A system is a set of activities with a common set of objectives and an annual report. For each objective one or more criteria are identified to measure progress or the lack of it and for each objective standards have been agreed and there are three standards:
- A minimal acceptable standard, for which no service should fall;
- An excellent standard, the best standard of care in the world;
- The achievable standard, the level of performance that distinguishes the top quartile of services worldwide from the rest.
These 3 levels of standards have been chosen because experience has shown that simply asking people to be the best, an approach once popular based on the book called “In Search Of Excellence” can be disheartening to those who are far away from the best or for those who see the best services delivered by what they perceive to be services privileged by either an excellent investment or rich resources, for example by charismatic or excellent people, as a result of chance. By identifying the achievable standard however is usually possible for a service in the lowest quartile to being shown a service serving a population in the top quartile which is very similar in terms of wealth and deprivation. Services in the top quartile can of course be encouraged to try to equal the best and the best service itself will be constantly looking for ways to do even better.
Systems of care are based on symptoms such as headache or pelvic pain, on diseases such as bipolar disorder or asthma or stroke or on population subgroups such as children or frail elderly people or people with the triple diagnoses namely physical health problems, psychological health problems and substance abuse, sometimes called people with co-morbidity.
It is useful at this point to distinguish between complexities and complicated because when describing the systems approach of Erewhon to clinicians from other countries they often remark that people have more than one condition. We recognise that maybe people have complex problems, for example an 81 year old woman with 4 diagnoses and 7 prescriptions who is looked after by her 52 year old daughter who lives 2 miles away and who has an alcoholic abusive husband and an unemployed son living at home. This is complexity but it is the need meant frequently by general practice or family medicine. Generalists excel in the management of complexity. Of those 4 conditions diagnosed one may cause problems from time to time requiring referral to a specialist because the problem has become too complicated for the generalist. Specialists excel in managing the complicated. The relationship between generalists and specialists need to be carefully worked out but the distinction between complexity and complicated is accepted as part of the language of the Erewhon Health Service.