Disassembling bureaucracy — and reassembling something better
How do you make a bureaucratic service or system more human? How do you go from being siloed, transactional, and standardised, to holistic, tailored, and asset-based? And how do you do this in a way that is reliable and repeatable?
As public services struggle with complex work for which they are ill-suited, this has become one of the most pressing questions facing government. Indeed, if you believe the estimates of the cost of our failure to support people with complex life circumstances, it is a multi-billion pound question.
In one sense, we don’t struggle for answers. We have known for years why traditional, bureaucratic services struggle to help people with complex conditions — their siloes and standardised procedures simply don’t mesh with people’s lives. We have also known the contours of a more human approach — in essence, support has to be positive and built around a person.
What we have not known — until recently, at least — is how to get reliably from bureaucratic to human. How do you unstick the many reinforcing bonds of a bureaucratic service, and reassemble a human approach from the same materials?
And not just that, but how do you do this work of reassembly in a safe, reliable, repeatable, and sustainable fashion?
I believe the answers to these questions are out there. But I also notice that this work of transformation is difficult, and near the frontier of practice, and so despite its importance it is rarely funded. This is partly because the work is not always legible to funders. It is poorly understood, and the system doesn’t yet have clear and consistent ways to describe it.
In this article — as one in an ongoing series at Kinship Works, on the codification of human practices — I describe a method for transforming a service from bureaucratic to human. I’ll keep this concrete by using the case study of Living Well, an initiative first developed in Lambeth, that has been running for several years in neighbourhoods across Greater Manchester, Derbyshire, Edinburgh and York, supported by the Innovation Unit.
I’ll describe how Living Well works and will use this to illustrate the more general practice of which it is an example, bringing this to life with the metaphor of a chrysalis. Then I’ll describe the impact of Living Well and explain why spreading work like this is important. Finally, I’ll end with some reflections on what it would take to spread these practices.
But let’s start with caterpillars.
A chrysalis
The chrysalis and imaginal fluid
Recently my partner and I became obsessed with the way caterpillars turn into butterflies. I forget how it started, but it was one of those moments when you realise you have no idea how something works, and so you Google it, and then you emerge hours later, wondering at the strangeness of the world.
It turns out — you might know this, but we didn’t — that a caterpillar doesn’t morph into a butterfly by its body changing shape. Instead, what happens inside the chrysalis is that the caterpillar’s body dissolves into a kind of soup. Then, once the body is almost wholly liquid, a chemical process activates the DNA for a butterfly, and a new structure is built from the soup. The soup goes by the wonderful name ‘imaginal fluid’.
If I’m honest it took me a while to get over the ickiness of this. But when I did, it struck me as quite a good metaphor for the work of reassembling bureaucracies into something more human.
I’ll come back to that metaphor in a moment. But let’s start with a more literal explanation of why the work of disassembling and reassembling public services has become so important.
The wrong kind of organism
We’ve known for years that bureaucratic services and institutions are bad at supporting people in complex situations. We have also known for years that this failure is not incidental — it is a function of the way bureaucracies are constituted.
Why are bureaucracies bad at helping people with complex conditions, and even more so people with complex mental health problems? Here are three important reasons:
Bureaucracies like to taxonomise, which means they put things in boxes. This means a person with many complex, interacting conditions has to interact with many siloed services, each of which treats them in parts. They have to attend endless appointments, which is exhausting and never gets to the root of their problems.
Bureaucracies — especially medical ones — tend to pathologise. This means they focus on what’s wrong with someone, not on their hopes and strengths. People who need support spend their lives explaining their symptoms and traumas, which is bad for anyone but is especially harmful for people with fragile mental health.
Bureaucratic services see people as individuals, in isolation from their social environment. This makes them blind to the ways a person could be helped by the community around them, and yet community support is often a more sustainable (and cheaper) answer than a clinical intervention.
Together these bureaucratic ways of seeing and acting on the world make for an awful, even actively harmful, experience for a person with complex conditions. And ironically, these approaches are not cheap; they are wildly expensive, wasting public money with repeated efforts to treat individual symptoms, never getting to the root issue, while often causing stress that exacerbates the person’s underlying condition.
The key takeaway is that none of this is a coincidence. These behaviours are functions of bureaucracy. They arise from the way bureaucracy is constructed, just as an animal’s behaviour and capabilities arise from its composition as an organism.
Living Well is a chrysalis
This takes us to the question I opened with: how do you reconstitute a bureaucracy into a service with a more human make-up, so that it can treat people as rounded human beings?
