Design Thinking is often described as a people-oriented way of solving complex problems.
When it comes to integrating health and social care, for sure, there are many complex problems to solve. And as I soon discovered, being people-oriented was key here! As someone who started life as a designer, and then moved on to IT, I found myself becoming Chairman of a startup social care agency five years ago, which was my introduction to the world of health and social care.
What followed forms the inspiration for this article: a journey through the challenge of applying technology to join up health and social care. This is, as I learned, all about breaking down silos.
What I quickly realised in peering into the journey from hospital discharge to provision of post-hospital care at home is that this process is, to say the least, disjointed and poorly managed. Journalists call the problem of ineffective hospital discharge ‘bed blocking’: NHS managers hate this term – they call it ‘Delayed Transfer of Care’ or ‘DToC’.
What is immediately clear is that no one organisation is responsible for overseeing this journey from hospital discharge to provision of care – at home or in a care home. This process relies on voluntary, ad hoc communications among many stakeholders: the discharge nurse, the ambulance trust coordinator (or other transport service), the local authority based social care assessor and usually, a manager from a private care agency, historically, selected by the local authority - but more recently, and rightly, selected by the citizen - to deliver care at home (or in a care home).
What followed was rising bed blocking and the ‘blame game’: local authority social care assessors complain about a lack of information on the patient (they call them ‘service users’) and a lack of funding to deliver the right care, post-hospital. In turn, the private care agency also complains about a lack of information or funding – and added to this – a lack of visibility into the timeline for starting care and assigning the right carer. In extreme cases, we see private care agencies handing back home care contracts to local government, complaining of a lack of financial viability.
Whilst all of this bed blocking is going on, hospital managers complete their DToC reports and report them to NHS HQ and journalists continue to write negative stories about the horrors of patients queuing in corridors, due to beds being blocked by elderly patients not being discharged, and so forth. For a number of years now we have had senior politicians going on about the need to have ‘joined-up’ care. The bed blocking problem is universally recognised, but is it truly understood?
What becomes immediately clear when looking at the bed blocking problem is that these different organisations serving the journey from hospital discharge to social care have little in common, other than a need to serve the same person: someone who the NHS calls a ‘patient’, and local government and private care agencies calls a ‘service user’. Neither refer to ‘citizens’ or ‘customers’.
What’s worse is there is no common funding for health and social care: and with this comes mistrust and resentment. Local government, in particular, complain that, whilst the NHS continues to receive more funding from central government, on the other hand, local government social care has to endure severe cuts in funding. The exception to this common funding is where some NHS Trusts will invest in 'super care' options for 2-6 weeks post-hospital discharge - often called Reablement. In some local government areas, there is some move towards integrated health and social care - e.g. Greater Manchester. But today, it's mostly talk and endless meetings - little action.
When I first brought together key people from the NHS, local government and private care agencies, I suggested that the answer to bed blocking was digital: a simple cloud based app used by all stakeholders in the journey from hospital discharge to social care. This would enable real time information sharing that was simply not there, when relying on a mix of ad hoc communications, mountains of paper and current state legacy IT systems trapped inside the silos of each stakeholder organisation.
There was some resistance from IT people who had a stake in legacy software and an aversion to risk. But the key to digital innovation here is to create solutions that place the citizen at the centre of health and social care - not NHS or local government IT departments. This, of course, is the biggest challenge in the quest for Empathy - the first step in the process - as explained below.
This was where Design Thinking had a crucial role to play, and in embracing the process developed by the Stanford Institute of Design (d.school), it was a case of completing a series of Mutual Value Discovery with all stakeholders together, engaged in five sequential steps defined by the d.school: Empathise; Define; Ideate; Prototype; and, Test.
The really important thing to get right here was the first step: Empathise. What this meant was ensuring that all stakeholders from the NHS, local government and care agencies could communicate and understand each stakeholder’s problems and concerns, in relation to their role in health and social care.
What followed was embracing an important Design Thinking principle: establishing sufficient receptivity and rapport among all participants in the Mutual Value Discovery Workshops. In turn, this led to the creation of trust among all stakeholders: enough to generate a new insight.
With this new trust and openness was the realisation that bed blocking was primarily a problem ‘owned’ by the NHS but, in turn, this related to another problem ‘owned’ by local government – namely, the ability to deliver sufficient post-hospital care with significantly reduced spend per citizen.
What we learned at step one is that being conscious of the need to Empathise will always lead to a better framing – or reframing of key questions for the next step: Define.
We had now reframed the problem as not one, but two interrelated problems, namely: (a) bed blocking; and, (b) right care, right funding.
