Is Dora dead?

‘Is Dora dead?’ asked her GP of the community based team who had been helping her.  It was an understandable question.  Dora was, how can you put it, one of those patients.  Daily calls for months on end in and out of hours were ‘normal’ for her – she was something of a ‘frequent flyer’.  Alongside the daily calls there were the 4 stays in hospital, 25 out of hours calls and 60 attendances to the practice in the last year alone.  The GP practice had become used to it.  In fact, truth be told, she was becoming a bit of a pest.

So when the calls stopped it was natural for her GP to assume the worst.  But Dora wasn’t dead.  She was not in hospital either.  Nor had she moved.  Something had happened but it wasn’t what the GP expected.

A new team had taken over Dora’s care.  

They had a different brief to how the system had conventionally been designed to respond.  Their job was to understand Dora in the context of how she lived her life; to help re-balance her so she could live the life she wanted and to do what it took to maintain this balance for her – ‘UNDERSTAND – REBALANCE – MAINTAIN’ was now all they were interested in.  With this they were also given the authority to do what it took to help Dora live well, not just exist; with profound results for her and the system.  

They first saw Dora in a hospital bed, a relatively common place of residence for her as her cancer developed.  She was a sorry and miserable sight.  The hospital staff said that she never stopped using the buzzer but there was nothing much they could really do to help her.  For the busy ward staff she was a bit of a pest, loveable maybe, but a pest nonetheless.  The doctor said, “I’d give her 8 weeks, that’s how long people in this state normally last”.  The team learned it was normal in this system for people to be ‘in this state’, as were the repeated demands on the various parts of the system.

So they set about really trying to understand Dora.  They learned that the system had numerous assessment processes – 105 assessments in the last year in fact – but not such good understanding processes.  They learned that the system had locked Dora into a cycle of ‘ASSESS-TREAT-REFER’ and because of this viewed the presenting demand as ‘I feel ill’.  Dora’s consumption of services, they learned, was driven by this design, rather than her behaviour in and of itself.  Through study they learned the presenting demand was actually ‘help me live well until the day I die’.  From that insight they began to change their perspective on what problem they had to solve and, in the process, realised that Dora wasn’t the problem, the system was.

So they started asking different questions, the right questions:  “What is a good life for you?  “What do you need?”  “What matters to you?”  They learned that what mattered to Dora was reconnecting with her family that had drifted apart.  They learned that she loved her birds and was incredibly anxious about what would happen to them once she was gone.  They learned that she wanted to stay at home, not go into hospital.  They learned that she wanted to get her affairs in order.  They learned she wanted to have some fun.

The team took it upon themselves to help to re-home the birds, save for the special one or two that she could care for.  They arranged for her to have a pulse oxymeter and oxygen on each floor of the house.  She would get breathless walking around the home, which in turn made her anxious which resulted in her ringing the surgery or out of hours service.  They helped get her affairs in order and, having learned that she had lovely neighbours who were prepared to support, helped her have some fun. Outside their job descriptions maybe, but it was what mattered to Dora so it was the right thing to do.  And something unexpected happened – both the calls and the visits to hospital stopped.

The team learned that understanding not assessing was the key to helping people live well.  None of the 105 assessments had helped do that.  Understanding Dora’s demand in the context of her life turned the teams attention to facilitating solving the problems that mattered to her instead.  In doing so the demands she made on the system reduced dramatically.    

Dora ended up living at home for 14 more weeks.  She never turned up at hospital again and stopped calling the surgery.  She consumed 50% less resource than she would have done under the conventional system.  She lived well until the day she died as the team helped her rediscover the sociable, independent and intelligent woman she was, not the lonely, unstimulated and anxious person she had become.  

There are thousands of Dora’s, costing the system billions of pounds through no fault of their own.  The system is blind to what really matters to Dora and people like her by design.  The system knows these people but doesn’t understand them – much to the systems cost.  Simply taking the time to understand rather than assess helps people to live the life they want, not the life the system has designed for them.  They are happy, staff are happy, demand falls and the system saves billions.  Isn’t this what we all want?

And the GP?  “I had no idea”, he said.  “This is real medicine”.

This article was written by Mark Cannon runs a regular blog, which can be accessed here. Simon Pickthall worked in the public sector in Wales for many years before forming Vanguard Consulting Wales.  He has worked with many leaders in Wales to help them understand their organisations from a Systems Thinking perspective –  and improve them as a consequence.  Simon worked on the Munro Review of Child Protection, and is committed to helping the public, private and third sectors deliver social justice.  [email protected]