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Chapter 6: Need for a whole systems approach
Our first report mentioned a need that had been identified to help stimulate the development required of the whole systems approach. This was seen as contributing to reducing both the incidence of delayed discharge and achieving the required shift in the balance of care from institutional to home-based settings and delivering faster access to better services and better outcomes.
The issue is the complexity of systems, for example in a health board or local authority area and between these bodies at local level, and the interaction of these systems. Any changes in part of the health system impacts on other parts of that system and often, and increasingly, on community care and housing providers (and vice versa). These services are provided by different providers in the statutory, voluntary and independent sectors. As these are interdependent, those who commission services needs to look across the range of services - the whole systems approach - and not just their own service or even their own organisation.
This has been picked up in different pieces of work, particularly in
Moving on? An overview of delayed discharges in Scotland and Moving on?A handbook on modelling the whole system for delayed discharges in Tayside (Audit Scotland June 2005). The main findings of the Report bear repeating here.
These looked at the operation of local services for health and community care in Tayside. The specific focus of the work was on reducing delayed discharges, but the lessons go much wider and are for the planning and delivery of services for older people.
The first report noted (paragraph 20):
Delayed discharges are a symptom of wider systemic problems in the delivery of health, social care and housing services, as our detailed work in Tayside demonstrates. Therefore, partnerships must:
- consider all aspects of their system when developing strategies to reduce delays, and integrate these strategies into mainstream capacity planning
- develop a shared, in-depth understanding of the way in which local health and social care services interact
- undertake detailed, long-term planning to take account of the projected growth in the older population
All these recommendations are of particular relevance to our review group.
Audit Scotland noted the complexity of local systems, and the interdependence of health care and community care services. Consequently a change in any one part of a system could have a substantial effect on another part. Decisions made about services made for one purpose may also have unintended consequences for other parts of the wider health and social care system.
The first report states (paragraph 67):
If the Tayside Partnership continues with its current delayed discharges strategies then the expected growth in the older population would lead to a steady increase in the number of older people admitted to Tayside's hospitals. This is likely to lead to more delays for patients being discharged from hospital. This means that the 'status quo' is not an option. The effect of a growing older population on existing provision will be of relevance to all partnerships in Scotland forecasting a growth in their older population.
The work looked at a range of strategies aimed at reducing delayed discharges over a 5 year period, and found (Exhibit 14 page 23):
- Reliance on purchasing extra care home places, in isolation, produces the poorest performance overall.
- Shortening the assessment time in hospital appears to sustain reductions in delayed discharges for longer than any other single strategy.
- No strategy, adopted on its own, can sustain continued progress in reducing delayed discharges beyond 2005/06.
- Strategies pursued in isolation result in significantly poorer performance than adopting all of the strategies.
- Short-term reductions may be achieved by implementing a chronic disease management programme, or increasing home care provision or increasing specialist housing. Long-term reductions may only be achieved by implementing all of these strategies.
Thus the model showed the need to introduce a range of strategies and the necessity to redesign existing services, such as reducing the length of the assessment period in hospital, as well as increasing service capacity in the community.
The report notes in paragraph 70 that:
Working together to reduce delayed discharges involves much more than local health and social care colleagues meeting to discuss discharge planning and to agree priorities for spending the additional funding from the SEHD. It is about ensuring that there is a shared understanding across the partnership of how the local system works; what the complexities and inter-relationships are; and how staff and services can influence what happens. Feedback from the Tayside Partnership showed that the whole systems approach we used enabled genuine joint working, where staff from across the four organisations in the partnership and a variety of professions came together to discuss a common issue.
Key recommendations (paragraph 74) are that local partnerships should:
- take a whole systems approach to developing a shared understanding of the interdependence of services
- ensure that all key stakeholders are involved in developing an understanding of the whole system
- link delayed discharge planning with mainstream capacity planning
- improve information on the cost, quality and provision of community care services.
The report demonstrated the complexity of local systems, comprising
- different providers in health care, social work, housing and housing support services, and voluntary and independent organisations.
- staff from a variety of professions.
Some general conclusions were reached, which are appropriate to capacity planning generally. These were:
- it is important to provide a balance of strategies to achieve the desired aim.
- there is no single one size fits all solution (the 3 council areas in Tayside needed a mix of different strategies).
- changes in process are as important as investment in capacity, and
- (in the delayed discharge context) although each of the strategies produce reductions in delayed discharges, without redesign of processes there appears to be a level below which it would be extremely difficult to go.
As we have indicated already, the points repeated here go much wider than the immediate context of reducing delayed discharges. The lessons are for the planning and delivery of whole system services for older people, and we endorse them wholeheartedly.
Building a Health Service Fit for the Future notes its conclusion "that the current organisation and infrastructure of both health and social care - with health still split into acute and primary sectors and social care managed as a traditionally separate entity - is far from ideal for the necessary development of the whole-systems approach essential for the good care of older people, both individually and at a population level".
They then state that "The introduction of unified NHS Boards and the implementation of Community Health Partnerships will provide a better context for flexible and innovative models of organisational integration". (Volume 2 page 47).
Building a Health Service Fit for the Future has a section on whole systems working, that refers to work by the Audit Commission in their report "Integrated services for older people - building a whole systems approach in England". (Volume 2 page 61).
All this emphasises the need for a whole-systems approach in the care of older people. Building a Health Service Fit for the Future is health focussed, however, and does not attempt to set out the implications of its recommendations for those who provide community care and housing services. We return to this later.
In conclusion, a whole systems plan should encompass populations, strategies ( e.g. reducing delayed discharge and waiting lists for health and care services), care models, costs of services, funding sources, finance and resource plans.
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