If this is the Anthropocene era life can be understood as being primarily shaped by human intelligent design. And if the early part of this era is characterised by destructive exploitation of the earth and its peoples by those with the power so to do, the ‘Upper Anthropocene’ perhaps offers the prospect of using power with rather than over, as a force for purposeful shaping of human society for the benefit of communities and the environment in a global perspective.
Guided by this philosophy and in the belief that collaborative action research can be applied to construct lasting improvements to human systems even at a small scale, our paper will describe our engagement as facilitators and co-researchers in a collaborative venture to improve one aspect of the health care of older people with complex health needs in South Gloucestershire in the UK.
The context of our work can be summed up as follows: a growing, ageing population; a monolithic National Health Service (NHS) with services free at the point of delivery; severe fiscal constraints; a sense of perpetual crisis as the dominant focus of management attention; little or no headroom at executive top level to re-imagine and re-engineer health services in communities; the NHS portrayed as a political battleground under constant media scrutiny; a dilemma at local level whether to manage within existing rules and systems designed nationally or to try to innovate, at least at the margins, to configure better services for patients and better system cost effectiveness.
Working as consultants and interim managers this paper will explore in case study format the insider/outsider perspectives of enabling complex patients often with multiple co-morbidities, to be assessed out of hospital for onward post-acute health care. These patients are often delayed from being discharged even after being declared medically able to leave owing to a number of factors. The result is that beds are ‘blocked’ further upstream at admissions, with serious consequences for admitting patients in need of an acute bed. This is an
Our story in particular concerns the process of reducing this problem through designing and enabling a system for discharging patients to an interim placement, thus enabling a faster turnover and availability of beds in the hospital and providing a better environment within which patients can recuperate and be assessed for eligibility for onward support.
We describe the emergent nature of getting to the starting line, taking the first steps to introduce a local change process that the various partners can agree on and support, in a context of risk aversion, financial restraint and a monolithic, highly politicised National Health Service (NHS). This stage is about building a shared understanding of the territory and building confidence to co-innovate
We then describe how alternative models were built and assessed, calibrated by an in-depth analysis of patient records which described typical patient journeys.
Finally we show how working participatively we developed feasible models that not only offered patient benefits (although these remain unvalued in fiscal terms), but also resource savings by shifting the locus for patient assessment out of hospital and into interim placements, largely in care homes, and by generating savings through bringing in self-funder resources into the system earlier.
The health system are now in delivery phase having adopted one of the models we constructed and being monitored to facilitate further systemic learning.
