Inside out, outside in.

Organisational structures are a major barrier to good care.

This is the premise behind integrated care. The organisations do not have to merge or cease to exist, but simply to recognise the barrier exists and deal with the problem.

Simply re defining discharges as transfers to primary care will change attitudes about how a "transfer" to primary care is performed.

However beneath this simplicity lies a complex issue, the knowledge and relationship of the competencies possessed by each of the parties is on both sides limited.

GPs who used to work in hospitals will remember how it used to be, Consultants who have never worked in primary care will imagine the jungle, the savages, the fear that returning the patient to the wild will see it lost forever.

How then to make visible those who provide safe passage and care through the jungle of primary care and the urban landscape of secondary care.

Choose and Book did much to separate individuals from communicating directly. Perhaps now is the time to pervert the Choose and Book directory of services into the tool to put those networked around the patient into a system which allows all participants to recognise each other and communicate.

it's networks all the way down.

Network theory offers some insights and structure to the study of systems, whether random or complex. In particular scale free networks "webs without spiders" are particularly resonant when it comes to looking at the NHS.
Scale free networks consist of nodes and links, some links are unidirectional, others work both ways. Some nodes are massively well connected, others have few links.
So far so good, but when it comes to scale free networks there are some caveats, the networks are robust, non random creations, which obey some key principles including a power law for distribution of connections.
Look at the NHS, consider clinicians as the nodes of the network and patients as the links between clinicians, either as direct "please see this patient" or as patient related data, letters results, conversations.
Now sit and visualise your surgery, hospital, patients.
Imagine the lines flowing linking you with the services and clinicians that you refer to and share information with.
Think about how those who work in hospital interact over patients, the discussions, referrals and the vast web of links that is created.
So far so good.

Network theory suggests that the disappearance or failure of some of those nodes will mean that the links reform with other nodes and in many cases the network re-forms, however in some cases removal of a key node results in a cascade of failures, with each subsequent node being subjected to a load with which it cannot cope.

We know this intuitively, as we see this when the clinicians in the local AED are overloaded, the Trust goes "red" and sure enough, the nearest AED takes the load and sometimes fails.

So far the NHS has just about coped with "nodal failures " in general they have been escalating pressures, either seasonal or semi predictable.
Unfortunately there is a property of scale free networks which is unpredictable and undesirable, in that they are vulnerable to attack.

Deliberate removal of a key connector node causes isolation and fragmentation of the network with subsequent failure or isolation of the remaining network.

The NHS has not been subjected to a deliberate attack in terms of removal of nodes, but it is conceivable that change in the infrastructure of hospitals, their service delivery models, and key staff may function as an attack. The consequences cannot be foreseen but could be catastrophic. In some way this could be seen as justifying the maintenance of status quo, no changes to services etc, but in reality Network Theory provides us with a warning, the changes can be done, should be evolutionary and must be thought through.