What Frontline Experience Teaches You About System Design
Systems can look very different depending on where you are standing.
From a policy document, a process can appear logical.
From a boardroom, a new model can appear efficient.
From a strategy session, a solution can look clear.
But from the frontline, you see what actually happens when that system meets a person.
You see the gaps.
You see the workarounds.
You see where a process that makes sense on paper becomes difficult in practice.
And you see the consequences when different parts of a system do not connect.
My early career in frontline healthcare shaped the way I think about organisations today.
It taught me that good system design cannot begin and end with how something is intended to work.
We also have to understand how it is experienced.
The frontline sees the whole system differently
People working closest to the point of delivery often develop a very particular kind of knowledge.
They see the impact of decisions made elsewhere.
They know which processes create unnecessary friction.
They understand where information gets lost.
They recognise when people are falling between services, teams or responsibilities.
And they often become very good at compensating for systems that are not working as well as they should.
That knowledge matters.
Yet organisations do not always create effective pathways for it to reach the people making strategic or governance decisions.
A system can therefore continue to look successful from one level while requiring enormous effort to function at another.
Workarounds are information
One of the things frontline environments teach you is that people are incredibly good at finding ways to make things work.
When a process is difficult, they adapt.
When information does not arrive, they chase it.
When roles are unclear, someone usually steps in.
When a system creates a gap, people often find a way around it.
That adaptability is valuable.
But it can also hide problems.
If an organisation relies too heavily on capable people compensating for poor systems, the workaround eventually becomes invisible.
Leaders see an outcome being delivered.
What they may not see is the additional effort required to achieve it.
That is why recurring workarounds should be treated as information.
They tell us something about the system.
Where are people repeatedly improvising?
Where are they duplicating effort?
Where does success depend on one particular person knowing how to navigate the process?
Where are formal systems being bypassed because they do not work well enough?
Those questions can reveal more about organisational performance than a process map alone.
Policy is experienced through people
Policies are necessary.
So are procedures, governance frameworks and standards.
But people rarely experience an organisation as a policy document.
They experience it through interactions.
A person experiences whether information is clear.
Whether someone listens.
Whether a process is easy to navigate.
Whether they have to tell the same story repeatedly.
Whether different parts of the organisation communicate with each other.
Whether the person in front of them has the authority to help.
That experience is where system design becomes real.
It means a policy can be technically correct and still produce a poor experience.
A procedure can be compliant and still create unnecessary barriers.
A service can be available and still be difficult to access.
The question cannot only be:
Does the process exist?
It also has to be:
How does the process work for the people moving through it?
Frontline knowledge should travel upwards
One of the recurring challenges inside complex organisations is how information moves.
Strategic decisions are often made at a distance from the people implementing them.
That distance is sometimes necessary.
Boards cannot manage daily operations.
Executives cannot be present in every interaction.
Policy teams need to consider whole systems rather than individual cases.
But distance becomes a problem when there is no reliable way for frontline knowledge to travel back into decision-making.
Good organisations create feedback loops.
They ask:
What are people seeing?
What is becoming harder?
What unintended consequences are emerging?
Where is implementation different from what was expected?
What are people doing to compensate?
And what needs to change as a result?
The goal is not to allow every individual experience to determine strategy.
It is to ensure decision-makers are not operating without the knowledge that exists elsewhere in the organisation.
Data matters, but context matters too
Data can tell us a great deal about a system.
It can show patterns.
Trends.
Demand.
Performance.
Variation.
Outcomes.
But numbers rarely explain everything on their own.
Sometimes a metric improves because staff have developed an informal process that is difficult to sustain.
Sometimes an outcome looks positive overall while a particular group is having a very different experience.
Sometimes a service is being delivered efficiently but is creating a burden somewhere else in the system.
This is where context becomes important.
Quantitative information tells us what is happening.
The experiences of people working within and using a system can help us understand why.
Good decision-making needs both.
Design from reality, not assumption
Systems are often designed around assumptions about how people will behave.
People will read the information.
They will know which service to contact.
Teams will communicate.
People will understand the terminology.
Staff will have enough time.
Technology will behave as expected.
Everyone will know what their responsibility is.
Reality is usually more complicated.
People are busy.
Services overlap.
Responsibilities change.
Information is interpreted differently.
Technology fails.
Unexpected needs emerge.
That does not mean good system design is impossible.
It means design has to start with reality.
What actually happens?
Where does the process become difficult?
Who is doing extra work to keep it functioning?
Whose needs were assumed rather than understood?
What happens when things do not go according to plan?
The strongest systems are not those designed for perfect conditions.
They are the ones designed with a realistic understanding of people and complexity.
The people closest to the work should help shape the work
This does not mean strategy should be handed entirely to frontline teams.
Different perspectives are needed.
Executives understand broader organisational constraints.
Boards hold governance responsibility.
Policy teams see regulatory and system-level requirements.
Communities understand their own context.
People accessing services understand their lived experience.
Frontline workers understand what implementation actually looks like.
Good system design brings these forms of knowledge together.
The challenge is not deciding whose perspective matters most.
It is creating a process where each perspective can inform the whole.
That is one of the reasons I place such importance on listening and co-design.
Not because every problem can be solved through consultation.
But because complex systems are better understood when we stop assuming that expertise sits in one place.
Good systems reduce unnecessary effort
A well-designed system should make it easier for people to do the right thing.
It should reduce duplication.
Clarify responsibility.
Improve the flow of information.
Create sensible pathways for decisions.
Make expectations easier to understand.
And reduce the amount of energy people spend navigating the system itself.
This matters for the people receiving services.
And it matters for the people delivering them.
When staff are constantly working around processes, chasing information or compensating for unclear responsibilities, that effort comes from somewhere.
Over time, inefficient systems create pressure.
Good system design removes unnecessary friction so people’s energy can be directed towards the work that actually matters.
Leadership needs visibility beyond the dashboard
The further leaders move from frontline delivery, the more deliberately they need to create ways of seeing it.
That might mean spending time with teams.
Listening to people who use services.
Creating better feedback pathways.
Asking different questions in executive meetings.
Looking beyond headline measures.
Inviting challenge.
And making it safe for people to explain where a process is not working.
Leaders do not need to know every operational detail.
But they do need enough visibility to understand the organisation they are leading.
Sometimes the most valuable question a leader can ask is simply:
What am I not seeing from where I sit?
Systems ultimately exist for people
My work has moved across frontline practice, organisational change, strategy, leadership and governance.
Those environments are very different.
But the lesson that has stayed with me is simple.
A system cannot be judged only by how well it has been designed on paper.
We have to look at what happens when people encounter it.
Does it make sense?
Does it support the people expected to work within it?
Does information move where it needs to go?
Can people navigate it?
Does it create the outcome it was designed to create?
And when it does not, are we willing to listen and change it?
Because ultimately, systems are not diagrams, policies or structures.
They are the experience created when all of those things meet people.
And understanding that experience is often where better design begins.
