Its that time of the year when things start to decide to break down. I’ve been having quite a few problems with my household boiler – not ideal at any time and especially during a winter, however mild. In the process of several visits I have been having chats with the plumber and been looking online about how a boiler system works – now fear not I shall not be visiting a boiler near you anytime soon!
But it did get me thinking because the way in which a boiler works is quite fascinating. Basically when I want to heat the house, I switch on the boiler with an electric switch or timer which for many of us today is now wireless. ‘A valve opens, gas enters a sealed combustion chamber in the boiler through lots of small jets, and an electric ignition system sets them alight. The gas jets play onto a heat exchanger connected to a pipe carrying cold water. The heat exchanger takes the heat energy from the gas jets and heats the water to something like 60°C (140°F).’ – and clearly I needed help to work that out!
I am not going to become a heating engineer but what a household boiler is illustrative of is the way in which so much we take for granted in our living is in effect made up of a series of systems which relate to each other in order to achieve a particular outcome. As I heard someone say recently when I get into the car in the morning and turn the ignition I don’t think of the 30,000 plus individual parts and hundreds of systems which make it work – I think about whether the car is working or not and by extension whether I will get to my destination or not.
One of the problems with my boiler has been that the fault has been hard to detect – sound familiar? This has meant repairing or replacing different elements of the system in order for the whole to work. But that comes with a price and introduces a weakness to the whole system. Dealing with part of the problem, even replacing a part or changing it, affects the whole system often in subtle and undetectable ways. Yet that is how we have often gone about not just repairing a heating system but addressing the problems in human service systems. Traditional technical approaches have addressed problems in individual parts without necessarily considering the impact on the whole machine. This has been a problem with designing new systems as much as it has been with repairing broken ones, so Amory Lovins wrote:
“Designing a window without the building, a light without the room, or a motor without the machine it drives works as badly as designing a pelican without the fish. Optimizing components in isolation tends to pessimize the whole system—and hence the bottom line. You can actually make a system less efficient while making each of its parts more efficient, simply by not properly linking up those components. If they’re not designed to work with one another, they’ll tend to work against one another.”
What we need is whole-system thinking which shows and maximises the connections between parts.
I’ve been reflecting on what these insights might mean for a whole systems approach to health and social care in Scotland. Indeed there is a growing literature on these ideas.
Just before Christmas the Scottish Government published its Health and Social Care Delivery Plan. In some senses there was not a great deal which was new in this work but it has helpfully brought together a whole range of policy initiatives and Governmental strategies and priorities. Indeed if you read between the lines you can get a sense of a system which is lurching towards a whole system approach if not by design then by inevitability.
The health and social care system is a multiplicity of systems which if dealt with in isolation might benefit the part but will not succeed in changing and fostering positive outcomes which enable the whole system to work.
Perhaps this has been most apparent in some of the media over the last few weeks which has addressed itself to what has been happening south of the border in relation to health and social care. Slowly, inexorably, and almost at a snail’s pace, the linkage between health and social care has started to dawn on our popular media. Put simply dealing with a crisis in A and E without addressing the underfunding of social care whereby people have no provider to help them get home or to move into a care home is a fragmented effort doomed to failure. In a Scottish context targets around delayed discharge and unnecessary hospital admission have to have social care providers at the heart of the design of solutions to the challenges.
With integration in Scotland there is a real potential to make whole system thinking and approaches a reality. But it will not come easy because the constituent parts of the ‘machine’ are so diverse and often instead of working collaboratively are designed or made to work against each other.
This is very much the case with the way parts of the system relate to the independent sector. We know that in some Integrated Joint Board areas in Scotland there has been and continues to be significant progress in achieving positive outcomes for people. Where this is happening the culture of partnership, collective decision making, shared risk, and consensual leadership is being fostered and nourished. Where things are not working so well, it is where the ‘them and us’ mentality, professional separateness, role defensiveness, lack of a trustful, transparent and respectful engagement are all too apparent. For instance, where the independent sector is at the table as a partner on IJB Boards then there are positive shared outcomes – where we are not present then a critical part of the machinery of care is left to rust on the side.
We can no longer tolerate an approach to health and social care which tries to deal with the distinctive parts on their own. The interconnectedness is self-evident. We have real potential to enable the whole health and social care system to work. This can be achieved only by whole system approaches; in planning for our shared workforce, in adequately resourcing social care, in developing reciprocal relationships between the NHS and social care, e.g in relation to nursing, in giving value to the contribution of social care staff and in so many other ways.
I hope 2017 despite the clear challenges ahead of us will continue to embed a culture which addresses the cracks of the whole rather than the fragments of those who attract the most attention. Whole system approaches result in whole system responses.
And lest we forget the outcomes we all want are not about getting a machine to work, but that every woman, man and child at the point of their need receives health and care supports when they require them, where they are and which serve to foster their wellbeing and wholeness.
And … I wish you all a working boiler and a ‘warm’ and healthy 2017.
Donald Macaskill
@DrDMacaskill
