There is more to life than services II

There was a report yesterday that delays to discharge from hospitals is up by 29% compared to August 2010 http://goo.gl/9NHx0.  This is seen by many as a major problem.  A cue for comment on and evidence of the cost of an ageing population and the folly of reducing social care budgets by £1.3bn.

My studies paint a different picture.  One where age and money (at least the lack of it) are not a problem.  Take this story about how the current design and management of work gets in the way of doing the right thing and ends up costing the system thousands of pounds more than it needs to.  I spoke before about a wheelchair user who was part of an experiment with a team of people working with the Vanguard Method (here).  Rome wasn't built in a day and all that, so unfortunately this chap continues to run into obstacles every step of the way in trying to get a good life.  

The one that stuck in my mind was how he wanted to solve a problem called "I want to be able to use my kitchen and cook for myself".  His answer was to have an adaptation to his wheelchair (we'll call it a cushion) at a cost of £600.  His OT says that they don't have a budget for cushions, try the housing department.  It turns out they don't have a cushion budget either but if the social worker refers for an assessment the housing department will pop round and measure up.  Assessments made and measurements completed they inform him they can adapt his kitchen for £6000.

He tells them that this will not be necessary, the accommodation is temporary, he is on the housing list for re-housing and anyway all he needs is the cushion.  Despite this the housing department refer back to social services who do another visit, complete a 21 page assessment and set up interim meals on wheels while the claim for self directed support is processed.  The good news is that he is entitled to £150 per week and he is still on the list for a £6000 kitchen adaptation.  The bad news is he just wants help with a one-off purchase of £600 for a cushion.  He still can't use his kitchen.

For some who deal with examples like this everyday, this will come as nothing new.  Another of a long line of frustrations in simply trying to sort out basic stuff for people.  Like the person who has had over 1000 assessments in 10 years and 200 in 12 months (here), or the 6 week stay in hospital for treatment of a UTI because the correct forms had to be filled in (here).  For others it will actually make sense.  How else can the system control costs?  It makes sense to continually assess people against agreed criteria, doesn't it.  Otherwise they will just abuse the services.  That is not what my evidence shows.


The point is, it is not about age, never mind that studies suggest that this has a marginal impact in the cost of healthcare (the red herring argument) or money.  It's about how we think about what works.


Our current design is transactional and episodic because we think this is more efficient and effective.  It isn't.  In fact it drives huge levels of unnecessary and unwanted consumption.  We think services matter.  No doubt they do, to a point.  But there is more to life than services.  We think in terms of service shaped solutions which leads us to try and control access to them and all the bureaucracy that this entails.


Better is to think in terms of person shaped solutions.  Taking the time to understand people in the context of how they live their life.  Building and tending to relationships end-to-end over time.  My experiments with leaders are showing that doing this has remarkable benefits in terms of service, efficiency and morale.


Right now, from what I have studied, I can see no evidence that an ageing population is the train wreck in slow motion it is portrayed as.  Neither can I see evidence that value demand is increasing. I do see a lot of failure demand based on the way we do things.  This is costing billions and not always solving peoples problems either.

The policy implications of this perspective are significant.  The failure to understand the importance of changing how we think about the design and management of work will have long term and costly implications for the NHS as policy makers fiddle with the wrong solutions to the wrong problems.  To avoid damaging decisions that affect peoples lives and the public purse adversely let's get knowledge about what matters to people before we take the way we do work today and project the implications of this forward.


I continue to learn but the evidence I have gathered to date reveals a number of counter intuitive truths:

• the NHS can be entirely self sustaining
• there is no need to talk of rationing or gatekeeping
• commissioning in the way it is currently conceived is creating not solving the problem
• people want to consume less, not more healthcare services
• the way we conceive of integration is polishing at best
• the industrialisation of public services is the single biggest driver of unnecessary cost in the system.

Delayed discharges are, from a systems thinking perspective, a symptom of how we think about the design and management of work.  Blaming ageing or funding will not help solve the problem.  The risk is that such an approach will make things worse.  We do not have the problems we think we have.  Even if we did, we can't solve these problems with conventional approaches anyway.