At the Define step we began to see possibilities for a new Service Design: a better way to take citizens through the journey of hospital discharge to social care, expressed as a blueprint for a digital solution. However, this also brought new challenges to the Mutual Value Discovery process: a new Service Design meant change and, in turn, this meant some uncomfortable truths for some stakeholders in health and social care.
One notable issue to emerge at the Define step was the role and pricing model used by private care agencies in executing the post-hospital social care – mostly care at home for elderly citizens. The possibility of disruption emerged!
In pursuing a ‘lean’ mindset, the stakeholders questioned the role and pricing model of private care agencies engaged by local government. Could the digital solution to the ‘right care, right funding’ problem for local government mean citizens hiring carers directly, significantly reducing the agencies markup of carers’ wages or encouraging a more innovative, new generation of care agency?
Could a more responsive care agency connection, enabled by a digital solution (e.g. social network) that connected citizens directly with carers be the answer in a ‘more for less’ outcome? Would this enable local government to reduce costs, and/or increase wages paid to carers? By increasing wages, would the shortage of quality carers be reduced? WouLd it enable local government to step out of the process altogether, except to provide part or whole funding of each citizen's social care?
For the NHS it became clear that bed-blocking – or Delayed Transfer of Care (DToC) as they prefer to call it – was inadequately defined. Whilst the cost of a hospital bed is known, what was not clear was the time based ‘opportunity cost’ of delay factors related to hospital discharge. This led to insightful questions, such as ambulance configuration or availability versus asking something more fundamental: could the patient make their own way home or make use of a taxi or charity run transport service? And so it went on, challenging the ten attributes that currently define DToC.
The first step of Empathise led us to reframe many questions about bed blocking at the Define stage – before we moved to the Ideate stage.
When we got to the Ideate step we confronted another cultural challenge, applying another important principle of Design Thinking: focus on doing, not planning. This is the disease that confronts all large organisations: too much planning, too many meetings – not enough doing or focus on action!
Now we turned our attention to what would be happening throughout the remainder of our Mutual Value Discovery Workshops. This was now moving through the final three Design Thinking steps of Ideate, Prototype and Test.
We were introducing three important concepts: (i) an emphasis on ‘doing’, not ‘planning’; (ii) the important of ‘failing fast’ and iterative loops; and, (iii) the use of no-code technology that would enable us to collapse the time between the three steps of Ideate, Prototype and Test.
Once we showed the stakeholders how modern visual design tools can enable the translation of ‘brainware’ into software, they began to see how a focus on doing, failing fast rapidly turned abstract ideas into digital realities – consumed in a desktop, tablet or smartphone device.
These visual design tools are software technologies that enable non-programmers to create forms-based apps, without the need to engage time-consuming, expensive syntax coding. It simply means that in moving through the Ideate, Prototype and Test steps we do it faster, cheaper – and in iterative cycles – and, of course, being prepared to fail fast.
Our stakeholders were now liberated: discharge nurses, social care assessors, field carers and citizens all beginning to collaborate around visual development of apps that worked towards solving the two big problems in hand: bed blocking and right care, right funding. What emerged was positive yet disruptive.
Many assumptions about the hospital discharge process were challenged, and some existing stakeholders were asked to consider changing their approach, or even exiting the health and social care area altogether.
With the five steps of Design Thinking comes three Principles relates to digital innovation and the creation of Software-as-a-Service (SaaS) solutions - Web and mobile apps: (1) Meaningful Journey; (2) Fierce Reduction; and, (3) Progressive Disclosure.
Meaningful Journey means apps used on desktop, tablet and smartphone devices that work the way users intuitively think and work.
Fierce Reduction means eliminating everything you can from a process, task or set of tasks: applying lean thinking to Service Design.
Progressive Disclosure means limiting what users sees on a device screen only what they need to see and act upon: avoid cognitive overload.
What became abundantly clear in this example of integrating health and social care with digital innovation was the power of Design Thinking.
This was clearly the right method for bringing together a disparate group of organisations and individuals who are co-dependent, yet somewhat wary stakeholders in a complex process such as hospital discharge to provision of social care.
In particular, being conscious of the first step of Empathise helped to generate trust, which in turn, enabled a reframing of the problem, leading to the discovery of new, related problems. Further along the process, the use of visual design tools and prebuilt technology enabled participants to get hands-on in the creation of a digital solution.
This was all about focusing on doing – not planning – and crucially, being prepared to fail fast and iterate, until the digital solution reached an optimum outcome.
But what followed was also disruptive: challenging business-as-usual social care and empowering citizens to connect with and choose a higher-paid, yet still affordable and crucially, a more readily-available carer.
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