Towards A High Integrity Health System

Health services in all developed countries are struggling with increasing demands and rising costs.  The problems are being experienced by both tax -funded countries like Ireland and also insurance funded services like the US.  In 2012 health accounted for 8.9% of GDP in Ireland, with approximately 70% of health spending being funded by public sources.  Per 1,000 of the population there are 2.7 doctors, 12.6 nurses, and 2.8 hospital beds.  The life expectancy is 81 years.  Eighty three per cent of males and 81% of females rate their health as being good or very good.

When measuring whether a health service is providing value for money, the usual parameters quoted are ED attendance rates, admission rates, waiting lists, and length of stay.  These give little insight into the patient experience and how best to improve his journey through the system.  In particular the issues that matter most to the patient are not being measured.  In many situations what’s being measured is not what matters.  There needs to be more attention paid to patient feed-back and patient satisfaction. 

Mulley et al¹ state that all stakeholders including management, patients, and health professionals are drawn to new technologies.  The limitations of technology are frequently not recognized.  Technology is invaluable when used correctly and effectively.  However it is not a substitute for the other needs of patients.  The technologies that we use are mostly related to making a diagnosis or monitoring the response of a disease to treatment.  The health services are excellent when there is a single clinical condition requiring a specific operation or treatment.  The challenges arise when the patient has a complex disorder requiring input from multiple services and agencies over a long period of time.  The 5 streams of professional activity are acute care, primary care, mental health, social care, health and wellbeing.  A patient who suffers a stroke will require most or all of these services.  The integration of the clinical streams is the key to the provision of optimal care.  The best definition of integration is the organization of health services so that patients get the care that they need.  Without integration patients can get lost in the system with needed services not being delivered. 

The HSE through the clinical programmes is actively developing this strategy.  While the concept of integration is easy to grasp, its implementation is complex with many factors hampering reform². The balanced score card is a tool that is used to track progress in completing tasks required for implementation of integrated care.  Integrated care is particularly suited for groups such frail older people, children with disabilities, and those with multiple chronic and mental health illnesses.

Clinical waste is one of the most frustrating aspects of current healthcare delivery.  Waste implies activities that do not add value or improve patient outcome.  The wrong model of care can waste as much as 40% of the annual expenditure.  Overtreatment and lack of care co-ordination are two obvious examples.  In an attempt to identify examples of overtreatment the American Board of Internal Medicine Foundation in its ‘choose wisely’ initiative sent a circular to all specialties asking them to identify 5 tests or investigations that are commonly overused.   An example of the latter is re-hospitalisation within 30 days of discharge.  In many instances it can be prevented by good discharge planning and early follow-up in the community.  Clinical research and quality improvement programmes are effective ways of identifying wasteful practices.

The Organization for Economic Cooperation and Development have stated that there needs to be a shift from a system based on providers to a system based on the patients’ needs.  There needs to be engagement with patients on the management of their own health and sustaining their wellbeing.  This change concept can produce better outcomes and save money.  Duplication and fragmentation are wasteful and lead to variation in the standard of care provided to the patient.

The term ‘a high integrity health system’ is defined as one that provides what patients need but no more and no less.  A number of current assumptions about healthcare are being challenged. 

The first one is that providing more services results in more health and wellbeing.  In many respects this is incorrect.  Education, social class, behaviours have a greater influence on a population’s health.  An over-emphasis on the new technology and acute services tends to neglect the preventative measures that can prevent illness in the first place.  The bias is towards rescue rather than prevention.  The role of health and wellbeing is central to improvement in society’s health.  It is a key strategy in the achievement of optimal health in children.  It also offers great dividends for adults in relation to smoking cessation, alcohol moderation, exercise and weight management, and good mental health.

The second assumption is that clinical evidence alone can determine the best treatment.  The patient’s personal circumstances and individual circumstances should be routinely included in the decision processes.  This clearly takes more time, and more explanation.  The benefits, however, are considerable.  The patient is both better informed and better prepared for the surgical intervention or medical treatment that has been mutually agreed.

The third assumption being challenged is that healthcare can only be delivered by healthcare professionals.  While this is true for surgery and complex medical conditions, there are many situations where key elements of the patient’s care can be provided by other family members.  There is room for more dialogue and co-operation between healthcare workers and community support systems.

Many families provide lifelong support to their relative with chronic conditions including intellectual disability.  Their major contribution needs greater recognition and support.

Overuse of high cost acute care and underuse of primary care and community services is both wasteful and costly.  Also it is not what patients want.  They want integrated care as close to home as possible.  Therefore patients should be a source of learning that informs healthcare planning. 

JFA Murphy

Editor

References

1. Mulley A, Coulter A, Wolpert M, Richards T, Abbasi K. New approaches to measurement and management for high integrity health systems.  BMJ 2017;356:1401
2. Darker C. Integrated healthcare in Ireland. A critical analysis and a way forward. tcd.ie/healthcare/integratedcare.

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