To make this less abstract, let’s bring in Living Well as a case study for how we can do the work of metamorphosis.
Living Well is an initiative that helps local leaders and practitioners to redesign services so that they work better for people with complex mental health conditions. It brings a practical, empirical eye to the work of metamorphosis. Over several years this process has been refined into a way of disassembling a bureaucratic service, and reassembling a more coordinated offer that treats people as humans. It does this in a comprehensive way, covering all aspects of metamorphosis — disassembly, re-imagination, reassembly, and even the survival of the new service/organism. It works with people who have complex conditions, learning from their experience. And the process is sufficiently systematic and well-documented that it can be reliably and affordably repeated.
This is a big deal because it means we can get beyond just exhorting bureaucratic services to be more human, as if we’re shouting at caterpillars to act more like butterflies. With Living Well, we can actually make the changes that are needed.
How does Living Well do this? The first step, as with metamorphosis, is to create a chrysalis. This is a space within which the old, bureaucratic service can dissolve safely. In literal terms this means bringing together local leaders, practitioners — psychiatrists, mental health nurses, social workers, voluntary sector workers — and people with experience of mental health services, for facilitated conversations that help people ‘take off their lanyards’. The space in which these conversations happen is one-step removed from the pressures and incentives of the day job, which helps people open up. The conversations are facilitated by an outside organisation, the Innovation Unit, to make sure they feel neutral and not dominated by any one perspective or part of the system.
Once the safe space of the chrysalis is established, a series of conversations are used to establish a kind of in-between state — the equivalent to the imaginal fluid. The local practitioners are helped to liberate themselves from their old habits and ways of working, so that they can listen to people’s stories, hopes and ideas, and start imagining something different. This is again done with facilitated conversations to dissolve the grip of old mentalities, hierarchies, and professional siloes.
Next, the group is helped to imagine the new service. Like the metamorphosis of a caterpillar, this process is not open-ended. It is guided by some elemental principles, which shape the formation of the new organism just as the code of DNA builds a butterfly. Some aspects of the old service are retained, such as the motivation and clinical expertise of the practitioners, but most of the new offer ends up being entirely different. The design principles for the new system are informed by decades of learning on what best helps people with complex conditions. They include being holistic, person-led, and strengths-based, and some basic structures/components: a mixed discipline team, and strong connective tissue into the local community.
Guided by these principles, the Innovation Unit helps the new team to design and start practising the new way of working, and here we move a little away from the metaphor. Services, unlike organisms, are made up of people, so it’s important that local practitioners build and own the new design themselves. The new model must also be tailored to the local context — the local population will vary, as will the relative strengths of disciplines, the relationships between institutions, and the geography. This is why Living Well does the metamorphosis in situ, led by the local people — you can’t just turn up and impose a model.
So what emerges from the chrysalis? The answer is a more human service: one that is very good at supporting people with complex conditions. And while the specifics of that service will vary — Edinburgh is different from Lambeth, which is different from Oldham — all Living Well services have some things in common, just as all the members of a species have something in common. For example:
The unit of delivery for the new approach is always a multi-agency neighbourhood team, formed around a person. This replaces the clinical siloes of the prior bureaucratic organism.
Conversations in the new service always start with the person’s life and aspirations, not with a list of symptoms.
The new service is never isolating in the way it sees the person. It sees the person as part of a community, and it has links to local businesses and community organisations.
Put simply, a metamorphosis has happened. The new offer created by Living Well is a different organism, with a different structure and constitution. And this in turn means — and here’s the important part — that it will behave differently to the old service, and it will have different capabilities.
What kind of capabilities? For one thing, the new, more human service will be able to see things that the old, bureaucratic service literally couldn’t. We might say that the new service can see a broader spectrum of colours — it can see a person’s hopes and dreams, as well as their symptoms. Maybe we could also say the new approach has a broader field of vision — for example, it can see the community around the person, which was not in the field of view of the bureaucracy’s more synoptic vision.
As well as seeing things the bureaucracy couldn’t see, the new service can do things the bureaucratic service could not do. In particular, a human-centred service is more dexterous and agile than a bureaucratic organism. It can do fine-grained things, like pay for a taxi, or look after a pet, if this is what will make the difference to the person it is helping. (And, thanks to its better vision, it will know when these small things are needed. So the seeing fits with the doing, as it does in any organism.)
We can see in this description why the work is so difficult and important. It strikes me as a rare case in which that over-used word ‘transformation’ is actually appropriate.
Surviving in the environment
So far our metaphor has served us quite well, but here’s where we might end up breaking it. Because there is a second stage to Living Well, which is about the wider operating environment.
