Editorial

Welcome to the final edition for 2018.

UKSS Conference 2018

The theme for the UKSS conference this year was “ Can Systems Thinking Save the NHS?” This theme attracted several interesting papers from across the spectrum of health matters, ranging from personal experiences through to the future structure of the UK NHS. One outstanding presentation came from a researcher describing his recovery from the serious physical injuries he had sustained following an accident on his mountain bike. He had used ‘systems’ ideas to turn the effects of a devastating accident into valuable lessons. His presentation described wellbeing as an emergent harmonious, satisfying state of being in the physical, mental and relational domains. He talked about how it helped him to make sense of his injuries and contributed to what is a truly remarkable recovery. The evidence-based approach was an aid in studying and evaluating human wellbeing. His experiences and ideas will, doubtless, help others in similar situations. Researchers from the Trauma Informed Care provided insight into the way patients experiencing trauma was not always recognised arguing that this has to be acknowledged and addressed at the level of service relationships and delivery (this paper is included in this edition). At a different level, another delegate presented a paper on the benefits of Big Data in health care. The speaker proposed an interpretative model system dynamics modelling. An overview of the most relevant dynamic drivers in the healthcare system was provided and discussed with the aim of tracing strategies and pathways with the aim of achieving a shared satisfaction of the multiple interests involved in the healthcare systems. At the other end of the spectrum was a presentation in which the speaker advocated that Systems thinking could help address the challenges facing the organisation and management of health care provision. The paper was entitled ‘NHS in Crisis: A systematic approach to understanding the causes’ and was presented by Professor Edward Borodzicz. In his paper, he highlighted, amongst other things, the difficulty of implementing a national health service viewed from a political and economic perspective. Edward pointed out that the reasons for the current failures in the NHS are multiple and complex, but for a long period of time underfunding has gone hand in hand with a reliance on ‘fixes’ taken from management science and used as a tool to make the NHS do more with less.  He pointed out that the problem with making ever-increasing efficiencies is that, from a systems perspective, this leaves less opportunity to deal with non-standard problems resulting in decision makers increasingly perceiving healthcare as an overly structured process. In other words, there is a distinct lack of ‘joined up thinking’ (looking at the ‘system’ as a whole). Trying to fix the problems in a piecemeal fashion only provides short-term relief and acts to, effectively, sweep it under the carpet for someone else to deal with at a later date.

The conference produced many examples where systems had been used to try to make sense of the situation, whether this was in management, using IT or as a form of physiotherapy. What emerged from the conference was the realisation that the challenges for health care are not confined to local or even National level – they are universal – but they must be addressed nationally. Demands on health provision throughout the world are increasing as the population increase (the UK presently c66.5 million, c77 million by 2050; World population 7.2 billion presently, predicted 9.7 billion by 2050). Coupled to this is the impact upon health arising from lifestyles such as Alzheimer’s disease, cancer, diabetes arteriosclerosis, chronic liver disease/cirrhosis, chronic obstructive pulmonary disease (COPD), hypertension, heart disease, nephritis/CRF, and stroke (MedicineNet 2018), diabetes and respiratory diseases. Ease of mass travel also brings with it the easy transfer of viruses and their mutations across the globe and the rise of the ‘superbug’ (probably the result of over-prescription of antibiotics). The emergence of Ebola, Chicken and Swine flu; the re-emergence of diseases once thought eradicated are just a few of the challenges that have to be dealt with every day by national health services across the globe. Whilst advances in medicine continue to amaze new illnesses continue to emerge, creating new challenges and new threats to world population. It is clear that ‘health provision’ and our apparent ability to destroy ourselves cannot be thought of in isolation and addressed piecemeal e.g. effects of global warming, pollution, virus mutations and so on – need addressing globally. As Professor Borodzicz argues what is required is a joined-up approach if we are to stand a chance of addressing these challenges.

