Overcoming ‘the barrier’ is not enough in complex health and social care systems

Sharon Brennan’s recent article in the HSJ (‘Treasury ‘the barrier’ as full hospitals desperate to discharge patients to social care’) reported that the Treasury was unwilling to pay for the additional insurance costs that would enable care homes to take on thousands of patients from hospitals.

Reading the article, whilst fully agreeing with the sentiments expressed, I was reminded of my time as an A&E nurse in the late 1990’s. At that time we were searching for a silver bullet to ensure that patients stayed no longer than 4 hours in the department.

We hoped that replacing the queuing barrier of triage with streaming was the answer. However – after a lot of trial and error, and plenty of blood, sweat and tears – we realised that what was actually needed was to address a range of barriers rather than just one. That meant we needed to introduce multiple changes, including a ‘see and treat’ approach by senior staff and the use of real-time digital tracking. We also needed to improve flow in the hospital and streamline the discharge processes to community and adult social care partners.

Fast forward to 2020 where I was part of the IMPOWER team working alongside health and social care partners in Somerset. Together, we agreed an inclusive ambition to increase the number of supported discharges to home, whilst investing in an increase in D2A capacity.

At this point we could simply have increased the D2A slots available and hoped for the best. Instead, we identified the range of barriers to supported discharge home within each of these 4 key areas, and used applied behavioural science to help overcome them:

• Acute Hospital Discharge Decisions
• Discharge Lounge Utilisation
• D2A Practice Improvement
• Practice in Community Beds

Interestingly, the HSJ article calls out blocks in these same areas as being major contributors to the crisis currently faced by systems across the country. Health and social care is a complex system, with multiple decision makers affecting people’s outcomes, and it is therefore vitally important to understand what behaviours are getting in the way of successfully meeting the challenges presented by Covid.

Employing tried and tested applied behavioural science techniques, we worked with frontline teams to co-design solutions that overcome the specific barriers identified during observation and structured interviews. We were careful to constantly refer back to the inclusive ambition set by Somerset health and social care partners. The main benefit of this co-design approach is tangible engagement, as the people involved really feel ownership of the work needed to deliver effective change. The Somerset Improvement Lead we worked alongside commented that ‘I have been very impressed and encouraged by the engagement that you have built with the teams and the enthusiasm that they have for the co-designed interventions.’

Successful improvement in health and social care doesn’t depend on discovering a silver bullet – but there does need to be a framework for uncovering the relevant barriers to achieving ambitions, and that framework does need to provide the head space to co–design solutions that really work.