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ANNEX NINE: CASE STUDY 8: WORKING WHOLE SYSTEMS: GENERATING NEW CONVERSATIONS FOR CHANGE - GOING HOME FROM HOSPITAL
Patients often describe poor experiences of going home from hospital. Hospital discharge involves the actions of many different interconnected individuals, professional groups and organisations. A good example of Whole Systems working is provided by the experience of the Newcastle Health Partnership. This approach is described in fuller detail elsewhere 42.
The Newcastle Health Partnership launched their adoption of the approach in 1995 with a Future Search event 43 to explore the question 'How can we improve the well-being of older people in Newcastle?' After the event small groups continued to meet to take forward issues they felt particularly strongly about. One of these groups heard a story from one of the participants about her distress about the discharge of her husband from hospital that went wrong. The group decided to treat the story as significant and to do something about it. They didn't try to fix the particular problem in the case they'd heard about, but they used the story as a source of energy for change.
They looked for other people that shared their concern and brought together a group of over forty people that contained a wide range of perspectives and included a number of elderly people. The group met for half a day at a time, to allow relationships to grow and understanding to be shared. They sat at round tables seating eight, sometimes with people from similar organisations and at others in mixed groups. They invited extra people along and always included older people and carers.
To look at what really happens when someone is discharged from hospital rather than what's supposed to happen, they undertook a system mapping exercise in which facilitators described an 'archetype', a description of an older person not coping at home due to illness. They invited participants to describe what might happen, and drew the many possibilities on the wall. Through this approach they realised the number of different people involved in the discharge process; the patient themselves, nurses, doctors, administrative workers, transport providers and GPs. They also saw the central role played by friends, neighbours, family, carers, voluntary organisations and social workers and became aware of a number of differing expectations, for example, that the general practitioner will initiate home visits. Then there was also the difficulties of co-ordination between hospital pharmacies and the ambulance service; access to private cars when collecting patients; the role that may be played by interpreters and the number of occasions at which it is the patient who is expected to think ahead and to make links between different bits of the system. By working in this way, they revealed to themselves the connections, communication links, delays and the many uncertainties involved.
An important breakthrough was a change in the use of language. They moved from trying to 'solve a problem' (how to improve discharge) to generating possibilities (how to make going home from hospital a positive experience). This is more then just a semantic point. Hospital discharge focuses on the institution; by framing the issue as a problem it invites organisations to shift the blame. 'Going home' turns this on its head by focusing on the patient. It helps create an understanding of the need for organisations and staff to work together to achieve a desired outcome. It emphasises shared responsibilities to make the system work better.
These shifts in understanding enabled the group to identify desired outcomes for hospital discharge which allowed the development of a deeper and shared understanding of possible options and of how to make the best use of resources. This formed the basis of a draft strategy document which set out common principles to guide action throughout the system. This was tested out through a further whole systems event that was based on a modification of a Real Time Strategic Change approach 44. This was a two day event involving 170 participants who worked on the question 'What can we do to make going home from hospital a positive experience for older people and their carers in Newcastle and North Tyneside?'. This was not a conference or a consultation process. All the participants were actively involved in developing understanding of the whole system, desired outcomes and guiding principles. They used the draft strategy as the basis for a final version and went away from the event committed to carrying out specific work to make going home a positive experience.
This approach has pioneered a new understanding of the nature of strategy. It has also demonstrated the central contribution that can be made by people who use the services, elders and their carers, and by operational workers - both in producing strategy and in initiating and sustaining the work.
Whole Systems working tends to lead to three different sorts of outcomes;
- A new climate of improved cooperation
- Pop-ups - things happen very easily as a result of the new connections and understandings that have developed
- New initiatives - some completely new things happen.
This initiative demonstrates an approach to being strategic in a complex system. It is not 'top-down' or 'bottom-up' but works across different hierarchical levels and makes use of the wisdom and enthusiasm of those working in different parts of the system. It also uses the active involvement of people who use the service and provides an example of genuine partnership working, which is clearly transferable to many other contexts.
For more information:www.wholesystems.co.uk
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