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Rudiger Wolf's avatar

Thanks for sharing, Oliver. A great description of the dilemma delivery leads face across large public sector transformations.

Your reflections on trying to build a value framework for a digital transformation program brought back strong memories for me. Back in the 2000s, I went through formal Theory of Constraints (TOC) training. I even spotted some NHS staff on the Tube carrying conference swag bags promoting TOC at that time, which is what helped to embed that memory! Ever since then, I can't help looking for constraints and bottlenecks in my context.

While reading your article, one core insight from TOC immediately stood out: when a system tries to optimise for everything, it effectively optimises for nothing.

If a transformation framework defines "value" as financial cash-releasing savings, clinical throughput, equity, and staff wellbeing all at once, the underlying metrics inevitably clash, paralysing operational decision-making. TOC's central premise was that a system doesn't need a complex matrix of competing definitions of value; it needs a ruthless focus on identifying and elevating the single primary constraint stopping the system from achieving its goal at any given moment.

This dilemma of keeping the causal thread intact across different organisational levels reminded me of a recent post by Justin Roff-Marsh on LinkedIn. See

https://www.linkedin.com/feed/update/urn:li:activity:7486514977814540288/ and a follow-up post https://www.linkedin.com/posts/justinroffmarsh_toc-folks-i-want-to-take-back-the-argument-share-7488358659262087168-0M77.

Justin differentiates between the declared strategic Constraint (set at the top level to reference all value-generating decisions) and local "rate limiters" (the transient operational bottlenecks discovered when you zoom into daily activity). As one of his commenters noted, confusing the two leads to senior management chasing the "de-icing truck" instead of making decisions about the fleet!

His distinction between strategic constraints and operational rate limiters addresses the exact challenge you raise, maintaining a clear causal thread from top-level "value" down to daily operational activities across different levels of an organisation.

Justin highlights how management often gets confused when "zooming in." If senior management declares the Constraint at the top level (e.g., in an airline, it’s the fleet of aircraft; in an NHS Trust, it’s most probably acute bed capacity or surgical capacity), that strategic constraint shouldn't constantly shift just because a sub-team zooms in.

Instead:

The declared Constraint (Strategic Level): The primary value-generating resource chosen by executive leadership to drive the organization’s overall goal. It remains fixed unless the strategy changes.

Then Transient Bottlenecks / Operational Rate Limiters (Tactical Level): The local obstacles discovered at lower zoom levels on any given day (e.g., waiting for lab results, or a missing digital sign-off etc).

As a commenter (Gustavo Valente) noted on Justin's post:

"The reason your correction matters is that these two get managed by different people on different clocks. Confuse them and senior management starts chasing the de-icing truck while the fleet decision goes unmade."

This perspective might offer a clean way to untangle the value framework: executive leadership defines the overarching Constraint (what generates primary value), while local teams focus on identifying and removing local Rate Limiters that impede that specific constraint.

I did a Google search on TOC in the NHS context and found this NHS Aqua QSIR guide to Theory of Constraints. https://aqua.nhs.uk/wp-content/uploads/2023/07/qsir-theory-of-constraints.pdf It serves as a reference of how the NHS explicitly frames bottleneck management.

My delivery experience in the last 10 years is in central government departments rather than the NHS, but I suspect that the real tension with "value" often comes down to system boundaries and zoom levels:

- Managing Inflow (Prevention): A close friend working in the NHS constantly reminds me of the grim impact Type 2 diabetes has on their patients and hospital resources. Upstream public health initiatives that prevent people from becoming ill in 10 years represent the highest long-term value, but I suspect preventing overall inflow to the NHS sits outside your immediate delivery remit. And I suspect that our policy "masters" have more pressing immediate priorities than "maximising healthy life years for the population overall".

- Managing Outflow (Social Care & Flow): Based on what I hear in the press, it seems that the primary constraint on acute hospital capacity hasn't been inside hospital walls for a long time, it sits downstream in social care. Maybe the new government push toward social care reform and shifting care from "hospital to community" highlights where the immediate flow bottleneck lies?

If your value framework can pinpoint where your digital and operational initiatives directly relieve that specific strategic constraint, rather than trying to satisfy every generic definition of "value" you might give your delivery teams the clarity and thus leverage they need to make a real difference.

Obviously, I think your article is on a thought-provoking and challenging topic! All the best.

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