Integrated health services, what do you mean?

It has been described as the holy grail of healthcare: the patient at the centre and the care team working seamlessly together, no matter where the team members are located, what tribe they belong to or who the paymaster is.

Integration has been talked about for many years. The fact that it’s high on the current political agenda means that there’s still a lot to wish for. Although we have high quality healthcare services, our patients tell us that their journey through the system is everything but smooth. Most health professionals are painfully aware of the shortcomings in the the system.

What is integration?

So what do we mean when we talk about integration? Co-location of health professionals? Team meetings between doctors, nurses and allied health professionals? Hospital departments talking to each other? Communication between GPs and specialists? Working across sectors? Packaging preventative and curative services? Patient participation? One electronic health record? A shared management and funding system?

Integrating health services means different things to different people. For that reason the WHO proposes the following definition:

“Integrated service delivery is the organisation and management of health services so that people get the care they need, when they need it, in ways that are user-friendly, achieve the desired results and provide value for money.

Integration is a means to an end, not an end in itself. Sharing resources may provide cost savings but, says the WHO, integration is not a cure for inadequate resources. Obviously, integrating services doesn’t automatically result in better quality. It’s also worthwhile noting that co-locating services does not equal integration.

There is a difference between integration from a consumer point of view, which often implies seamless access to services, and professional integration, which is achieved through mixing skills and better collaboration. These two types of integration don’t necessarily go hand in hand.

So it is useful to ask: what problem are we trying to solve? Are we trying to improve the patient journey through the health system? Do we want to support health professionals to deliver better care? Or is the main driver government concerns about costs?

How to achieve it?

One thing is certain: we must fight fragmentation. This is challenging as we are seeing a wave of commercially driven, disruptive services appearing in the healthcare sector. These solutions may be attractive to consumers because they are convenient, but they usually don’t contribute to a better or more integrated health system.

Unfortunately the evidence around integration is limited, but the authors of this MJA article are suggesting a way forward. They have looked at international health reform initiatives improving integration between community and acute care delivery, and they found that the following 10 governance elements are essential to support integration:

  1. Joint planning. Governance arrangements included formal agreements such as memoranda of understanding
  2. Integrated information communication technologies
  3. Effective change management, requiring a shared vision
  4. Shared clinical priorities, including the use of multidisciplinary clinician networks, a team-based approach and pathways across the continuum to optimise care
  5. Aligning incentives to support the clinical integration strategy, includes pooling multiple funding streams and creating equitable incentive structures
  6. Providing care across organisations for a geographical population, required a form of enrolment, maximised patient accessibility and minimised duplication
  7. Use of data as a measurement tool across the continuum for quality improvement and redesign. This requires agreement to share relevant data
  8. Professional development supporting joint working, allowed alignment of differing cultures and agreement on clinical guidelines
  9. An identified need for consumer/patient engagement, achieved by encouraging community participation at multiple governance levels
  10. The need for adequate resources to support innovation to allow adaptation of evidence into care delivery.

Major paradigm shift

The first thing we need is a shared vision. A major paradigm shift towards more integration requires motivated and engaged stakeholders and champions, a shared sense of purpose and a culture of trust. This should be established before embarking on a new journey. We must avoid making the same mistakes that have caused so much havoc in projects like the PCEHR.

It will be a challenge to get health professionals to focus more on coordination instead of daily care delivery. An essential step here is to increase capacity. The last thing we need is an overloaded primary care sector such as in the UK. The RACGP is suggesting an overhaul of primary care funding to faciliate integration and coordination. Similar changes will be required to free up hospital doctors to e.g. discuss patient cases with primary care providers.

The big question is: who will take the lead? It is likely that a lot of  work will happen at a local level and primary health networks could play a crucial role here. A shared agenda, clear goals and genuine stakeholder involvement are keys to success.

The Medicare freeze: A storm is coming

Health Minister Sussan Ley said at the annual AMA conference in Brisbane that the Government is not claiming we’re in a healthcare funding crisis.

At the same time dark clouds are gathering as the frustration about the patient Medicare rebate freeze rises.

