"Integrated - care": What's in a word, or two?

This blog post was sat in 'drafts' since 28/01/2007 (yes, I know what that suggests). It concerns an issue, or more properly a theoretical and experiential aspiration in health AND social care that should in truth have provoked many papers for Hodges' model by now.

In the almost 18 years since, I wonder about the total number of papers devoted to this subject, the service's delivery, policy, outcomes, reviews and reports on integrated care? In nursing theory, philosophy and the start of many 'learned papers', it is customary to begin with a definition of terms. What happens when we divide 'integrated care' and first treat integrated and care separately? Does this aid our understanding? Do we divide and conquer? Is there a difference in results? Conceptual analysis would see us do both, and conduct a literature search.

In practice, (and clinical - especially) we often use words in rather lackadaisical way. Not surprising really, after all we've got a job to do! When pronouncements are made regards health and social policy I hear it as good intentions. I also reach for my soap box. It is often hyperbole, rhetoric. The same applies to the related idea and ideal(?) of holistic care, and person-centredness. I'm biased, of course, but I believe that Hodges' model can help to scope, and define these idealised features of health and social care (and education). As noted, people don't have the luxury of time to stop and deliberate on the precise meaning of the language they routinely use. As noted, at the end of the day - if it gets the job done then that's sound.

In a poll of words that are both much used and the meaning taken for granted integrated must be near the top for several reasons:

• its seniority: it has been around for decades.
• its scope across sectors and day-to-day life.
• our dependence on its fulfillment.

N-Gram suggests some possible insights into integrated and related forms of care:

https://books.google.com/ngrams/graph?content=integrated+care,holistic+care,person-centered+care&year_start=1800&year_end=2022&corpus=en&smoothing=3 

[Trying to embed, results in 1/3 white space at the bottom?]

It seems that integrated care [IC] has been a standing agenda item in health and social care media, education, the workforce, conference, exhibition and policy for several decades. Perhaps, things have calmed somewhat? So either IC is either very important, complex, a hard thing in practice or maybe it's all of these and more besides? IC is a undeniably a compound concept. Is this a cop-out though? You declare something 'compound' then sit back - job-done? I've suggested the same of threshold concepts in health (and probably other contexts?). Time will tell. In the meantime I have reflected on 'integrated care' across the domains of Hodges' model:

self

|

INTERPERSONAL : SCIENCES              

humanistic ------------------------------- mechanistic

SOCIOLOGY : POLITICAL   

|

other

INTEGRATION OF: PRACTITIONER; Team; service; org... Philosophy* assessments threshold for acceptance into service (referral criteria) patient experience & engagement health education / literacies programmes spiritual research involvement	INTEGRATION OF: health record (e- or paper) location - team base care disciplines geographical area referral sources assessments - tools/scales data and statistics research involvement
INTEGRATION OF: HEALTH & SOCIAL CARE public engagement hospital  carer (parent/guardian) experience community services social care - NHS family experience public engagement in research Patient / Public Community Advocacy Treat demand :: Support prevention	INTEGRATION OF: funding leadership / management accountability - complaints (not the same thing!) outcome measures ILLNESS - PREVENTION / education self-care <> planetary care -  Sustainability assisted dying! palliative care! Public - Private - Voluntary Sectors Provider :: Purchaser [Systems] All-Party Parliamentary Groups^

*ethics, values.

^One aspect of so-called 'joined-up government'.

Dramatherapy i - thresholds, liminality and wounded healers

Individual

|

      INTERPERSONAL    :     SCIENCES               

HUMANISTIC  --------------------------------------  MECHANISTIC      

 SOCIOLOGY  :    POLITICAL 

|

Group

A personal journey The 'wounded healer' - Halifax (1982) ".. it is the experience of our own wounding that will enable us to engage with our clients in a healing process". p.15.

"Therefore we can begin to understand that rather than the drama being the chaos, the drama is both the container of the chaos and the means of exploring it. Accompanying our groups through such dangerous territory may seem too frightening for the dramatherapist to contemplate, let alone the client". p.15.

"The attributes of liminality or of liminal personae (threshold people) are necessarily ambiguous, since this condition and these people elude or slip through the network of classifications that normally locate places and position in cultural space. Liminal entities are neither here nor there: they are betwixt and between the positions assigned and arrayed by law, custom, convention and ceremonial. As such their ambiguous and indeterminate attributes are expressed by a rich variety of symbols in the many societies that ritualise social and cultural transitions. This liminality is likened frequently to - death, being in the womb, to invisibility, to darkness, to bisexuality, to the wilderness and to an eclipse of the sun or the moon". p.14.

