Traditionally reliance has been based on two types of organisation for delivering health services –  bureaucracy and the market.  In the United Kingdom for example the NHS was introduced in 1948 as a bureaucracy, in England with 14 regions and clear lines of command from the Secretary of State to, as was once famously said by one Secretary of State, to “the person cleaning the ward floor” with a line of accountability running through this long chain of command.”  During the 1980’s there was growing concern about the lack of effectiveness of bureaucracies combined with a growing faith in the market and this led to the Health and Care Bill in 1990, with competition, not necessarily for the best outcome, as the criterion should be used to judge the different bidders for a commissioner’s resources became a dominant cultural theme.  However it is now clear that neither bureaucracies nor the market, nor either a combination of those two types is the best way for organising health services.  Credit for this must be given to Oliver Williamson and Elinor Ostrom who jointly won the Nobel Prize for Economics in 2009.  Oliver Williamson’s famous quote is given below

“if the market is a marvel, then why do we need firms? But then the question can be turned around.
If internal organisation enjoys advantages over markets, then why is not all production carried out in one big firm?’”

Elinor Ostrom’s contribution was the importance of developing the culture of stewardship when common resources were managed. Studying grazing rights and fisheries she pointed out that neither privatising a common good nor giving it to government control nor increasing external inspection and regulation were effective means of avoiding what has been called since 19th Century but more recently, publicised by Garrett Hardin as the Tragedy of the Commons. Her famous quote is also powerful:

“If those using the resources are allowed to manage those common pooled resources themselves, then sustainability is possible. They become stewards.”

So what are needed are systems, with a system being a set of activities with a common aim and a common set of objectives and the example of a set of objectives for a system for people with type 2 diabetes is shown below:

  • To prevent Type 2 Diabetes
  • To diagnose type 2 diabetes promptly and accurately
  • To treat type 2 diabetes effectively with minimal side effects
  • To enable the person with type 2 diabetes to be confident and their management of their condition
  • To minimise the possible psychological adverse side effects of diagnosis
  • To reduce the risk of complications from Type 2 diabetes
  • To minimise the effects of deprivation and inequity
  • To make optimal use of resources
  • To educate all the relevant professionals, for example pharmacy assistants and care home staff about type 2 diabetes and its management
  • To promote and support research
  • To produce an annual report for the population served

It is important to note that these objectives include not only clinical objectives applied at population level but also broader objectives related to value.

The Oxford Value and Stewardship Programme provides learning about systems but is also actively involved in the development of systems. The design method relies on working with multi-stakeholder groups that include the key stakeholders in the care pathway (i.e. patients, GPs, specialists, nurses, para-health professionals, IT, commissioners, etc.) to design ideal population-based systems of care that deliver value to patients.  Below is a summary of the 10 keys steps in designing a system specification:

  1. Define the scope of the system.
  2. Define the population to be served.
  3. Reach agreement on the aim and objectives of the service
  4. For each objective to find one or more criteria
  5. For each of the criteria identify levels of performance that can be used as quality standards
  6. Identify all the resources used in the system, thus creating a system budget and prioritise within the plan using the STAR tool
  7. Define all the partners so that they need to be engaged in a Clinical Network and produce a system specification
  8. Define the pathways and key decision points in the patient’s journey
  9. Prepare the necessary outcome based contract; describing the risks that have to be managed
  10. Introduce the system

This is the century of the system.