The Medicare rebate is the amount patients get back from Medicare after they visit their doctor. This amount is supposed to go up every year to compensate for inflation and higher costs. The government has frozen the annual indexation for four years.

The Consumers Health Forum said in its analysis of the latest Budget: “The retention of the $1.67 billion freeze in Medicare payments to doctors may mean many patients are likely to face higher medical bills.”

The Guardian reported: “The AMA president, Brian Owler, used his opening address on Friday to call for both sides of politics to lift the ‘damaging’ freeze which could force GPs to start passing costs on to their patients, amounting to a so-called co-payment by stealth.”

And: “The federal government could face another fierce campaign from one of the nation’s most powerful lobby groups if it does not lift its freeze on doctors’ rebates before the next election.”

The RACGP has also indicated that it would consider a new campaign. It looks like we’re going to get some fireworks again.

Doctors get sick too

Doctors get sick too
Image: pixabay.com

I took a sickie the other day. Nothing serious, but when you’re in the line of fire you get burned now and then. Patients always respond the same. They may say, half-surprised half-joking: “I didn’t know doctors could get sick.”

I can kind of see the humour of a sick doctor, but unfortunately finishing medical school doesn’t make us immune. Yes, I had my flu shot this year. No, I didn’t write a doctor’s certificate for myself. I also don’t have a secret cure that prevents me from falling ill.

Have a look at the headlines in the news this week, and you will be forgiven for thinking that medical science can cure anything:

“Implantable device ‘lowers blood pressure’ through electrical brain pulses”

“Duchenne muscular dystrophy may be treated with erectile dysfunction drug”

“DNA used to build tool that may literally shine light on cancer”

“3D-printer hearts ‘in 10 years’”

“Immunotherapy may work in cancers: study”

Hope vs false expectations

Health news is usually positive, which is great as most other news is depressing. News about scientific discoveries and new medical treatments gives us hope. Hope that one day, we may be able to live without suffering. But it also creates false expectations.

I would like to see more headlines that reflect reality, like:

“Doctors often don’t know cause of illness”

“Lifestyle just as important as medical treatment”

“Many diseases still without cure”

“If you eat healthy you probably don’t need supplements”

“Doctors get sick too”

Writer and philosopher Alain de Botton wants the news to take on new roles. I think he’s got a point. He warns about our appetite for the latest news: “We constantly want a new update on things and it’s become very hard to talk to ourselves… the news is from outside and any of that quieter news that bubbles up from within is being squashed by endless stories.”

The news often only tells part of the story and this may cause anxiety. It would be good if the news could educate us a bit more and help us to put things into context.

Wrap-up: 3 things I have learned from #AHPRAaction

And so the AHPRA Action came to an end this week. The Medical Board announced on Wednesday it would work with the other Boards to change the advertising guidelines.

The media statement“(…) practitioners are not responsible for removing (or trying to have removed) unsolicited testimonials published on a website or in social media over which they do NOT have control.”

Hats of to the Medical Board and AHPRA for listening to the feedback. I have learned three things:

#1: We now all know the rules

The media attention and focus on the law and advertising guidelines has made the road rules clearer than ever. Testimonials mentioning clinical care & used in advertising are out, and unsolicited comments including thank-you’s are in. Of course we will have to wait for the final revision, but it seems we all know where we stand.

#2: Consumers and health care professions united

The controversial advertising guidelines united not only health professions, but also consumers and professionals. This should happen more often. Some have already raised ideas to bring the health care social media community together on a more structural basis – watch this space.

#3: Big government should involve stakeholders

Consumer health advocate Anne Cahill Lambert noticed that AHPRA had not received consumer submissions during the guidelines revision. In this Crickey Blog she wrote: “Genuine consumer participation is sometimes difficult. But it should not be dismissed out of hand because of its difficulty.”

AHPRA has already started engaging and listening via Twitter. Here’s hoping that AHPRA will genuinely engage all stakeholders during future guidelines and policy revisions – without further increases in registration fees of course.