A systems view of health and social care

Social Policy Research for Cornwall

A copy of this page can be downloaded as a pdf file here.

On this web site I have posted (under POSTS) a collection of case studies of planning and policy-making in the field of health and social care that I have amassed over the past five years. Many are specific to Cornwall, in the far south-west of England, where I have lived since 2005, but all of them to a greater or lesser extent have required me to look at the national context, so they have a much wider application and relevance.

I look at health and social care organizations with one question in mind: How does the system work? As someone who was brought up as a physicist, I have a keen interest in exploring and revealing the mechanisms and processes within systems made up of interconnected parts. I have been particularly struck by the difficulty I encountered in discovering the processes, other than recognised medical and surgical procedures, that take place within the National Health Service. 

Take planning, for example. Having spent a number of years researching urban planning processes, I knew of course of the existence of the Royal Town Planning Institute in the UK, and I was aware that a number of British universities offer post-graduate degree courses in urban planning. So I was at first surprised to find there are no equivalents for health care planning. However, it was then less of a surprise to read documents setting out plans for the NHS, such as the 2019 NHS Long Term Plan, that say nothing whatever about how those plans were arrived at. I found myself asking whether there was anyone at all in the NHS who had a sense of how to plan, let alone any training in that skill.

Another example: NHS England’s guidance on counting ‘delayed transfers of care’ from hospital sets out three decisions that have to be taken before a patient is ready to go home but does not say whether they have to be taken in a certain order or how they relate to certain administrative steps that are required. This absence of a clear process leaves hospital trusts free to make up their own rules as they see fit, and these differ widely from one trust to  another, so adding the figures together to arrive at a national total makes no sense.

Processes take place within a structure of some kind. The term ‘structure’ conjures up visions of an organizational hierarchy, such as NHS England / regional teams / hospital trusts, while within hospitals we find the paediatric team, emergency team, etc., headed by consultants in charge of junior clinicians and working alongside ward-based nursing teams. The traditional organization chart, with a hierarchy of boxes connected by various lines denoting accountability and communication channels, describes these structures perfectly well. Observe that the teams that we see are teams designated as such by the management.

But we can take a very different approach. Consider a patient who is taken into an acute hospital with a medical or surgical condition that requires treatment. We can trace their path, their ‘trajectory’, through the hospital, from emergency department, via assessment and testing, to treatment, recovery, subsequent care and eventual discharge. Many of the clinical and other practitioners involved along this trajectory will have no occasion to meet, but we can view all of those people as members of a team concerned with that patient, and ask questions about the relationships – and especially communications – among them.

We can also make a distinction between a ‘core team’ of people concerned with the patient and a ‘wider team’, comprising the core team and people beyond it – especially family and close friends – who have an interest in the patient’s welfare and may have useful insights into their condition and behaviour. I would put the patient himself or herself at the centre of the core team.

Finally, we can invariably distinguish one or more ‘cultures’, which may be specific to a particular profession or department or group or a whole organization. This would embrace ‘how we do things here’ and attitudes to how strictly ‘the rulebook’ should be followed.

This battery of concepts – process and structure; trajectory; core team and wider team; communications, relationships, culture and rulebook – provides the theoretical underpinnings of the case studies in this collection.

For an illustration of what can be done with this approach, see the post (on this website) at bit.ly/COCO123.

Peter Levin

12 July 2020