Content uploaded by Kees van Haperen
Author content
All content in this area was uploaded by Kees van Haperen on May 09, 2018
Content may be subject to copyright.
Content uploaded by Kees van Haperen
Author content
All content in this area was uploaded by Kees van Haperen on May 09, 2018
Content may be subject to copyright.
1
Integrating Social and Health Care
With Soft Systems Thinking Making the Difference
Needed to Developing Foundations for Accountable Care Systems
Kees van Haperen
1
VH2 Ltd
Introduction
Over the past decades the gap between the demands for two forms of care, i.e. health and social
care, and the available funding for them has gradually been rising. It has been forecast
2
that over the
coming five years this gap will increase even further reaching unsustainable levels. With these two
main types of care developed as essentially separate services, it has been accepted that
fundamental change is required and is to be based on the creation of a single, integrated system of
care and which brings together a plethora of stakeholders and places the citizen at the centre of the
services. That change was defined in the Five Year Forward view and it identified Sustainability and
Transformation Plans (STPs) as the main means for achieving this.
It has been recognised that change at this scale is highly complex, and cannot be shaped and
ordered from a central government organisation and imposed top-down, instead it can only
emanate from within a local level. Only then will the complexity arising from bringing together the
variety of different organisations and arrangements be addressed. On the one hand the design
needs to accommodate and at the same time overcome that each organisation serves a specific
purpose, is structured in some manner, and possesses a unique culture, in order to instil the
practices and develop new behaviours that are required for an ‘accountable care system’ (ACS) to
become a success. The approach needs to accommodate that these organisations are already in a
state of flux due to ongoing demands on them to change and respond to pressures arising from
internal and external developments such as Brexit, work force decreases, and new technologies.
Leadership and collaboration will form a crucial role in bringing about the ACS, but it needs to be
acknowledged that different individuals will have different perceptions due to their backgrounds,
education and training, experiences and viewpoints; these perceptions cannot be ignored in any
description that tries to be relevant to this new organisation.
In summary, the development of an accountable care system through bring together and integration
of a range of different stakeholder organisations constitutes a complex challenges and requires a
fundamentally different way of thinking. This paper discusses how a branch of systems thinking
could provide an effective method to help support the leadership involved in structuring the
development of ACS and at the same time will support the instilling of a collaborative culture in
which providers can develop new, productive relationships needed to bring about the much desired
transformation of health and social care to become truly citizen centred.
1
Kees van Haperen is co-owner / director of VH2 ltd and a management consultant specialised in strategic
transformations. He became involved with the integration of health and social care when working for PA
Consulting. His earlier systems thinking and health care related involvements took place during his time as
owner and consultant of Koios Group, and are published in a book co-authored with Professor Brian Wilson
Soft systems thinking, Methodology and the Management of change, 2015, published by Palgrave Macmillan,
and which is on the recommended reading list of University of Oxford Brookes post graduate and masters
programmes for health and social care leadership. Some of the SSM modelling artefacts referenced in this
paper were developed with Professor Brian Wilson.
2
Kings Trust (2017) Delivering sustainability and transformation plans - from ambitious proposals to credible
plans.
2
Background
Historically, a number of key factors cause spending on health and long-term care to be driven up.
These include growth in national wealth, costs of care and technological developments, as well as
the size and, to some extent, the age of the population. For most Western countries spending on
health care has experienced a steady growth. According to the United Nations World Health
Organisation (WHO), from 1995 to 2014 the UK has seen expenditure on health as a percentage of
total government spend rise from 13.1% to 16.5%. For 1995 this equates to 6.4% of GDP and 9.1%
for 2014 respectively, albeit with a peak in 2009 of 9.8% after which spend shows a steadily declining
trend. During the same 20 years, the UK population grew in size by 11.32%, with an increase in the
average (median) age in the number and proportion of older people in the population. The point at
which half the population is younger and half is older was at 40 in 2014 (compared to 33.9 in 1974;
Source ONS).
The Government has reported that for the coming decade the spending is likely to remain at the
same level or, at most, increasing commensurate with the growth in the rest of the economy. Yet, it
is expected that demand for health care will continue to rise as individuals will have more complex
health issues and more advanced treatments become available. The funding and demand trends will
result in a significant gap, which is forecast to grow to £30 billion per annum by 2021. To meet this
financial challenge, services must change fundamentally if the quality of care is to be warranted.
