Pressure Mapping

A New System Metric

Louise Patmore, Systems Change Lead, Changing Futures Sussex & Maud Pedemonte-Ellis, Partnership Manager, Making Every Adult Matter (MEAM) reflect on a new way of measuring system pressure.

Introduction

The process by which we currently understand the system, is built on journey maps, case studies, or Swimlanes to track and evaluate a person’s experience of multiple compound needs (MCN) as they interact with services. These metrics are then used to inform a service’s efficacy, to commission new services, and to influence policy. There is a tension here as these metrics are critical to understanding the work, but they are often ‘lagging’ or ‘remedial’ metrics. I.e. they are based on review and reflection and are often retrospective: ‘this has happened’. Once these metrics are recorded, they become a static truth and an influencing tool, so it is essential that we interrogate our process.

What has become clear is that we need to move to more real-time, ‘leading’ or ‘potential’ metrics: ‘this is happening’, or ‘this will happen next’. As we’ll highlight in this blog, there is a lot of progress and potential as we move towards this with the advancement of AI and data solutions such as Plexus. Until these technologies are embedded into our sector country-wide, in the intermediate period, we continue to evolve our process of understanding the system. We’ll outline the evolution of our work thus far and offer some solutions for other areas to adopt

“Common Mess:” How we understand the system.

Juliette Yog produced an ecological theory map (below) illustrating all the systems present in a person’s life. This is what we aim to capture through swimlanes—mapping how someone with MCN navigates a system that isn’t fit for purpose. Though this seems unmanageable, it is precisely the work required to ensure we fully understand these lived experiences.

We know that mapping experiential data from both individuals and professionals helps us better understand the interface between social determinants and health systems—not as speculation, but as a structured process. This requires inter-agency agreements and a shared principle of data alignment—on a monthly, weekly, or even daily basis—linking narrative experience with system data.

Using the swimlane method, caseworkers can record both positive and negative input across two types of data:

1. Known service use via integrated datasets (e.g., A&E, GP visits).

2. Tacit, personal interactions—like when services feel safe or trusting (noting that this is inherently subjective). Phenomenological frameworks help us bring this tacit knowledge—often distrusted by systems—into scope for trend analysis.

The Measurement Problem:

Currently, case studies and journey maps address this in a limited way—usually offering a single point-in-time perspective. But what if this was live? What if system lines of inquiry were joined in real time? We're moving toward this reality with AI and data solutions such as Plexus.

We often request a “mapping” exercise when launching a new service or making changes. However, these are often just snapshots—disconnected from the larger system, quickly outdated, and shaped by the perspective of a single organization. In contrast, if we could see client pathways in real time— “Where have you come from?”—we’d gain a far more accurate picture of how the system truly responds.

This will require significant system changes—such as the use of Plexus and the Sussex Integrated Dataset—as well as cultural shifts: from lagging to leading metrics, and from siloed risk-holding to shared risk and responsibility. A living journey map or swim lane can help address at least part of this challenge.

The system is currently experiencing what MEAM calls a “common mess”: interlocked and overlapping systems within systems. The various MCN qualifiers affect individuals who must navigate these systems, often simultaneously.

Take, for example, a housing officer and a mental health nurse. While both support the same cohort, their roles are tied to entirely different systems—each with unique data, technical language, and institutional expectations. This results in siloed specialisms. While this may work for someone with a single need, it fails those experiencing multiple unmet needs.

To quote a lived experience expert:

“I am not 20 people experiencing one problem each. I am one person experiencing 20 problems.”

This “shared mess” requires shared action. Without this, services will continue to offer ineffective short-term solutions for individuals who often become trapped in cycles of care—stigmatised as “high-intensity users,” “revolving door clients,” or other derogatory terms. As some have described it:

“It’s like being the ball in a table football game, a penny drop machine, and playing Tetris—all at the same time.”

The consequences are severe. For clients, it means unmet needs. For workers, it means moral injury, burnout, and staff turnover. As a result, trauma-informed training has shifted its focus to include staff wellbeing, not just client care.

