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.

Irreconcilable Differences?

Writing in his book Blink, Malcolm Gladwell tells the story of a marriage guidance counsellor who is able to predict success or failure of a couple after only a few minutes of interview time. The key he believes is contempt, if couples show contempt then all is lost, the relationship is doomed.

This week I have been speaking to people in primary care and secondary care.

In truth there were times when it did feel like being a marriage guidance counsellor.

All the red flags for relationship arguments were being waved in to the debate. The sin of absolute generalisation-"You always (then insert the apparent sin) in primary/secondary care" - really?- We always send out letters late? We always fail to refer appropriately? The sin of dragging in the in-laws "social care doesn't do its job and that's your responsibility to commission" is guaranteed to raise hackles.

Once absolute generalisation is used it tends to suggest that a fight is on the cards and that ignorance of each others feelings and functions is the underlying cause.

The main tragedy this week is that there is starting be be a little hint of contempt. "I never take my child to the GP he's rubbish- I don't know why any parent would."

Really? All GPs are rubbish?

Perhaps we should take a leaf out of the marriage guidance book and concentrate of creating a conversation in every health community which might just avert contempt, otherwise we will really find Irreconcilable Differences

Shift your paradigm please, I'm trying to get home.

What would happen if we discharged people from primary care to hospital and readmitted them back to primary care?
Just take a moment to consider what that simple shift in thinking would mean.
Yes the discharging practitioner would need to prepare the patient for their brief exit from the wrap around support of primary care, but also it would not be possible for patients to slip out of primary care and in to the hospital without it being sanctioned by a primary care physician.
Similarly on readmission to primary care the appropriate information would need to flow but the decision about readmission to primary care would again be controlled by the primary care physician.
I know some of us will argue that that's how it already is- but ask yourself honestly- do primary care physicians get consulted or have knowledge a priori of admission?
What would happen if we worked like this? I suspect reassurance that Mabel is always like that, and "yes, I'll see her in the morning" might, in many cases, prevent Mabel entering the hospital walls.

In a similar way when it came to the return of Mabel to primary care, her re-admission as it were, the checks on availability of a primary care bed, the required systems, and of course the information, would ensure that Mabel was not admitted to primary care unnecessarily and that since her readmission would be the default, the Hospital would need to find daily justification to keep the patient.

Perhaps Primary care physicians would like to consider doing the ward rounds in the hospital in order to decide who must stay behind in secondary care and who can leave to be readmitted into primary care.

If we all adopted this simple mind shift I'm sure less people would end up in hospital, they would spend less time in hospital and ultimately remain longer where they wish to be- at home in primary care

What kind of bike do you ride?

Do you ride a bike? What kind of cyclist are you? If you ride a bike you know what I mean, generally there are two tribes, the roadies and the MTBers. Although the are different demographic features of the two groups, certainly different appearances and features in the various bits of mechanics they employ in their leisure pursuits, I would like to suggest that there is a more fundamental difference in the way you think in the two pursuits. As a Roadie the Tarmac is endless, your body settles in to the rhythm, the pace line, the drafting and, odd pot hole aside, the Zen. The mental quiet, conversation and interaction in the group is the reward and in many cases reason to be a roadie.

MTBers on the other hand are always physically interacting with the bike, the terrain, the changing challenge, conversation is impossible especially on the "gnarly bits". The impact is that MTBers focus on the here and now, no chance to think beyond the next rock, dip or bend.

Neither group is superior to the other, no one is wrong or right. They are just very different in how the same activity is performed and the thought processes which the activity requires and generates in it's performance.

Medicine is like that, we have at the moment two tribes, the generalists and the specialists, each performing and to a certain extent thinking in different ways. 

Neither is "better" than the other and both are required to deliver a functional healthcare system. 

My issue at point is that there are a group of cyclists who are happy to wear Lycra, ride the road, accept the zen of the racing bike on a Sunday morning. Those same cyclists will have been out on the Saturday morning attacking the trails, making the jumps and wearing the baggy shorts of the MTBers. 

Where are those who straddle both primary and secondary care? The GPWSI is one breed, but the Consultant with interest in primary care is not yet on the map.

Should it be? Isn't there a piece missing from the landscape? Perhaps consultants in intermediate care are the closest we have at present but their value needs to be recognised and we all need to recognise the beauty inherent in each others craft.