"The 'illness/treatment' model has by its nature to emphasise what the patient cannot do rather than what he might be able to do; to emphasise that what requires to be done is carried out by others rather than what the patient might do for him/herself". p.262. Power as exercised (degrees of freedom?) through the therapeutic turn: the history of therapies; social, industrial, occupational, physical, drama, psychotherapy et al. ...

Turner, V. (1969) The Ritual Process. Structure and Anti-Structure. Routledge, London. cited in Jennings, S. (1987) Dramatherapy and Groups, Chap. 1. pp.1-18. In Jennings, S. (Ed.), (1987) Dramatherapy. Theory and Practice for Teachers and Clinicians. Routledge, London. p.14.

Mitchell, R. (1987) Dramatherapy in In-patient Psychiatric Settings, Chap. 12. pp.257-276. In Jennings, S. (Ed.), (1987) Dramatherapy. Theory and Practice for Teachers and Clinicians. Routledge, London. p.14.

In theoretical terms, Mitchell also describes the creative model, the learning model and the therapeutic model (p.265).

Halifax, J. (1982) Shaman: the wounded healer. Thames and Hudson, London [England].

Previously: theatre , threshold , liminal

Domain walls ...

"A domain wall is a type of topological soliton that occurs whenever a discrete symmetry is spontaneously broken. Domain walls are also sometimes called kinks in analogy with closely related kink solution of the sine-Gordon model or models with polynomial potentials.^[1][2][3] Unstable domain walls can also appear if spontaneously broken discrete symmetry is approximate and there is a false vacuum.

A domain (hyper volume) is extended in three spatial dimensions and one time dimension. A domain wall is the boundary between two neighboring domains. Thus a domain wall is extended in two spatial dimensions and one time dimension.

Important examples are:

• Domain wall (magnetism), an interface separating magnetic domains
• Domain wall (optics), for domain walls in optics
• Domain wall (string theory), a theoretical 2-dimensional singularity."
  
  https://en.wikipedia.org/wiki/Domain_wall
  

 INDIVIDUAL

|

 INTERPERSONAL    :     SCIENCES               

HUMANISTIC --------------------------------------  MECHANISTIC      

SOCIOLOGY  :   POLITICAL 

|

GROUP

conceptual spaces threshold concepts [#h2cm as] relational ontology	magnetism optics string theory
a space to tell stories of and compare walls seek openings so many spaces of / to welcome	these walls: are they necessary? whose needs do they meet? we know walls listen and talk too who do they protect? who do the respect?

Among the domain walls
are those that bring us together,
those that bring us - 'I' into being,
and yes, those that [try to] take us apart.

Inspiration:
Leslie Rosenberg, THE COSMOS IS MOSTLY MADE OF SOMETHING WE CANNOT SEE, Scientific American, January 2018, Volume 318, Number 1. pp.48-53.

Axioms, Domain Walls, and the Early Universe, P. Sikivie in Physical Review Letters, Volume 48. No. 17, pp.1156-1159; April 26, 1982.

Call for Papers - Basic Needs: Normative Perspectives

Call for papers*

for a special issue on

Basic Needs: Normative Perspectives

(Editors: Lukas Meyer – Daniel Petz – Alessandro Pinzani)

Lessico di Etica Pubblica

http://www.eticapubblica.it/

 

In recent years the debate on basic needs and their place in normative theories of ethics and politics has been rekindled. This controversial concept has finally been openly adopted by authors who adopt different approaches to discuss issues of social justice. There are good reasons for this.

As a currency of justice, needs have several advantages. First, in contrast to preferences, desires, and some other currencies, basic needs are fully objective, i.e., whether a person has a basic need for a certain thing is independent of her own or anybody else’s mental attitudes towards that thing. A second important reason for preferring basic needs as the currency of justice is that they are also universal, although their definition might be culturally influenced. Thirdly, basic needs are intrinsically morally demanding: that P has a basic need for O by itself entails that P ought to be able to have, be, realize, etc. O. Finally, basic needs also have an important advantage in the particular context of sufficientarianism. One of the main objections against sufficientarianism is that it is unable to provide a plausible substantive specification of its threshold of sufficiency. The concept of basic needs, in contrast, essentially entails the idea of a qualitative difference. Being able to fulfill such needs takes precedence over being able to fulfill non-basic needs and desires. Moreover, it distinguishes a life that has a certain minimum quality from a life that lacks this quality.

