Rewriting the Rules
"The system isn't broken—it was built this way. So we rebuild it."
CPD Learning Time: Approximately 2 hours (including reflection and practice) | Level: Foundation
By completing this lesson you will have demonstrated: system mapping and role reversal to see healthcare from multiple perspectives, practice in challenging policies and processes that perpetuate racial inequity, design of at least one specific practice change, and mastery of the CREP-D² framework applied to complex real-world scenarios.
In practice, this may change how you identify leverage points, question routine processes, redesign team responses, and act on inequity in your service setting.
Building New Architecture
Ava moves from seeing the system to changing the system. From individual awareness to collective transformation. The rules are about to change.
You may move through this lesson at your own pace. Observation is also participation. No participant is expected to represent a community or educate peers through personal disclosure. You may return to any section later if needed.
Systems change without the people most affected is just rearranging furniture. As you plan interventions, keep asking: whose voice is centred here? Who benefits? Who decides?
Ava Thompson
From Awareness to Architecture
"For months, I saw the problems. The patterns. The ways the system disadvantaged certain patients, certain colleagues, certain communities.
But seeing isn't enough. Understanding isn't action. Knowledge without practice is just guilt with extra steps.
So I started asking different questions. Not 'why is this happening?' but 'what would different look like?' Not 'whose fault is this?' but 'who can build something new?'
I learned to map the system—to see where policies connected to practices, where practices connected to outcomes, where outcomes connected to suffering. And in that mapping, I found the leverage points. The places where a small push could create a big shift.
Today, you'll practice stepping into other perspectives—experiencing the system from multiple positions. You'll map the forces that shape your ward, your team, your practice. And you'll master CREP-D² not as a framework to learn, but as a tool to wield.
We're not just learning anymore. We're building."
Seeing the pattern is not the end of the work. Once inequity is visible, the next task is to amend the service, workflow, decision path, or accountability structure through which the harm is being reproduced.
Funtumfunafudenkyemfunafu — Unity in diversity — Shared stomach, shared destiny
From Engagement to Empowerment — Rewriting the rules and leading change
In this lesson, we treat harmful outcomes as system-produced. We learn to see the system, locate the leverage points, and practise rebuilding the rules.
Role Reversal Theatre
Start with one response. You can refine, skip, or return later. You may reflect privately, skip a prompt, or revise your response.
Step into different perspectives. Experience the same moment from multiple positions. Empathy isn't agreement—it's understanding that enables change.
Step Into Another's Shoes
Experience the same moment from different positions
“Role reversal theatre is not just drama — it is a safety investigation in real time. When you step into the patient’s shoes, you see clinical practice from the inside. The mental models that shape how care is delivered become visible when you stand where the patient stands.”
▸ What evidence are you noticing?
- What you saw differently about clinical practice when standing in the patient’s position
- A safety concern that became visible only through role reversal
- How this experience shifted your mental model of what ‘good care’ looks like from the receiving end
You’ve completed this step. You can move on when ready.
Care & Opt-Out Options
Some activities in this lesson explore bias and institutional harm. If any content feels overwhelming, you have options:
• Take a break and return when ready
• Take a Cultural Pause™ to ground yourself
• Skip this activity and continue to the next section
• Reach out to your line manager or support services
You are not required to share personal experiences. Silence, reflection, and private note-taking are equally valid forms of participation. No one is expected to educate others from lived experience.
Your wellbeing matters. Growth happens at the edge of comfort—not past it.
Your insight here feeds into the wider evidence architecture — it is system insight. Your insight here has implications at three levels:
A shift in how you see, interpret, and respond in real situations
A pattern that may be present across patients, decisions, or interactions
Evidence of how care is experienced, where inequity may be present, and where change is needed
Systems redesign of this kind is how NHS services move from awareness to amendment — using disparity data as an operational signal, not just a dashboard statistic.
When multiple learners surface similar patterns, this is designed to support system-level intelligence as evidence and patterns emerge over time. As deployment scales, this insight can become visible and actionable at service, Trust, ICS, and national level — not opinion, but signal.
Pause
Breathe once. Notice what you are carrying. You may continue now or return when ready.
You are not required to share personal experiences. Silence, reflection, and private note-taking are equally valid forms of participation.
System Mapping
Every outcome is produced by a system. Map the layers—from individual actions to structural forces—and find where change is possible.
Rewriting institutional rules and policies changes the conditions under which care is delivered. System-level change reduces the harm that individual good intentions cannot reach — and creates the structures within which equitable care for racialised patients becomes the default, not the exception.
You do not need to map everything. Focus on the key forces you recognise, or identify just one leverage point where change feels possible.
Map Your System
Click each layer to identify the forces shaping outcomes in your practice
“Mapping a system is an act of leadership. When you trace the connections between policies, practices, and outcomes, you are using data to make the invisible architecture of inequity visible. This is how leaders create the conditions for culture change — by seeing the whole picture.”
▸ What evidence are you noticing?
- The system map you created and what it revealed about how inequity is maintained
- Data points you identified that show where the system produces unequal outcomes
- One leverage point for culture change that your map revealed
CREP-D² in Action
You've learned the framework. Now apply it in real-time to a scenario you might face tomorrow.
