Systems Engineering and Thinking To Transform Transitions in health and care for people with multiple long-term conditions

Background People with multiple long-term conditions (MLTC) are high users of health and social care, but transitions between services are vulnerable to weakness, such as poorly coordinated care across multiple individual specialties. Systems Engineering (SE) integrates an understanding of people, systems, design and risk. Adding broader Systems Thinking (ST) techniques and real-world data allows for better understanding of the interactions occurring in complex health and social care systems. Aim and objectives Our aim is to understand the challenges that people with MLTC and service providers face at critical health and social care transitions, and to use SE/ST to develop a co-design process for system-level improvements with our health and social care collaborators. Our specific objectives are: (1) Discovery to systematically identify the problems faced by patients, carers, professionals, and stakeholders at multiple transitions; (2) Understanding to conceptualise systems through mapping and modelling; and (3) Design to apply the knowledge gained to design an Innovation Hub. Methods In our 'discovery' phase, we will undertake key informant interviews, focus groups and workshops involving MLTC patients, carers, health and social care professionals, and a wider stakeholder network to understand challenges at transitions of care. This activity will be based across our regions covering South East Scotland and North East England. Understanding health inequalities is central to our work, and we know that the risk of MLTC is higher in less affluent populations earlier in life. We have engaged widely with charities, social care providers and existing Patient and Public Involvement (PPI) groups to ensure we will access a diverse and representative panel. In the second 'understanding' phase, we will perform network mapping and system dynamics of key transitions highlighted as important by our PPI group and other stakeholders. By supplementing this work with real-world data, we will undertake systems modelling work, culminating in a research and impact plan for a future Innovation Hub. The third 'design' phase will focus on the Hub plan, using SE principles to facilitate co-design with our stakeholders. This will produce an operational plan and business case as a clear roadmap to deliver our ambitious Hub vision to be leaders in improving health and social care transitions for people with MLTC. We will support this ambition by building capacity in SE education and methodological research, linking with industry to create an expert advisory panel, developing a PPI strategy that will put the public at the heart of a Hub, and leveraging our existing vibrant ecosystem of MLTC research and innovation to maximise impact. Timelines for delivery We will deliver the three phases sequentially. The understanding and design phases will overlap prior phases by two months to fully integrate learning as we progress. Anticipated impact and dissemination Our development period will systematically prepare the groundwork for a major Innovation Hub focussed on transitions of health and care for people with MLTC. There will be direct impact in understanding the complex challenges faced by this population, mapping systems and deepening stakeholder relationships. We will widely disseminate our findings through our stakeholder network, PPI groups, academic publications and in bidding for a future Innovation Hub.

More people are living with multiple long-term conditions (MLTC) affecting their health and well-being and these individuals tend to need more health and social care. MLTC become more common in older age, but many younger people are also impacted, particularly in more deprived areas. Previous research talking to people with MLTC has found poorly coordinated services with little communication between professionals involved in a person's care. Patients report systems that manage multiple individual problems rather than providing personalised treatment for individuals. We are particularly interested in the points where responsibility for care changes, known as health and social care transitions. Examples include the transitions between a GP and a specialist hospital clinic or between a hospital and a social care service when discharged home. Our panel of people affected by MLTC told us how difficult it was to coordinate appointments and how the system was not flexible to their more complex needs. Our work aims to identify problems in transitions of health and social care for people with MLTC and to build a new 'Innovation Hub' that will design and launch solutions. Our team comprises clinicians, systems engineers, health and care policy experts and public contributors across South East Scotland and North East England. Systems Engineering and Systems Thinking are widely used in industry to design change and improvement. These approaches focus on developing a deep understanding of systems, how they interconnect and how people interact with them. We will identify the risks of these systems not working as well as intended and how positive changes to one system may negatively affect others. We are planning three phases over 18 months: 'discovery', 'understanding' and 'design'. In the 'discovery' phase, we will work with patients, carers, health and care professionals and other key groups (like the NHS, social care providers and charities) to identify critical problems for people with MLTC at transitions of care. Activities will involve interviews, focus groups and workshops. We will also find out from these groups what 'good' should look like so that we know what measures to use to test our future solutions. In preparing our application, we already have agreement from many key stakeholders to participate in this work. Tackling health inequalities is critical to our proposal, and we are committed to creating a widely representative panel. In the second 'understanding' phase, our systems engineers will focus on some key transitions identified in the discovery work. They will map out exactly what happens to people with MLTC and how services interact at these points, using real-world data to understand these transitions. This work will find key targets for research and change in a future Innovation Hub. Our final 'design' phase will focus on the steps needed to create the Hub. We will use co-design, where our patients and other stakeholders will again be involved. We will produce a series of operational and business plans to make sure that a Hub would work well if funded in the future. We have a big vision for an Innovation Hub to be a future leader in health and social care improvement and recognise the need to build capacity to deliver Systems Engineering. We will do this by increasing training programmes for health and care professionals, embedding public involvement throughout, and making expertise available more easily across our regions.