The challenge in this is that community care systems,
in common with other public services, are hugely complex. And there is a wide
diversity of organisations involved in public service delivery, often not
directly accountable. An effect of this complexity is that it is more difficult
to predict the outcomes of an intervention. Feedback loops and delays in one
part of the system can lead to false assumptions about the effects of actions,
and this in turn can cause initiatives to fall flat or have unintended
consequences. Take for example the Government's pledge to eliminate NHS waiting
lists - admirable as an aspiration until you read the National Audit Office's
findings that around 20% of consultants are having to routinely juggle clinical
priorities to avoid financial penalties of long lists.
So how can systems modelling and whole systems thinking help?
We believe that the greatest insight comes from:
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Engagement with key stakeholders to arrive at a shared understanding of the
problem and its drivers
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Identification of the data required to populate the model
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The use of a good software package such as iThink® to allow a variety of
assumptions and their sensitivities with regard to the system as a whole to be
tested
Woodville Consultancy has worked with health economies in a number of ways to
help "unstick" intransigent problems.
One approach might be the series of three workshops run in conjunction with
Social Services and housing colleagues in Leeds. The aim was to deliver a model
that enabled partners to understand factors influencing the demand and supply
of long term care for older people, and therefore to plan better for this
provision through to 2021.
The workshops were attended by a project team of key stakeholders from social
services, housing, health, and the independent sector, with a facilitator
experienced in whole systems thinking.
The first workshop set out to scope the issues and produce a visual
representation of the system and the influences on supply and demand over the
specified period of time. For the Leeds project team the first step was to come
to a shared understanding of the system within which long term care was a key
element. A fundamental change in the "mental map" of what was meant by the
brief was the inclusion of a growth sector of long-term care provided outside
of an institutional setting.
Having established a shared view, the period between the first and second
workshops was used to obtain data consistent with those drivers and influences.
Feedback is a crucial element in developing any model. At Workshop 2, the
project team checked that the emerging model accurately reflected learning from
the first workshop in terms of importance of influences and drivers. They
identified three sectors: a demographic sector; a hospital/intermediate care
sector; and the long-term care sector itself. Assumptions were made for each of
these sectors based on intelligence acquired within the workshops. These
included:
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The relationship between 65-74 year olds and 85+ as a pool of carers
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Changes in the growth rate of intensive home care over time
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Average length of stay in care homes, modified by intensive home care
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The effects of government strategic initiatives on emergency admissions
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The changing balance over time of intermediate care between diversion from
hospital in the first place and early discharge from hospital
The final workshop was an opportunity to explore the behaviour of the model and
any resultant learning, in particular any behaviour that was contrary to what
might be expected. For the Leeds team, the modelling process broadly confirmed
participants expectations of the need to sustain a healthy care home sector at
levels similar to today to reflect demographic changes, but also highlighted a
need to focus attention on providing long term care in non-residential
settings, and also the importance of intermediate care in the process.
As well as delivering consultancy in four key programme areas (whole systems
review, partnership development and support, whole system dynamic modelling,
and project and programme management), we also run bespoke training of 1-3 days
duration for clients interested in learning how to use iThink® effectively in a
health or social care setting.