We invite authors to explore these and other aspects of the concept of basic needs and its use for normative theories of social justice, including intergenerational justice.

Contributions can be in English, Italian, German, and French. The deadline is September 30, 2022

For inquiries please contact: Alessandro Pinzani <alepinzani AT gmail.com>

 

*currently.

PHI MAGAZINE (Φ) - Liminal Issue [ii]

Individual
|

INTERPERSONAL : SCIENCES

humanistic ------------------------------------------ mechanistic

SOCIOLOGY : POLITICAL

|

Group

mental disorientation study - philosophy - ideas liminal - liminality ethical practice creativity reflection threshold concepts uncertainty - meaning - ambiguity	physical disorientation time, place, 'person' process theory transition - threshold - doorway media
art - arts practice socialisation (orientation) rites of passage status meanings	-isms political orientation power - boundaries professionalism posture? status

 

Previously on W2tQ:

'threshold concepts' 

Q. Do we, must we, always 'stand' when presented with a 'threshold'? Discuss ...

PHI MAGAZINE (Φ) - Liminal Issue [i]

 Submissions are OFFICIALLY open for our Liminal Issue.

The word ‘Liminal’ encompasses the quality of ambiguity or disorientation that occurs in the transitional stage of a process, boundary, or threshold. It comes from the Latin word līmen, relating to participants of rites of passage who no longer hold their pre-ritual status but have not yet begun the transition to the status they will hold when the rite is complete. During a rite's liminal stage, participants stand at the threshold. In many ways, this is where the world stands today.

We take all kinds of submissions: prose, photography, poetry, painting, opinion pieces, film or music—you make it, we want to publish it!

Submit to us before 14/02/2022 to be considered for our Liminal Issue.

Submit here: https://phimag.org/submit

For enquiries: submissions.phimag AT gmail.com

+++

WHAT IS PHI MAGAZINE (Φ)?

Φ Magazine is a quarterly publication aimed at showcasing the creative talents of Philosophy students across the globe outside the academic realm. Be it photography, painting, poetry, prose, or anything in between then it can find a place in the pages of Φ.

My source: 

Philos-L "The Liverpool List" https://www.liverpool.ac.uk/philosophy/philos-l/

@PhilosL @LiverpoolPhilos 

Thanks to Chiara at PHI Magazine for the cover image by Taudalpoi.

n.b. I will add a further post to relate the above call to threshold concepts and Hodges' model.

Michel Serres in "A planetary art beyond the human"

Individual
|

INTERPERSONAL : SCIENCES

humanistic ------------------------------------------ mechanistic

SOCIOLOGY : POLITICAL

|

Group

"In the mid- 1990s, Michel Serres was already registering the devastating impact of ‘dense tectonic plates of humanity’ on a hitherto ‘mute world’.1 Our excesses, he writes, have awoken the ‘mute, passive, obscure things’ around us that had ‘obediently slumbered’, but will now respond to us with violence.2 In such discourse we recognize the now common tropes of thresholds and tipping points, often deployed by climate scientists and echoed by scholars who assert that humans are now truly ‘geological agents’ in their impact on the planet.3 ...

... Getting to grips with the consequences of human activity for the Earth’s systems is unarguably an essential step in forging policies to mitigate the damage. But in the political urgency that shapes many debates about climate change, there is a risk, as Dipesh Chakrabarty points out, that ‘humans emerge as the subject of the drama of the Anthropocene’ while geological time fades from view.4 An emphasis on human agency may simply lead us full circle, back to the anthropocentric conception of a docile Earth made up of inert matter, only stirred by our own excesses, and waiting to be saved or destroyed by its human inhabitants." p.31.

 

Page, J. (2021). A planetary art beyond the human. In Decolonizing Science in Latin American Art (pp. 31–65). UCL Press. https://doi.org/10.2307/j.ctv18kc0mw.6

 

Joanna Page is Reader in Latin American Literature and Visual Culture at the University of Cambridge. 

See also:

Jones, P. (2008) Exploring Serres’ Atlas, Hodges’ Knowledge Domains and the Fusion of Informatics and Cultural Horizons, IN Kidd, T., Chen, I. (Eds.) Social Information Technology Connecting Society and Cultural Issues, Idea Group Publishing, Inc. Chap. 7, pp. 96-109.

Michel Serres on W2tQ

Consider also - 'deep' within Hodges' model:

DEEP space, time, ecology, links, design ... DEEP CARE.