Although efficiency gains and improvements in productivity could probably free up a certain level of
funding it is improbable that this will come close to the filling the gap. Instead, it has been accepted
that a radical overhaul of services should take place to form a single health and social care system
that works better and more appropriately for individuals and their carers. The budgetary and
financial arrangements should be changed accordingly to form a singly commissioned budget. These
ambitions have been articulated in the ‘Five Year Forward View’ which has been widely supported
and which is to be delivered through local plans in 44 regions better known as STPs. Whilst these
plans define the general direction for the transformation of health and social care, in 2017, the Kings
Fund reported that the context in which STPs are emerging is proving to be much more challenging.
It has been suggested STPs should evolve into ‘accountable care systems’ (ACS), while eight areas
have been identified to lead their development. In the next paragraphs it will be explained why this
constitutes a complex challenge.
Fundamental Change: Need to Think Differently!
Disciplines such as programme and project management are well known for offering a structured
approach in effecting change especially when this is intended to realise strategic objectives and
particularly when the envisaged end state is relatively well known. With many health and social care
decision-makers not allowing themselves ample time for ‘thinking’, as a result the application of
these approaches is shaped by a strong desire and believe that complexity can always be reduced, or
explained, by simpler, more fundamental things. These can then be tackled separately and
sequentially. Regrettably, this type of thinking has already slipped into some of the localities as
evidenced by their decisions to break-up their STP or ACS initiatives into functional or organisational
workstreams rather than conforming to the ‘systems-thinking principle’ to develop and explore the
whole system first. Most worryingly is that one of the pathfinder or pilot areas ‘Nottingham and
Nottinghamshire Sustainability and Transformation Partnership have exactly done this and now
others are to follow their leading example.
Yet, a challenge of such scale as the creation of ‘accountable care systems’ which integrate health
and social care and are to address many of financial shortcomings through potential redesign of
3
services and which may differ per region or locality, requires a significantly different philosophical
approach. Such challenges are highly problematic and ill served by the behaviours and practices
stemming from more traditional, reductionist problem solving methods.
It takes many people to ‘transform a system’
3
; the organisational arrangements of providing health
and social care to a local populace are exceedingly complex. Not least because there are a large
number of different agencies involved in the planning and provisioning of a wide range of health and
social care services. These include clinical commissioning groups, which replaced the PCTs, and are
responsible for planning and commissioning of health care services in a local area, General
Practitioners, local authorities, hospital trusts, and a range of different care providers. Starting a
transformational journey of this magnitude requires strong and driven leaders, but leadership must
become collective, shared and distributed for the transformation to be successful and lasting. As
with any major transformation, development of a system of truly integrated health and social care
requires a clear vision, shared and communicated widely across the care community. Within that
community behaviours will need to change and bring together parties with different viewpoints and
apparent stakes to shape services to reflect the common interest: i.e. that of the citizen.
One key issue of bringing together different organisations, is the fact that each is uniquely defined in
terms of what it does, i.e. what purpose it serves, and therefore the resultant cannot be based on
the simple aggregation into a new entity tasked with delivering integrated health and social care,
whilst also operating within reduced funding envelopes. Instead, the focus must be on the complete
system as a new design and overhaul of what has gone before, and, thus, cannot be based on a
‘tinkering in the margins’. Whilst the answer to this question is problematic it drives all forms of
organisational analysis and development, and consequently cannot therefore be applied in isolation
or implemented in parts.
Each of these health and social care organisations consist of resources of various kinds and are
structured in some way. As it is not possible to manage a total organisation as an aggregate, the
resources get carved up into a range of departments, e.g. operations, finance, marketing, etc.
However, the associated organisation structure is arbitrary. It changes fairly frequently since re-
organisation is a common activity within most organisations even the NHS. Thus, since there is
nothing fundamental about a particular structure, it should not constrain the approach to the
analysis of any of the aforementioned concerns. It may need to be taken into account in some way in
formulating recommendations for change, but should be ignored in undertaking a fundamental
analysis of each of the organisations, their units or the aggregation of them.
An organisation is always in transition; it is never static. Change is always taking place at some level
and at some time in response to both internal and external pressures. Whilst the STPs imply a
complex degree of organisation change, the organisations involved may already be undergoing some
form of change related to other aspects, e.g. due to continuous improvement, productivity gains,
increases in efficiency or introduction of new technologies. Care must therefore be taken in
developing the ACS for many aspects of the organisation are already undergoing change adding
another factor to the transformational complexity. Thus, it will always be more productive focus
outcomes and consider where an organisation might be going rather than where it is, or has been.