It was clear from the conference and from contacts with colleagues across the global health and wellbeing is not just about finance, albeit vital, it is also about attitudes and the need for a heightened sense of personal responsibility for our wellbeing and for our environment. We cannot separate the damage we are causing to the environment from the impact it is having upon individuals. For example, increasing temperatures across the globe impacts upon food production and it also removes barriers created by temperature zones e.g. spread of mosquitoes and other minibeasts into regions where, in the past, the climate was not habitable for them. We are all aware of the damage that discarded plastics is having upon the environment and, [in]-directly, upon our own health and wellbeing. Yet we tend to speak of ‘the environment’ as if it is separate from our own existence, something we can ignore and carry on regardless. Attempts to raise awareness through waste disposal have largely backfired as many think provided they dispose of their rubbish into the right bin that is job done. But it isn’t. For example, the rubbish we send abroad (out of sight) directly affects the health and well being of those who are left to sort through it e.g. Electronic waste. Once again disposing of our waste out of sight is a piecemeal and short-term fix. Our existence depends upon how well we look after our environment but the signs are not encouraging.

It is worth reminding ourselves that as long ago as1970 the Club of Rome produced a systems dynamics model of the world (a touch ambitious), and even though it was at the height of the cold war one of the key dangers identified for the planet was ‘pollution’ viz ‘…We affirm that the global issue of development is, however, so closely interlinked with other global issues that an overall strategy must be evolved to attack all major problems, including in particular those of man’s relationship with his environment…’ We are likely to satisfy the demands of an increasing population ‘…by exploiting our natural environment and further impairing the life-supporting capacity of the earth… we cannot expect technological solutions alone to get us out of this vicious circle…’  (Meadows et al 1972, p192. – also see p69-87). We seem not to have paid heed to that warning and here we are decades later beginning to feel the impact of ignoring that prediction. The way we live and the demands we make upon the planet and ourselves are interlinked.

From a Systems perspective ‘all systems tend to entropy’, but what delays this is the import of ‘resources’, in the widest sense, into the system. We have no external resource aside from the sun and what that enables us to grow and mine. But our present model seems to be consuming the earth’s resources (and de facto finances and people) at an unsustainable rate. We need a different model rather than patch up the one we have. Whilst the conference was about health care the issues that it raises go beyond that. Our health and wellbeing are directly related to the way in which we look after our planet.

Health care

Few would disagree that the mark of a civilized society is reflected by its ability to care for its citizens, but when health care is thought of as a ‘system’ one begins to wonder what this system is. On this point, we were very fortunate to have two significant keynote speakers from the [UK] National Health Service. Both experienced practitioners and in positions of great responsibility. The first speaker was Alex Winfield who is the CEO Hampshire Hospitals NHS Trust and the second was Heather Caudle, the National Director of Nursing – Improvement. Both these colleagues have an immense and vital portfolio of responsibilities who also have to match citizens expectations with the reality of a finite budget.

Alex Whitfield described Healthcare as consisting of systems within systems, some are there because of the nature of medicine and care, and others are artificial creations we have imposed as a way of managing a ‘free at the point of use’ service for our diverse population.  In her talk, Alex explored some of the current practical realities of the existing system and some of the changes that are starting to happen to allow the UK’s national health service to flourish.

Heather Caudle’s presentation was entitled ‘Helping to further Integrate Health & Social Care Systems’. In December 2017, NHS England launched a new winter framework that was designed to help health and social care staff to ensure patients do not spend any time longer than they need to in a hospital. There was a particular emphasis on maximising the use of care homes across sustainability and transformation partnerships (STPs), making the best use of available beds in care homes so that patients who require formal care in supporting settings, do not stay in hospital longer than they need to. Heather said that digital occupancy trackers in care homes were playing an important part in connecting health and social care providers and there is a national endeavour to ensure all NHS England regions deploy this way of working. Hospitals and local authorities are to be asked to monitor and better utilise access to bed occupancy in the care home sector. She described the lessons learnt from the NHS England London Region showed how technology can help better integrate the health and care sectors to make it easier for patients to be transferred to, and cared for in, an environment other than their homes after a stay hospital.

NB the abstracts and presentations can be found on the UKSS web page http://www.systemsforum.org

This edition

In this edition we have three papers, two were from the UKSS conference in June this year and are related to health care. The third paper is unusual in that it relates to prophesy and power shift in Ethiopia.

