, that they have to provide you with the services or link you with the right person. They can't abandon you. Is that what people end up sort of the changes that people end up making? Is that if you go into a social service office or you go into your municipality, that person starts on a journey.

SPEAKER_00 36:25

That's how it should happen. And and one of the dangers of of someone in health hearing what you've just said is that they go, Oh, that sounds good. So what they'll what they would typically do is go and instruct all their staff that this is how and their managers as to this is what should happen now. Uh-huh. And that's it. And they think that that's going to change the system. You don't change behaviors by sending out an email or having a gathering where you know you you talk to them for two hours. You do this by physically changing the aspects of a person's work around them so that people are actually able to take that responsibility. When you've got a queue of people that are in front of you and someone says, hello, I've got this complex need. What's that frontline person going to do? Are they going to act on that queue of people? Or are they going to really listen to this person and spend the 20 minutes that's required to actually listen to them? So people at the moment don't have the ability to do that.

SPEAKER_02 37:29

Yeah.

SPEAKER_00 37:30

So they need to have the ability to do that. And at the moment, that's not going to happen in this country. And that's a good example why Bird Talk doesn't didn't work. A very good example. And you've got all these great ideas that you that you know you and I can come up with, and they can't be implemented because they're all characteristics of a different design to healthcare and a different way of managing and uh operating healthcare.

SPEAKER_03 37:57

What's your experience with leadership after you've done this work with people?

SPEAKER_00 38:02

So the team actually consists of leaders as well.

unknown 38:06

Okay.

SPEAKER_00 38:06

So in the work that I'm starting in a few weeks, not only do we have a list of frontline staff, but we have a list of leaders, and I'm going to work with those leaders to help them connect with the team and learn with the team what the team are learning and what the team are doing and how that impacts on the thinking that the leaders have and the strategies that they've developed and the way of working that leaders think in terms of what health should look like. So by the end of this, we should have leaders that have gone through this as well, and that's key. And that usually doesn't happen.

SPEAKER_02 38:46

Yeah.

SPEAKER_00 38:47

Normally they get sent to reports or they see some kind of workshop or presentation or whatever, and they they think this is great. But those leaders haven't gone through what the team have gone through. They have to go through the same unlearning learning cycle as the team have. In fact, it's more important that the leaders do that. So if the leaders don't do that, I know from the very beginning that this isn't going to work. So in answer to your question, it is essential. And um I guess that speaks of why this is difficult. Yeah.

SPEAKER_03 39:22

And the risk that they have to take and the vulnerability they have to experience.

SPEAKER_00 39:27

Yeah, all of that. And at the moment in the NHS, leaders are far too busy to do anything else.

SPEAKER_01 39:33

Yeah.

SPEAKER_00 39:34

And the last time I did this a few years ago, um the team brought leaders to where the team were. So the only way that we help leaders to understand is for the leaders to come to the team. And the chief executive of the NHS Trust at that time stood up and said, I want everyone in my trust to work like this. And then we never saw her again. Why did we never see her again? Not because she wasn't passionate about this or she wanted this to happen, but she was totally submerged in trying to figure out how to match the funding that she had got with the end-of-year results that she was going to have because she knew they weren't going to match.

SPEAKER_01 40:19

Yeah.

SPEAKER_00 40:20

What does she have to cut to make them match? She wasn't focusing on health, she wasn't focusing on value, she wasn't focusing on how to improve the whole of health because she couldn't. And she really, really wanted to. That is a problem that needs to be uh understood very clearly. So when I started this, I used to kind of do a bit of that pushing and helping people to see what I could see, and I found that that didn't work very well. What I realized that this the learning journey that I had gone on and the transformation that I had gone on, other people need to go through that journey, and it's a unique journey to them, and it takes some time and effort for them. So, what I've learned to do is to do more of a facilitation and to help them to see those things. So we have those challenges in front of us. I'm not I'm not medically trained, I know nothing about the health service. So they're the ones that can do this. So I go into a team and I don't know what they do and I don't know how they do it. So I have to help them with new sets of principles, new ways of thinking, new concepts. We have a lot of discussions in the room. We go out there, we work with people, we bring those challenges back into the room, and as a whole team, we discuss those challenges. And by using those new principles, that team slowly starts to try and test new ways of working, and they've got the freedom to do that, and I think that's really important, and it's a safe environment to be able to find out that sometimes what we do doesn't work very well, and then we have to work out why didn't it work very well. Um, and so we need to do that, and that's how they learn, they become more confident in that approach because they haven't done this before in this way, they haven't been allowed to, but they realize that that's something natural for them, and so they start to get confidence that they can do this a little bit more and do it a little bit more, and then as a team, they realize oh my gosh, look at the impact we're having. This is great, and they become confident they can make those decisions, and that they're kind of like is a is a hump that I can see when they've gone over that hump, I go, Oh, this is great. Right now they're moving. Yeah, yeah, it's it's now a different team, and I have to work with that team differently.

SPEAKER_03 42:56

And you uh some of your principles are like, you know, you can't do anything that breaks the law. What are the other ones you have?

SPEAKER_00 43:03

Well, those are the the two rules. We have two rules. Two rules, yes. One of them is we don't can't break the law and we can't make the person's situation worse compared to the what that would have happened to them. But the main ones are things like we have to understand that person, we have to focus on what matters to that one person. We have to take ownership of that person end to end. So if I'm in the team and I'm the one that takes ownership of Mrs. Miggins, I'm gonna be the one that talks to Mrs. Miggins most of the time. Okay, and if I need to pull someone in someone in, it'll be me pulling that person in. And what I do is that I understand Mrs. Miggins and she trusts me.

