It's the system, stupid

Colleagues at Symmetric turned our attention to health and social care issues some 15 years ago, having spent many years researching, studying and designing whole system interventions in many different types of supply chains.

Patient pathways in health and social care are essentially supply chains, not dissimilar from those encountered in food chains and general logistics and this perspective is slowly becoming understood. As systems practitioners, we have always been consistent in our messages about improving the performance of patient pathways. The launch of our new web site and changes in the health a social care world would seem an appropriate time to restate these systems insights, which can be summarized as follows:

  1. Flow is the key to productivity in patient pathways. Without sustained flow throughout the supply chains, stagnation arises and queues grow and this often results in a demand for expensive capacity increases in parts of the chain. 
  2. Changes in flow variables (admissions and discharge rates from services for example) sustain throughput and are a much cheaper intervention than increasing capacity 
  3. Good control of flow variables is essential. Changes in flow variables must be coordinated throughout the pathway to improve the value of the overall chain (to patients and suppliers). Without integrated control we merely move bottlenecks around. 
  4. Autonomy and selfishness along the chain leads to blame, bad investments and poor overall value 
  5. To achieve good control requires that information and action is fed back and shared along the chain and in particular between different agencies 
  6. Control of the chain in practice is determined by the agencies with the greatest power. Hospitals have long been the supermarkets of health supply chains 
  7. Powerful players along the chain must support less powerful ones. Such magnanimity provides a financial win-win for all agencies and, more importantly, for patients 
  8. If patients are really to come first we must have a world where agencies believe in such shared values and not just respond to imposed performance measures 

So it is with great satisfaction that we are at last seeing some changes, which match our messages and aspirations. There is a growing focus on:

  1. Improvement in hospital discharge rates to solve A&E waits
  2. Investment in post hospital social care to facilitate hospital discharge. This is definitely a win-win for both health and social care 
  3. Investment in community services and the creation of virtual capacity in the community to keep people out of acute hospitals 
  4. Shifting the power balance along patient pathways 

We would dearly like to see more of our systemic answers implemented. In particular we would like to see a move towards carrying out strategic systems analysis across whole patient pathways before any detailed process improvement within agencies. We would also like to see this paralleled by recognition that in caring agencies, sharing and integration should be the norm rather than the exception.

Professor Eric Wolstenholme, Symmetric Partnership