Apply the Full Framework
Work through each step for this real scenario
"Systems change when enough people refuse to play by the old rules and start demonstrating new ones. You are that person. This is that moment."— Ava Thompson
“Mastering CREP-D² means you can now apply it to the most complex situations — where power, policy, and patient experience collide. When you advocate for different outcomes by co-producing decisions with patients and communities, you are working at the heart of what PCREF envisions.”
▸ What evidence are you noticing?
- How you applied CREP-D² to a complex scenario and what outcome it produced
- One way you advocated for a different result by centring the patient’s voice
- How co-produced decision-making changed the outcome compared to a top-down approach
You’ve now completed this section. Next, you will apply it. Before you commit, take a moment. What is sitting with you? What needs a breath before you name your next step?
Personal Integration
Name one rule you will rewrite—and the new rule you will practice instead. Consider how this commitment translates to your workplace practice, patient care, or team interactions.
Your Rule Rewrite
"What unwritten rule will you challenge—and what will you practice instead?"
For example: "The old rule is 'family members slow down ward rounds.' The new rule I'll practise is 'family presence improves care planning and cultural safety.'"
Systems Change Across Roles
Direct-Care Practitioners
Systems change begins at the bedside. When you notice that a pathway disadvantages certain patients, naming it is the first leverage point. Ask: who designed this process, and whose experience was absent from that design? Your clinical observations are evidence for redesign.
Managers & Leaders
You hold structural leverage. Policies, rotas, referral criteria, and escalation procedures are all systems you can redesign. The role reversal theatre in this lesson asks you to experience your own systems from the patient’s chair — that perspective shift is where equitable redesign begins.
Peer & Support Workers
You are uniquely positioned to see where systems fail the people they claim to serve. Your lived experience is not anecdotal — it is structural intelligence. When you identify a leverage point, you are doing the most important work in systems change: making the invisible visible.
MDT & Team Contexts
Systems change is not a solo project. Use the Systems Change Planner to identify one process your team could redesign together. Start small: a referral form, a handover template, a ward round structure. When the team co-produces the redesign, the change is more likely to hold.
What This Lesson Asked of You
This lesson asked you to move from understanding to architecture. From naming what is wrong to designing what could be right. Sankofa teaches that we must go back to get what was left behind — and in systems change, what was left behind is the perspective of those most affected by the system.
Intersectionality, role reversal, leverage point analysis, and practice redesign are not abstract concepts. They are Monday morning tools. The question is not whether you understand the system — it is whether you are willing to change it.
The system was not broken. It was built this way. Now you have the tools to rebuild it.
Anti-Racist Responsibility Prompt
“What rule, routine, or assumption in your professional setting most needs rewriting for anti-racist practice to deepen?”
Part 3: Transformation & Application
Lesson 1 of 2 in this Part
PCREF domains explored in this lesson:
This Lesson Builds
Hover over each outcome to see what it means in practice.
Your Learning Record
This structured reflection is designed to travel with you — into supervision, appraisal, revalidation, or your professional portfolio. Take a moment to consolidate what this lesson has surfaced for you.
This reflection can inform supervision, service review, or governance discussion.
This lesson may be used as evidence of continuing professional development. It is compatible with NMC revalidation, HCPC Standards of Proficiency, Social Work England CPD, BPS/BABCP/UKCP frameworks, and the NHS Knowledge and Skills Framework. Bring your Learning Record and PCREF reflections to your next supervision session.
This system does not itself confer profession-specific accreditation, but the learning and evidence you generate here may support your portfolio, appraisal, or revalidation process.
Lesson Resource
A strategic planning tool for identifying leverage points and designing structural interventions.
Download Systems Change Planner (PDF)Take a moment to note what feels most important from this lesson.
- • What stands out most for you?
- • What challenged, stretched, or shifted your thinking?
- • What might this change in your role, practice, leadership, or response?
- • What is one reflection you may want to bring to supervision, team discussion, or further journalling?
This lesson may land differently depending on your role. You might use it differently in practice.
For direct-care practitioners
How might identifying leverage points and planning systems change change the way you notice, interpret, assess, respond, or communicate in care?
For managers and leaders
How might identifying leverage points and planning systems change shape what you make visible, prioritise, protect, challenge, or support in your team, ward, or service?
For peer and support roles
How might identifying leverage points and planning systems change strengthen the way you hold voice, trust, belonging, advocacy, and practical support in your work?
For teams and MDT settings
How might identifying leverage points and planning systems change change the way people listen, share power, reflect, make decisions, and work across difference?
As you leave this lesson, consider both:
- • what anti-racist practice might require from you in how you see, relate, lead, or respond
- • what anti-racism practice might require in the team, service, policy, or system around you
Before You Move On
Pause here if you need to.
You do not need to finish every reflection in one sitting. If something difficult has been stirred up, you might:
- • write one private note before moving on
- • bring one reflection to supervision, pod discussion, or trusted dialogue
- • pause and return later
- • carry one question forward rather than forcing closure now
Observation is still participation. You do not need to push past your current capacity to continue meaningfully.