SPEAKER_04 43:47

Yeah.

SPEAKER_00 43:47

Okay, so it's that that kind of relationship. And because of that, then that begins the way that we start to work differently. And we focus on the value work, which means we only really Want to do things that matter to Mrs. Miggins? So all the other stuff that we do, let's try not to do that and see what happens. And question why are we doing this? And can we automate those things? Can we make them shorter? I mean, reporting to managers. Okay, is there an easier way for a manager to know what I'm doing? Rather than writing reams and reams of paragraphs and stuff that the manager probably doesn't read half of it anyway.

SPEAKER_02 44:28

Yeah.

SPEAKER_00 44:30

You know, so how can we work differently as a manager? How can a manager now start to support that team to work like this? That becomes an interesting question.

SPEAKER_03 44:40

So if someone's listening to this podcast and they're like, ooh, I like this idea. What do you recommend they do? Where do you recommend they start? What are some small things they can do to move in this direction?

SPEAKER_00 44:54

That's an interesting question. I would say um that they need to start realizing that this is about reform. This isn't about improving what we do. This is about changing the way that we do things. And that starts with me. That starts with me as a manager or as a senior manager. I have to first understand what that means. So I need to put that aside how I currently work now. And I need to go and explore. I need to read, I need to talk to people, I need to find out what this actually is. And once I've done that, I can then ask the question now, how can I make this happen? And the one thing that we do know, it's we know more about how not to do it than how to do it. And that's very important. It won't happen by using the same methods that we've been using before.

SPEAKER_01 45:47

Yeah.

SPEAKER_00 45:48

Okay, we need to learn why Bertzorg didn't work when we tried to bring it in. And we need to realize that there are better and different ways of making reform happen. We need to start finding out what they are, go to different parts of the country where they are happening, physically go there and visit them. That's what I would do if I was a senior manager in health at the moment. I would physically go and find out. I need to see it for myself. I'm not very good at believing in things I read. I need to see it. I need to I need to talk to those people. That's one of the reasons I put out videos because it's almost like talking to somebody. It's not about reading. Um, and so that's what I recommend. And there is there are a lot of good examples around the whole world, um, including Bert Sorg, of course. But how did Bertzorg get to where they were? It's not about just learning about them, it's learning how did they get there. Yeah, there's a lot of good work happening in Singapore at the moment.

SPEAKER_02 46:49

Yeah.

SPEAKER_00 46:50

What are they doing and how are they making that happen? It doesn't happen by waving a magic wand or getting a bunch of consultants in and making it happen. No, it doesn't. It has to work in a different way. So the NHS at the moment is trying to explore how to do that. So they've set off a load of pilots to try and figure that out. And I think that's a that's a good smart move.

SPEAKER_03 47:11

Yeah, to start experimenting. Yeah, and trying different things.

SPEAKER_00 47:15

Yeah, and then go and speak to them, go and find out what they're doing. It it that doesn't take much effort, actually.

SPEAKER_03 47:20

Yeah. And I think the what I really appreciate about the human learning system is yes, do the experimentation, but then there needs to be a structure in place to learn from that experimentation, share that learning, build on that knowledge. Um, because we've done a lot of pilot projects in our system, but we rarely learn from them or learn how to spread them in different contexts. Or so it just stays again in that spinning cycle of testing and and not learning and spreading. So uh that that model I think is has promise for how we take what we're doing and and learn from it in different ways across and up and down.

SPEAKER_00 48:00

Yeah, and that there are a couple of key points to what you're saying because when I started doing this, I didn't recognize what I needed to do to change. So I needed someone to help me to reflect. So it's very difficult for an organization to transform themselves. It doesn't happen. Very difficult, almost impossible, I would say. So you do need someone external to come in and to show you.

SPEAKER_03 48:27

Yeah, and to challenge and ask good questions.

SPEAKER_00 48:30

It's the challenges, it's the pushing you in front of the Mrs. Migginses. So I take leaders and and they go and visit Mrs. Miggins in her house. That's what I do. And the second thing is, and this is just as important, there's a big long list of things not to do. So a lot of what a lot of people do at the moment is, oh, we need to get lots of data about our region, about loneliness, about different cultures and what kind of issues people face. No, we don't. That doesn't tell you anything. What you need to do is start to work in new ways and experiment and learn from new ways. All of that, uh those other things, which is what we've done before, which is gather lots of data, make lots of graphs. That'll come later. We do need to do them, but that's not the priority. Priority is a different way of thinking and a different way of working. Yeah.

SPEAKER_03 49:25

Well, thank you, John. That was really interesting. And uh again, I feel like the elastic got stretched a little bit more. So um I'm going to think more and reflect more on the approach that you use, the things that you're doing. Um, hopefully, this will plant some seeds for other people in the system to start thinking about how they can do things differently. And um, and I'll be sure to link your work and your examples and your videos in the show notes as well so people can follow up and learn more if they're interested. Great. Thank you. Thanks to John Mortimer for sharing his insights with me today. As always, you can engage with me on Facebook, Instagram, and now YouTube at Shift Podcast Canada. And you can always reach out to me at ShiftPodcast Canada at gmail.com with any feedback or show ideas. And remember, systems don't change unless we do. This is Shift. See you next time.