  

Gatekeeping: Across the care domains

individual
|

INTERPERSONAL : SCIENCES

humanistic ----------------------------------------------- mechanistic

SOCIOLOGY : POLITICAL

|

group

Cognitive gate (access): Mental state: Risk to Self/Others? Literacy: My articulation of my needs Understanding of Consultation/plan Service name: acronyms My understanding hence awareness of services, referral Opt-in Self-neglect	Physical gate (access): Physical state 'emergency'? Telephone call, reception Obtain appointment Phone/Video, Face-to-Face Surgery, Clinic, Hospital, Home Letter: 'x' days? [ Triage Assessment, Planning Intervention Evaluation ] Individual: Collective: WAIT data?
Social-Cultural gate: Cultural diversity/Accessibility Service - Semiotics/Semantics/Signage Family/Social commitments (access) Sociology of Illness/Sick role Carer role Community/Local Understanding & Involvement? Reporting, Info sharing	Political gate: Service Provision/Use [by postcode?] Referrer's knowledge ... "Policy says..." ... URGENT, routine, 1,5 days... Service Pathways/Signage/Appearances Work commitments (access) Previously known? [ MAIN GATE: Therapeutic Modality? ]

 

Open to suggestions... 

'Faulty thinking' or 'Thinking faulty'?

By Mikenorton - Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=4050363

Mikenorton, CC BY-SA 3.0 <https://creativecommons.org/licenses/by-sa/3.0>, via Wikimedia Commons

Fortress of the Mind :: Fortress of Slavery

From 16 May – 5 July 2020
 Gallery 1957 
Accra, Ghana 
will present

“The Past is Never Dead”

 a solo exhibition by Langlands & Bell that explore 
the architecture of the ‘Slave Forts’ built on the coast 
of Ghana by European slave traders following the construction
of Elmina Castle by the Portuguese in 1482.
Langlands are working with local artisans to produce
 many of the art works for the exhibition.


INDIVIDUAL

|

INTER-PERSONAL : SCIENCES

HUMANISTIC -------------------------------------------------- MECHANISTIC

SOCIOLOGY : POLITICAL

|

GROUP

individual resilience FORTRESS of the MIND ?
	English Fort Komenda, 1695 (2019), Langlands & Bell.   Courtesy the artists and Gallery 1957

My source:
Christopher Turner (in Accra), 'The dungeons are decorated with wreaths left by slaves' descendants', Letters. Apollo, November 2019. Vol CXC No. 680. pp.33-34.

Liminality in "How ancient rituals help us adapt to the digital age" c/o G. Tett

How ancient rituals help us adapt to the digital age

Ceremonies and symbols matter more than ever in a disorienting world

Context: "This week I made a pilgrimage to the east coast of Scotland to participate in that classic ritual of modern middle-class life: a university graduation".

"However, heritage marketing is not the only factor, given that such rituals also occur in places that do not have 600 years of history behind them. Another way to frame the issue is to ponder a concept first developed by the ethnographer and folklorist Arnold van Gennep, and later elaborated by the anthropologist Victor Turner and the psychologist Carl Jung – “liminality”.

This word comes from the Latin limen – doorway or threshold – and refers to the idea that whenever societies or people make a transition, they typically use rituals and symbols to mark this. 

These usually contain three parts: a ritual to show the end of the old life; a ritual to mark the entry into the new one; and a “liminal” stage between the two, when the transformation occurs. Moreover, in that liminal state the normal rules of life tend to break down. Liminality is the cultural equivalent of the pupation that insects undergo: patterns become untethered and fluid, to be remoulded".

Tett, Gillian. 2019, How ancient rituals help us adapt to the digital age. FT Weekend, Magazine, June 29-30, p.46.

Pandemic Bonds: Beware perverse incentives and instruments?

individual - self

|

INTERPERSONAL : SCIENCES

humanistic ----------------------------------------------- mechanistic

SOCIOLOGY : POLITICAL

|

group- population

Geography Number of Countries Number of fatalities Instruments: Legal, Science, Social, Policy, Financial ... ?

"On Wednesday [24 July], the World bank said it  would give $300m in grants and loans to DRC to step up its aid response. But funding connected to the World Bank's pandemic bonds, issued in 2017 have been less forthcoming. One relatively small slice - the so-called "cash" element - has delivered $31.4m to help with the crisis." Ebola's latest resurgence in central Africa has led to more than 1,700 fatalities. But for the insurance element of the bonds to pay out, the disease must cross an international border and there must be at least 20 fatalities in the second country. The total possible insurance payout for Ebola is $150m and comes in three tranches: when 250, 750 and 2,500 people have died across at least two countries, $45m, $45m and $60m, respectively, will be disbursed."

