Month: June 2022

Professor Johan Mackenbach, of Erasmus University Medical Centre in Rotterdam, believes that the greatest medical advancement of the last few hundred years doesn’t have anything to do with medicine. He could have chosen the invention of the contraceptive pill, the vaccination of children, the discovery of the structure of DNA or the use of computer technology in the diagnosis and treatment of disease, but instead he choose the sanitation reforms of Edwin Chadwick from the early nineteenth century.

Chadwick didn’t even understand the problem. He thought diseases like cholera and typhoid were airborne and he was actually trying to prevent men from getting sick because they needed to be going to work. But still, implementing his ideas for piped water and flushed sewer systems cleaned up London, set the course for building sanitation systems across the globe, and prevented the deaths of millions of people. So sewers are regarded as a great medical advancement.

That’s the thing about problems; they are hard to truly understand, difficult to explain, and almost impossible to predict the outcome of any given solution. Our traditional approach to problem solving is to define, analyse, and solve a distinct problem in sequential steps. Charles Franklin Kettering, Head of Research at General Motors, thought it was a good approach. He thought that “a problem well-stated is a problem half-solved”. But maybe he didn’t understand the problem with problems. Really, every problem is always an interconnected mess of lots of problems.

Russel Ackoff, organizational theorist, consultant and professor, coined the phrase “mess” to describe these dynamic situations with changing problems interacting with each other. He understood problems differently. He argued that taking the traditional approach was only one way to tackle problems, and named four ways: We can ‘absolve’ ourselves of the problem – give it time to solve itself, ‘resolve’ the problem – look to the past to find a solution that is good enough to use now, ‘solve’ it – use research and experiments to figure out the best thing to do in the current circumstances, or ‘dissolve’ the problem – redesign the system so the problem no longer exists.

Lets redesign a system.

More than 15 million general practice appointments are missed every year at a cost of £216 million. The solution suggested by the NHS is for patients to let the NHS know if they cannot attend an appointment. Sounds good. Obvious, simple, puts the solution in the hands of the people with the information. But hang on… Don’t those people who booked the appointment still need to see a doctor? Wouldn’t a better solution be to help more people not miss appointments by attending their appointment? What if the problems that caused people to not be able to attend were fixed? What if those with caring responsibilities had support to look after their children, parents, grandparents, so they could attend the appointment? What if those who couldn’t afford taxi fare’s had another way to get to the appointment? What if those who suffer from conditions and disabilities that make leaving their home difficult had a way for doctors to visit them? What if there were more drop-in sessions so that people didn’t need an appointment? What if GP surgeries had better bus routes or more parking? We could go on and on thinking of ways to make it easier to attend appointments.

Professor Mackenbach draws three conclusions from Chadwick’s sewers that we can check against our thinking about redesigning the system to dissolve the problem. First, he says, you don’t need to know very much about the cause of a problem to intervene effectively. We don’t need to know why patients are missing appointments, we just want to make it easy as possible for patients to get to their appointment. Second, changing the environment in which the problem occurs can be more effective than trying to persuade individuals to change their behaviour. Our approach isn’t about getting the patient to do something different or extra, such as contacting the NHS, it is about changing the circumstances that surround and lead up to the appointment. And third, interventions targeted at all the people may be more effective than those aimed at particular groups. Making it easier to attend appointments makes it easier for everyone to attend appointments.

Will this be a quick fix? Definitely not. Problems take time to be completely ‘solved’. Solving the problem of water supplies being contaminated with disease-causing micro-organisms started thousands of years ago with the Nazcas and Mesopotamians. The Romans constructed systems of aqueducts and pipes to provide indoor plumbing, and Chadwick brought sewers to the streets of London. Yet today, many settlements in many countries still don’t have effective water treatment and sanitation. Solutions have a leading edge, where they might be seen as innovative, but they also have a trailing edge that means it can take a long time for everyone to get the benefits. Why? Because, as Ackoff reminded us, problems are always a mess of lots of problems. Sanitation problems are also economic and financial problems, skills and resources problems, beliefs and assumptions problems.

So, if you want to solve a problem, even one far less messy than sewers or GP appointments, don’t spend lots of time defining and analysing it as if it were an isolated thing, but do recognise that it is connected to and affected by everything going on around it, and that you can make changes to some of those things that dissolve the problem you were facing.

Stop solving problems. Start redesigning systems so the problem no longer exists.