The difference between a bureaucracy and a caterpillar (Ok, one of the differences) is that the word ‘bureaucracy’ doesn’t just describe a service, it also describes the system around it.
This means that, if we are transforming a service to make it more human, then we will also need to make sure the new service can survive in its (still bureaucratic) environment.
To be more literal, what we are talking about are aspects of the service’s operating environment — things like accountability, training and culture, the way risk is managed, and so on. And what we are saying is that all of these aspects of the operating environment are bureaucratic, and will make it continually difficult for the new service to treat people as humans.
Let’s return to our metaphor, and say that when the human service emerges from the chrysalis we need to do some work to protect it — to help it survive the bureaucratic environment.
This is precisely what Living Well does. As the local team dissolves the old service and assembles the new one, helped by the Innovation Unit, they also spin-off side-projects to work on the wider environment. Or, to be more precise — since the environment itself tends to be beyond the team’s control — the team is helped to work on the interface between the new organism and its environment. They do this partly by linking up with other teams doing similar work, sharing barriers, and then working with local leaders to remove the barriers.
What does that mean in practice? Again the answer depends on the local context, but here are some common examples of environmental adaptations the Innovation Unit might help local practitioners and leaders to negotiate:
A change to reporting requirements, so that the new service is allowed to report a more holistic range of measures. For example, the new service could be measured on patient outcomes, or on system-wide cost reductions, rather than on narrow output or efficiency measures, like the number of appointments.
An amended accountability regime. For example, the team might negotiate with their HR function to make sure practitioners are rewarded in performance reviews for working in a collaborative way, and not punished for the time they spend building the mixed discipline team.
A different approach to risk. For example,.the Innovation Unit might help the team to swap a tick box assessment, based on narrow clinical criteria, for a ‘warm conversation’. This can establish a trusted, transparent relationship, meaning they learn more about the person than they did with the tick boxes. This is all done with care, to avoid unnecessary risk; sometimes the team even temporarily increases oversight, and works with just a few people at first, before scaling the new approach.
This final aspect of Living Well, focused on the relationship to the operating environment, is vital to its success. Indeed, whenever the Innovation Unit sets up a new site for Living Well, much of the effort goes into working with local leaders, building the buy-in and trust that will be needed to negotiate these kinds of system changes.
Does this break our metaphor? I guess at a stretch we could say we are making survival equipment for the human service, for when it leaves the chrysalis. We are equipping it with breathing equipment, armour, and tools so that it can survive — and even thrive — in the inhospitable bureaucratic environment.
What is the impact? And why?
What matters is the outcome from all of this work, and here we have some unambiguous good news. Services that have been transformed by Living Well deliver better outcomes for people, while also reducing costs. Evaluations also show that Living Well improves outcomes at a price that is well within NICE guidelines for the efficiency of QALYs added. So if Living Well was a medication, the NHS would fund it. Living Well neighbourhoods also see wider reductions in demand and less pressure on waiting lists. These are useful lessons as the NHS embarks on its plans for a neighbourhood health service.
What drives these impacts? The simple way to think about it is that the new organism is better suited to the work that needs to be done. The old, bureaucratic service could not see people’s lives in high enough resolution, and this was especially damaging when a person’s life was fuzzy and complex. Also, even if the old, bureaucratic service had seen the complexities of a person’s life, it was incapable of acting with enough dexterity.
The shortcomings of bureaucratic services drive costs for several reasons. Bureaucratic services tend to see all problems as clinical, jumping to expensive clinical treatments (or, more likely, they add people to long waiting lists for clinical treatments). They often undermine people’s sense of agency, which acts as a drag on people’s ability to recover and live well. They give staff little discretion, so that frontline practitioners cannot do the little things that would make a big difference. And, finally, they are blind to relationships, so they can’t draw on the reservoir of potential support from a community. By contrast, a human service of the kind that emerges from Living Well starts with non-clinical options, emphasises positives and builds people’s confidence, trusts staff to make decisions that will make a difference, and often finds ways to help people in the community without needing clinical treatments. In short, it saves money because it sees and treats people as humans.
Perhaps the clearest way to see these impacts is in the testimonials from people who have been helped by Living Well’s redesigned support offers. People glow with thanks for the compassion and care they have felt. This comment is typical:
For much of my life, I’ve hidden behind a mask, blocking support and pretending everything was fine, but with you, it felt as though you saw through that. For the first time, I truly felt heard, supported, and safe. … Thanks to your guidance, I’ve been able to move from such a dark place to a point where I can finally start seeing a future for myself — something I once thought was impossible.