Pandemic Bonds World Bank: Pandemic Emergency Financing Facility DRC - Rwanda border

My source: Asgari, N. (2019) World Bank pandemic bonds spark Ebola anger, FT Weekend, 27-28 July, p.17.

Photograph - adapted from original by The Independent.

Motivating the Gut to Walk, to Run

individual - self

|

INTERPERSONAL : SCIENCES

humanistic ----------------------------------------------- mechanistic

SOCIOLOGY : POLITICAL

|

group- population

motivation: "I must go for run again  - regularly -  build up the distance to long ..." *Walk, run, do something ...	On long distance runs: the body produces lactate -  a by-product of muscles working in reduced oxygen. Guts of marathon runners nurture colonies of bacteria that can consume lactate. The bacteria transform lactate into propionate. Propionate "has been shown to increase the heart rate and maximise  the rate of oxygen consumption, making it essentially a natural performance-enhancing drug." Whipple, p.13.

Scheiman, J. et al. (2019) Meta-omics analysis of elite athletes identifies a performance-enhancing microbe that function, via lactate metabolism, Nature Medicine.

https://doi.org/10.1038/s41591-019-0485-4

Fitbiomics
https://www.fitbiomics.com/

*I'm sure I recall reading in Bortz's 'Next Medicine' stressing the importance of movement to independence.

My source:

Whipple, T. (2019) Gutsiest endurance atheletes have the running bug, The Times, 25 June, p.13.

The adjacent possible

"The adjacent possible is a kind of shadow future, hovering on the edges of the present state of things, a map of all the ways in which the present can reinvent itself." p.31.

SELF - individual

|

INTERPERSONAL : SCIENCES

humanistic ----------------------------------------------- mechanistic

SOCIOLOGY : POLITICAL

|

group - POPULATION

"The strange and beautiful truth about the adjacent possible is that its boundaries grow as you explore those boundaries. Each new combination ushers new combinations into the adjacent possible. Think of it as a house that magically expands with each door you open. You begin in a room with four doors, each leading to a new room that you haven't visited yet. Those four rooms are the adjacent possible. But once you open one of those doors and stroll into that room, three new doors appear, each leading to a brand-new room that you couldn't have reached from your original starting point. Keep opening the doors and eventually you'll have built a palace." p.31.

Johnson, Steven (2010) Where Good Ideas Come From, London: Allen Lane.

'Dead End Tunnel Folded Into Four Arms With Common Walls' by Bruce Nauman

‘Dead End Tunnel Folded Into Four Arms With Common Walls’ (1980), by Bruce Nauman
Photo: Hauser & Wirth

My source: FT Weekend, Collecting, 28-29 April 2018, p.3.

Conference: The Foundations of Conceptual Engineering

A conference on The Foundations of Conceptual Engineering at NYU, on Sept 14 and 15, 2018. To attend, please register by following this link no later than August 31, 2018.

One dimension of cognitive success is getting it right, i.e gaining knowledge of facts. Another dimension of cognitive success is using the right concept, i.e. framing a topic in the right way. This view, if correct, tasks inquirers with critically examining the concepts they are using and perhaps replacing those concepts with new and better ones. This task is often known as “conceptual engineering”.

The idea that conceptual engineering is an important task for inquirers in and outside philosophy has recently gained traction. Some philosophers think conceptual engineering is an important task for inquirers to pursue.  The conference is focused on foundational issues in connection with conceptual engineering. Topics to be addressed include the following:

• What are the semantic mechanisms that underlie conceptual engineering?
• What are concepts, and which role (if any) do they play in conceptual engineering?
• How can a theory of conceptual engineering be integrated with large-scale semantic theories? 
• Which precise changes does a language undergo when its speakers engineer concepts?
• Is conceptual engineering something that speakers can ever purposefully bring about?
• What is the relation between changing concepts and changing reality? 

The planned conference will focus especially on the semantic foundations of conceptual engineering and push towards a better understanding of the process.

The conference is organized collaboratively by members of NYU (Vera Flocke and David Chalmers) and members of the research project ConceptLab, located at the University of Oslo (Herman Cappelen and Andrew Peet).

 More...