The first paper is entitled  ‘A Case for TIC’ and is co-authored by Steven Thirkle, Angela Kennedy and Petia Sice, TIC is a mnemonic for Trauma Informed Care  and is an approach to human services that is based on the informed observation that most people in contact with health services are likely to have experienced a degree of trauma, adversity and loss. The authors suggest that those involved in health care should be made aware of the impact of the patients’ experience so that it is may be taken into account in service relationships and delivery. In their paper, the authors review TIC literature and introduce a case example outlining the successes and challenges of TIC implementation in practice.  Insights from complexity and interpersonal neurobiology are interpreted in the context of facilitating TIC implementation, i.e. parallel safe-to-fail interventions, managing constraints and boundary conditions, monitoring change through trusted sensor networks, maintaining awareness development practices.

In the second paper, which is co-authored by Gary Evans, Layne Hamerston , Lynn Cherrett and Debbie Sadd is entitled ‘The use of Systems Thinking, Systems Practice, to elicit the effectiveness of cancer support services in the southwest of England’. The article summarises findings of a systemic analysis of Living Well and Active’s coordination and delivery of physical activity, health and well-being interventions for those living with cancer in the Southwest of England. The research was based on a 16-month analysis of information sourced from cancer charities, consultants, healthcare professionals, local government officers, patients and physical activity health and well-being deliverers. Whilst the findings proved there were pockets of good practice some organisations were operating in a fragmented way, they were starved of resources struggled to make sense of the top-down approach of changes in healthcare policy. The outcome of this was that the cancer referral process, which helps patients on their pathway to normalisation, only captured 1:10 cancer survivors. The systemic analysis into the effectiveness of physical activity, health and wellbeing interventions for those living with cancer in the Southwest of England concludes that these cancer support services cannot be considered as a system. There are various elements to suggest some purposeful activity; however, the elements were found to mostly function independently of one another and do not operate holistically. This meant detected emergent properties were not responded to in a meaningful way, and the hierarchy of activities, the levels of recursion, were not coherently structured. The research suggests that a hub of practice undertaken by the collaborators, deliverers and service-users could address some of the lack of ‘joined up thinking’.

The third paper is unusual for this journal but fulfils the basis of our mission to publish a paper that take a holistic approach to understanding areas of interest. This paper is written by Alelign Aschale Wudie and is entitled Prophetic Discourses and Power Shift in Ethiopian History: A Critical Discourse Analysis.

Here the author critically analyses the historic role of prophecy for a power shift in Ethiopia. The research involved collecting data and critically analysing it sourced from archives, accounts from travellers and historical documents. Critical Historical Discourse Analysis was used as a framework and methodology of analysis. Interpretation, symbolization and operationalization of dreams, prophecies, and “told spiritual accounts” by prominent mystics and interpreters had been the critical turning-points of Ethiopians in history. The author says that their role was consequential and influential. For example, in the paper, he claims that Royal families used to “invent, disseminate and operationalize” dreams, prophecies, and superstitious practices. Consequently, their instinctive wish for abundant fulfilment and power grant had been gained by “revelations” and “connections” of each interpretation with supernatural powers. To scale up the benefit, ecclesiastical intervention had been badly sought out. He argues that as a consequence prophetic discourses and ideologies had been very instrumental in Ethiopian theopolitics, sociocultural practices, and power use.

AGM

At the AGM held at the conference in 2018 it was agreed that there will be an annual membership fee payable each June [usually to coincide with the conference] For members wishing to add access of the online editions of the UKSS journal [currently the International Journal of Systems and Society – incorporating Systemist] there will be an additional fee to cover the publishers costs.

We plan is to shift the conference from the traditional position of September to June as this proved popular this year. Plans are in hand for the 2019 conference to be held at the University of Bournemouth. There are also plans to introduce regular workshops on specific topics the first of these will be in February 2019 at the University of Northumbria. Details of this and more can be found on the UKSS web page  (http://www.systemsforum.org)

A new committee was elected following an agreement at the AGM. The new committee comprises

President: Frank Stowell

Treasurer: Ian Roderick

Conference Chair: Gary Evans

Membership Secretary:  Pauline Roberts (with special responsibilities for practitioner recruitment)

Workshops and external events: Petia Sice