When you consider all of this, you start to see why some of the estimates for the cost of our failure to address complex problems might not be so fanciful. For example:
Families with multiple disadvantages are estimated to need support costing £75,000-£100,000 annually, which reduces significanly with holistic support, saving the cost of such support several times over [1]
People with four or more chronic conditions average 29 primary care consultations over a two year period, compared with 10 consultations for people with one condition [2]
Deteriorating mental health in the UK is driving up spending in multiple areas, from healthcare to incapacity benefits, with especially high costs for those with the most complex needs [3]
All of which suggests there would be huge value in spreading approaches like Living Well, so that we can transform more services from bureaucratic to human. So let’s wrap up by exploring how we could do this.
How can we spread this work?
I’ll end with some reflections on the task of spreading initiatives like Living Well. This is not straightforward because, as we’ve seen, the Living Well process is organic, so we can’t just impose it, or change a rule, or ‘roll it out’. We need to avoid the temptation to think we can scale the model by replicating it.
This does not mean, however, that we can’t spread these ways of transforming services. Indeed I think there are four concrete things we could do to spread this kind of work.
1. Fund lots of chrysalises
The first is the simplest: we could fund a whole layer of chrysalises. Senior leaders and commissioners in many parts of the state — NHS Trusts, Combined Authorities, central government departments — could pay for initiatives like Living Well. We could start in areas where we are helping people with complex conditions, whether in healthcare services, or in domains like long-term worklessness.
It would also be wise to acknowledge that funding this kind of work from core budgets is very difficult. So there might be a role for national government, earmarking transformation funding — a kind of ‘chrysalis fund’ — to accelerate progress.
As well as exhorting people to fund this work, we could also make the work easier to fund. For example, we could make the work more legible, so that people understand it and can picture it. (This is part of what I’m trying to do in this post, as part of Kinship Work’s wider mission to make human work legible and fundable.) We can also make sure this kind of work is not undervalued by the evidence funders and commissioners require, or by our procurement processes.
2. Give people tools for making chrysalises
The second thing we can do is make it easier for people to build chrysalises. In literal terms we can do this by codifying and maturing the processes and disciplines that are involved, and building infrastructure to support them.
This kind of work is already a big focus of organisations like the Innovation Unit. It’s why they treat Living Well as a branded initiative, and not as just a series of disparate projects. It’s also why they put lots of effort into describing the process (see here, here, and here), so that it can be repeated. We should make sure there’s money to support enabling work like this.
Beyond this, there is work we could call ‘field-building’ (to borrow a phrase from David Robinson of The Relationships Project). This is about codifying and supporting the skills and disciplines the work requires, and developing things like training, communities of practice, re-usable tools (service patterns, playbooks, libraries of techniques), and even new institutions. For example, we could establish a centre of excellence for chrysalis-making and similar ‘bureaucracy-transforming’ practices.
This infrastructural work can sound abstract. But if we think of it as mass-producing tools to make chrysalises, we can see why it’s good value for money. The work itself still needs to happen in situ because the local leaders and practitioners have to go through the process, to develop new ways of working themselves. But by giving people tools — role profiles for hiring, skills to apply, service patterns to use — we make it much easier and cheaper to do the work well, wherever it is done.
3. Mass produce survival equipment
The third and fourth ways of spreading this work relate to the wider operating environment. I’ll start with the more modest version and then I’ll move onto the more ambitious.
Let’s say we accept that, for the foreseeable future, our public services will be made up of bureaucratic institutions with bureaucratic operating environments. If that’s right, then in order to run services that are holistic and human, we will need to find ways to help these services survive, and not get worn down and burned out by the system around them.
When I talked about this earlier, I used the metaphor of producing survival equipment for a human service, so that it can survive in a bureaucratic environment. The challenge with this work is that it requires lots of arduous manual effort. The delivery partner — in this case the Innovation Unit — has to mediate between local leaders and practitioners, helping people to negotiate manual changes to things like reporting requirements, or risk management, or HR processes.
With the right support, the local team gets there in the end, but the process is time-consuming and emotionally demanding. Also, progress often slides back later. A key official moves on, and the team has to start the work of persuasion all over again.
How can we make this aspect of the work less manual? In metaphorical terms, we could mass produce survival equipment. In practice, this would mean developing and socialising a common set of techniques for how human work can interface with a bureaucratic system.