<>

If this conference needs a workshop, a workbench, or conceptual engineering facility they might care to look at Hodges' model. Whether for conceptual brainstorming, requirements, prototyping, refactoring, combination ... Hodges' model can have a role. Some musings in this vein follow...

individual

|

INTERPERSONAL : SCIENCES

humanistic --------------------------------------- mechanistic

SOCIOLOGY : POLITICAL

|

group

One dimension of cognitive success is getting it right,
i.e gaining knowledge of facts.
Another dimension of cognitive success is using the right concept,
 i.e. framing a topic in the right way.

Acceptable to the patient (or advocate) and ethical? Achieving concordance - agreed  relevant to the context, issue, problem? Logical consistency, coherence and permanence? Holistic bandwidth is tested - semantic scope? Conceptual Engineering instantiated in software, argumentation? AI? Conceptual Spaces? Topic is person-centred  (patient, student, carer...) Testing: Concepts with positive :: negative are switched - re-framed?  Other dichotomies? Conceptual slide-rule? Known 'semantic drift' in vocabulary - concepts: disuse, archaic, new, re-purposed?

Assessment is comprehensive? Knowledge of 'conceptual engineering'  how to - rules, laws (mechanisms)? Concepts were measurable (as were previously defined) quantifiable? Flagged interdisciplinary use of concept? Transdisciplinary? Visual tools - representation, diagrams? Reversible quality: 'engineering' disassembly? Conceptual dependency on threshold(s)? Engineering concepts:  tolerance, project, professionalism, failure, risk, benefits, techne? 'Conceptual engineering' defined units & standards: word, words ... corpora? Research methodologies, methods? Literature

Available social sources were utilised, or at least pursued? Narrative derived from concepts references life history (story)? Tested and accepted by peers - multidisciplinary team? Inclusive? Quality criteria were met Cultural, ethnic due regard  met

legal? concepts used were appropriate  to outcome(s)? 'Space' for uncertainty, constraints, unwise decisions? Policy influence on language, examples found in health and social care 2008-2018 austerity? Accords with and assures the Sustainability Development Goals? 'Macro conceptual engineering' -  Level of required change in health systems:  new & existing

Threshold and Conceptual Mobility: Hodges' model

threshold ramp

conceptual - inter(trans)disciplinary ramps

INTRA-INTERPERSONAL	SCIENCES
SOCIOLOGY	POLITICAL

Image source:
http://www.wheelchair-ramps.co.uk/d/

Blanc:Individual:Population - Dichotomy, Polar Opposition, Planetary Health

individual

|

INTERPERSONAL : SCIENCES

humanistic ---------------------------------------  mechanistic

SOCIOLOGY : POLITICAL

|

group

Pole-to-Pole (Upper Marginal)

Image: WOPA, Greenland, Pole-to-Pole

Tiles, gates, gems and beds

 

Hansje van Halem

'On a tile just by the head of my bed, I have placed a list of the ancient gates. It looks like a gold ring, with gems set into it, each a different kind of stone'.






Part of: Memory Palace exhibition at V&A 

More to follow.

Study the hoops, but care about the thresholds

When you are on a course you really have - quite rightly - to do things by-the-book. That is the way - they say - you learn which corners of the pages you can turnover. Students learn early on that you have to jump through various hoops in order to complete the course and earn the stripes. The art and science of caring presents its own hoops, but in addition it is thresholds that present a barrier, thresholds that need to be negotiated in order to meet need.

Suddenly this is not about one person (you) it is about a partnership. A partnership of professionals allied and directly collaborating with a 'patient' and their carers.

One of the hoops is the paper or electronic referral form. Are you still sure this referral of yours is necessary? Are those two assessments really necessary?

There are a host of thresholds that may (or may not?) shift like a tide around the local and increasingly extended health and social care community, or 'economy' if you prefer, for example:

The threshold at which a nursing home will contact a GP surgery; or mental health services?
Just exactly what is residential care's capacity to cope internally and manage with a given range of health and social care challenges? What exactly should that capacity be? Should the public have access to referral data from care homes - to accident and emergency, mental health services, primary care? What proportion of 'referral problems' are dealt with at the nursing - social work level? What is the mental health service's threshold in terms of responding to a referral? What is the threshold for relatives believing that sufficient is being done for their loved one?

As lifelong learners of course we are all perennial hoop jumpers, learning the art of scaling and re-framing the thresholds that cross our way.

Image sources:

Seed-and-threshold segmentation

hula hoop (no longer available)