The system often opts for “low-hanging fruit”—small pilots and short-term initiatives that are nurtured and then forgotten. This cyclical reset attempts to address long-term, wicked problems without addressing root causes.

Through Changing Futures, we’ve identified several gaps in the national costing framework—namely, metric infallibility and the guesswork involved in assigning costs to services and experiences. Traditional fiscal or throughput-based metrics fail to reflect value for money or effectiveness.

Swim lanes and Pressure Mapping: The work ahead

Journey maps traditionally describe a client’s movement through the system retrospectively. But what if they were live? We see increased demand for mapping exercises to identify gaps and improve client-service interactions. However, static outputs quickly lose relevance and only reflect organizational perspectives.

If we could track pathways in real time, we would gain a far more accurate view of how the system responds. Doing so requires both technical infrastructure—like the Sussex Integrated Dataset—and a cultural shift: toward risk-sharing, metric-sharing, and organizational trust.

This work began as a swimlane and cost-avoidance exercise. We aimed to understand the cost of multiple disadvantage and to highlight cost savings when MCN clients are connected with Changing Futures support. But we quickly realised that cost-avoidance metrics are often crude and speculative.

Unit cost estimates are largely based on national datasets—especially from Greater Manchester Combined Authority (GMCA)—which often feel like underestimates. A service interaction’s "felt" cost rarely aligns with its calculated cost. This exposes a fundamental problem: metric infallibility.

To address this, we designed a Pressure Matrix—a tool to better reflect the human cost of service interactions. Each interaction was categorised in the first instance as:

1.      Urgent or Non-Urgent

2.      Statutory or Non-Statutory

3.      Planned or Unplanned

We also introduced a multiplier effect to account for how many people were involved and how long the interaction took. This allows us to demonstrate how a trauma-informed MCN service reduces systemic costs and pressure—for example, helping a client access a GP rather than attend A&E for a non-urgent issue.

Our evolving model includes a multiplier-based index—based on four factors with five levels—purely focused on system pressure. To complete the picture, this must be balanced with real-time client experience to create a truly “live” journey map.

• Specialist staff

• Facility

• Restrictive

• Reactive

So What?

We understand this project as having evolved through several phases: from static journey maps to cost-avoidance models, to axis-based interventions, and now to pressure mapping. It begins to articulate the complexity of the system as experienced by real people. We can see service relationships, the cliff edges of support, and the need for systemic responsiveness to lived experience.

To understand cost, we must first understand context. We can’t continue to segment, silo, and specialise in the ways the current system encourages us to. So where do we go from here?

As we continue to evolve the Pressure Matrix, we need input and collaboration across sectors. A systems-based approach to MCN is everyone’s remit. It requires dropping ego, scarcity thinking, and competition. We are already in a stronger position than when this paper began—particularly with developments around the Sussex Integrated Dataset (SID). If this process can be integrated into SID, it can accelerate learning and traction—and bring SID closer to its intended purpose: connecting partners through shared data. We also need a demonstrable, analytical framework that can meaningfully align with Integrated Care Board (ICB) priorities: high-intensity use, health inequalities, and urgent care.

System-wide consensus is increasingly difficult in modern health and social care. Solutions may be controversial. Multiple stakeholders, differing metrics, and clashing priorities often cause trust breakdowns and reinforce silos. Issues like drug use and mental health are as complex as climate change or pollution—and need to be approached with the same systems-thinking mindset.

The Pressure Matrix continues to evolve in Sussex with support from local and national partners. We see parallel work in Northumbria and Lincolnshire (e.g., the Liberated Approach). We ask that all partners lean into the “common mess”—not shy away from it. This requires a different kind of leadership, one that understands geography, culture, and empathy between silos. It’s about becoming more human—genuinely convening systems, managing risk positively, and acting because it’s the right thing to do.

To find out more about Pressure Mapping, contact Louise Patmore, Systems Change Lead, Changing Futures Sussex