One example would be developing a standard way for holistic services to report their impact. Another would be developing a standard way for a person-centred service to report into a bureaucratic risk management process. As well as developing standard processes like these, we would also need to familiarise the relevant professions with these processes — whether that is project management, governance, commissioning finance, HR, or leadership teams. People working in these professions need to recognise these adaptations and be comfortable using them.
4. Make the environment more human-friendly
The final way of supporting this work is the most ambitious: it is about changing the operating environment itself.
We might wonder as we read this: why are the institutions that oversee public services so hostile to human approaches in the first place?’ Why are we having to create specialist adaptations in order to help a human approach survive in our systems of government? Why can’t we just change the environment?
This is a reasonable question, the short answer to which is that changing the environment is extremely difficult. Bureaucratic systems are locked into place by formidable forces, sticking people and processes into place with the glue of inertia.
Still, as governments struggle more and more — from collapsing trust, to a dire fiscal position — there is growing interest in this question of system change. (It is telling when nerdy takes on systems change in bureaucracies go viral.)
So, as the pressure rises, what techniques can we use to change the operating environment? The answer to this question could fill many reports, so I’ll just share some relevant examples.
One is that we can change the way accountability works, so that people in public institutions are held to account for delivering holistic outcomes — both for people and for the system (e.g. system-wide cost savings) rather than narrow efficiency targets. Over time, this will actively encourage frontline practitioners to take a more holistic approach.
Another example is that we can adopt more empowering management practices, so that staff across the system have more discretion. We can support these practices by also investing to build a culture of trust.
This idea of changing the system itself might sound ambitious, but I feel hopeful for a few reasons.
One, our public institutions are now struggling so badly that senior leaders are more open to change than I’ve seen in nearly 20 years working in and around government.
Two, we have examples to learn from. Pioneering Local Authorities, like Wigan and Camden, are more than a decade into efforts to change their operating environments, and their success is starting to snowball
Three, we have lots of mature methods to draw on. For example, thousands of firms across the private sector now use outcome-based accountability regimes, and the practice of building mixed-discipline teams around an outcome is also now widely used.
Four, there are in-between options if we don’t fancy our chances of changing the whole system. For example, I’m supporting some work with the New South Wales government in Australia to codify what we’re calling a ‘Mode B’ way of working — a set of pre-authorized alternative approaches that can be used when teams are tackling especially complex, human challenges.
Stepping back from these four recommendations, one final thought strikes me: these efforts would be far more powerful if done together. So maybe the real dream is a more systematic effort. An initiative driven by the highest levels of government — backed by proper money and political capital — to ease the bonds of bureaucracy and support more human ways of working.
Conclusion
I’ve covered a lot of ground, and got carried away with the metaphor, so here’s the precis:
We’ve known for years that bureaucratic services are bad at supporting people with complex conditions, and we’ve also known roughly what a better and more human approach looks like. What we haven’t known is how to get reliably from bureaucratic to human, escaping the sticky bonds of inertia. As a result, we have often just exhorted services to be more human. This is like shouting at caterpillars to act more like butterflies.
What people have now developed, after years of practice, is a process of metamorphosis — a reliable way to transform a bureaucratic service into one that’s more human (holistic, person-centred, tailored, and strengths-based). This starts with building a chrysalis — a safe space in which leaders and practitioners can dissolve the bonds of bureaucracy, and form a more liquid state, full of possibility. Then, guided by some elemental principles, practitioners are helped to design — and practice — a more human way of doing things. Evaluations show that this works, delivering better outcomes and reducing pressure on services, at a cost that falls within NICE guidelines.
What we need to do next is scale these approaches, and there are four ways we can do this:
We can fund more work like this (and make it easier for commissioners to fund it);
We can codify the work and invest in the skills and techniques it uses;
We can develop a common set of adaptations to help human work survive in a bureaucratic environment;
We can change the operating environment itself, so that everything from accountability regimes to evidence standards allow for — and even actively encourage — services that treat people as rounded human beings.
This article is part of our wider effort at Kinship Works to help make human approaches more legible. If you’d like to follow our work, or partner with us, you can reach us on LinkedIn and Blue Sky and you can subscribe to our newsletter on our website. You might also be interested in our partnership with JRF — The Centre for theEdge — in which we are helping senior leaders in government to support emerging alternatives. Or, for wider context, you can read more about Kinship Works here.
For more on techniques we can use to change the system, you can read my recent post, How to save bureaucracy from itself. Or for a deep dive on the role of narrow evidence requirements, you can read Are policies like medicines?. To follow my wider work, you can find me on Blue Sky, Medium, or Substack.