It has also been long acknowledged that successful transformation relies on strong leadership and
collaboration. In the bringing about the ACS these will also form a crucial role, but it needs to be
3
Kings Fund report on the Canterbury, NZ experience
4
Reference Concept ‘whole ACS’
[activities, information,
measures of performance]
Statements of Purpose
[relevant to ‘whole ACS]
Leadership
Key-stakeholders
Citizens
Comparison
& Analysis
‘As Is’ Health
& Social Care
services
Identification and
Agreement for Desirable
and Feasible Change
Transformation
Objectives
‘To Be’ Integrated
Health & Social
Care services
Description of current
problematics, triggers
and trends
Demands
& Funds
Work stream
Definitions
Dynamic Interactions:
Shared understanding & Key metrics
Governance, Defensibility and Accountability
acknowledged that due to their backgrounds, education and training, experiences and viewpoints
different individuals will have different perceptions. These cannot be ignored in any description that
tries to be relevant to this new organisation and thus will need to be at the heart of the approach.
The need for conceptualising projects and programmes from different perspectives, whilst focusing
action in the midst of complex practice, could be met and enabled by the application of soft systems
thinking. Especially in ill-structured, ambiguous, complex, and uncertain situations, such as that
posed by the development of ASC the secrets of success in programme management will be
learning; i.e. the structuring of the problematic situation should focus on facilitated participative
learning. It assumes that collaborators will develop and improve their insight as time progresses and
this will lead to systemically desirable and structurally feasible change.
Applying Soft Systems Thinking
One major task in the development of the ASC is the realisation of buy-in from the variety of
stakeholders involved in affecting the changes as well as the beneficiaries of the integrated health
and social care service. Since change is a fundamental feature of a real world organisation, any
intervention, (planned or introduced), must recognise that it is introduced alongside other changes
and must seek defensibility in order to be acceptable to the particular population of interest.
Change may be derived or driven entirely from informed opinion. Although the resultant change
may be shown to be beneficial to the situation, through the process of change evaluation, the whole
process is indefensible, since it is driven solely by opinion, or worse, may give rise to disputes and
conflicts. If some “reference concept” were derived on the basis of information acquired from that
situation and this were to be used to compare against that situation, the results of the comparison
will provide support for the opinion. This total process then represents a defensible process for
change derivation.
The reference concept is an aid to design of the whole system, e.g. as an overarching blueprint, and
can be used as comparison and stocktake of existing programmatic definitions - e.g. those defined as
work streams – and monitoring of progress in terms of benefits and key metrics. Specifically, in the
context of the ACS, the derivation of such a reference concept will bring together representatives
from the relevant stakeholder groups and define the overarching purpose of the ACS which forms
the basis of the reference concept. The reference concept will contain the minimum set of activities
that needs to be undertaken to achieve the stated purpose. The focus will be on ‘what’ needs to be
done rather than ‘how’, thus preventing conflict and allowing disagreements to be diffused easily.
With the scope of the
reference concept that is
equal or even wider than
the integrated health and
social care service it
becomes possible to
compare and analyse
existing services and
arrangements to identify
desirable and feasible
change. Undertaking this as
a concerted effort
collaboratively will ensure
that stakeholder buy-in is
5
achieved and these changes can be agreed. Rather than designing services as commissioners, it is
suggested that the active involvement of care providers at this stage may accelerate changes in
behaviours which will drive improvements faster than would otherwise be possible. Defining key-
metrics and benefits in relation to the reference concept and purpose of the Accountable Care
System means progress is measured in terms relevant to the new system rather than based on what
is either currently measured out of habit or simply because it has been easy to measure.
Benefits
STPs or the development of ACS do not present a transformation like any other before. The
complexity of services, organisational and financial arrangements and political differences means
that leadership needs to be exercised collaboratively. Soft systems thinking will enable that
collaborative leadership to come together. The adoption of a reference concept bespoke to the
specific locality will offer an independent map along which the transformation can be planned and
progress monitored. The involvement of key stakeholders, including the citizen, in the derivation of
the reference concept will lead to transparency, ease of communication, and strong buy-in. The
availability of this reference concept will enable care providers to change behaviours which in turn
will enable them to drive change collaboratively and affect outcomes much earlier than would
otherwise be possible.
Why VH2?
VH2 consultants have a long track record in Soft Systems Thinking and, over many years, they have
been involved with a variety of health care related transformations at central and local government
levels as well as the third sector.