Integration, not fragmentation - Public Service

Health and Social Care Issue 31 - Integration, not fragmentation - Public Service

8/29/13 17:22 PM

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Foreword Introduction

PUBLIC SERVICE REVIEW: HEALTH AND SOCIAL CARE - ISSUE 31

EUROPEAN HEALTH AND SOCIAL CARE »

Digest

Integration, not fragmentation

Talking Point

13 April 2012

Overview

Fragmented health services can lead to 'Patient Bermuda Triangles', but integrated care offers a possible solution, argues the Nordic School of Public Health's Bengt Ahgren

Public Health Speech and Language Therapy Infection Prevention and Control Procurement and Best Value Energy Efficiency ICT European Health and Social Care

Healthcare systems all around the world are continuously developed to match changes in the demands and needs of stakeholders. Common effects of this development are, in brief, increased differentiation of roles, tasks and responsibilities in healthcare. There are three gradually reinforced and rooted conditions behind this outcome: decentralisation, where extensive responsibilities and authorities have been placed on the front line of organisations; specialisation, where healthcare personnel have developed in-depth knowledge in an ever-decreasing area; and professionalisation, where health professionals work independently and with individual responsibility towards the patients. The outcomes of these developmental approaches can, on the one hand, be regarded as success stories. However, there is also a flip side. All three driving forces, individually and together, have contributed to a state of differentiation, with manifold negative consequences for the healthcare system as a whole. This is often described as fragmentation, which can be defined as a state of differentiation without the integration required to achieve a unity of effort. Further-more, it can be divided into different categories, depending on the interaction between the driving forces: structural, clinical and cultural fragmentation. A fragmented healthcare system is characterised by patients often being transferred to other departments or institutions without complete information about their condition or medical history, services provided in other settings, or medications prescribed by other clinicians. These conditions may lead to increased waiting times and delays for the patients, as well as duplications of tests causing additional costs to the healthcare system. In this way, fragmentation may cause difficulties in the co-ordination of activities for patient treatment. Thus, patients can be lost as a result of these conditions of fragmentation – a situation that can metaphorically be described as a 'Patient Bermuda Triangle'. Patients within the Bermuda Triangle are thus lost due to an incoherent provision of services by the healthcare providers involved, which can especially happen to patients with manifold needs, such as the frail elderly, patients with chronic conditions and disabilities, as well as patients who require multiple clinical treatments of distinctive diseases or injuries. The way out of the Patient Bermuda Triangle is commonly labelled integrated healthcare. This global buzz term has driven and shaped healthcare systems to be more coherent and patient-centred. The concepts of integrated healthcare could include intra-organisational integration, for instance within a hospital department, and inter-organisational integration, for instance between hospital departments and primary care. 'Chains of care' and 'local care' are two Swedish concepts included in this later form of integration. A chain of care could be defined as 'coordinated activities within the health sector, linked together in order to achieve a good final result for the patient'. In other words, a chain of care includes all the healthcare provided for a specific group of patients within the defined geographical area. Patients belonging to a particular chain of care are characterised by having the same illness or symptom. Furthermore, chains of care are based on clinical guidelines, that is, agreements on the content and distribution of the clinical work between different healthcare providers and professionals. Most chains of care can be described as coordinated networks, where the financial and clinical responsibilities of the parties involved remain separate. Some years ago, a national survey was conducted in Sweden. It demonstrated that the development of chains of care have high priority. At the same time, however, the results showed that the development work was making slow progress, because of difficulties in implementing sustainable solutions in a predominantly non-integrative context, and negative reactions from healthcare professionals to top-down development approaches. Conversely, if chain of care projects are initiated locally by dedicated professionals, there is a good chance of successful outcomes. Such a reversed approach often gives the development work legitimacy among colleagues, which is of vital importance to the work's success. Despite doubts about the development of chains of care, Swedish healthcare providers have made clear that they will continue their development work. One reason for this position is that chains of care are increasingly regarded as building stones of the emerging local care. This is an upgraded family and community-oriented primary care, supported by flexible hospital services. Many policymakers are convinced that such an integrated system will assure both high-quality and cost-effective healthcare. Although considerable efforts have been put into this development, there is no common definition of local care. Most providers have the ambition to create a system that is tailor-made for the needs of a local population. This means that the content of local care may differ from one area to another. Nevertheless, some common characteristics can be distinguished. Local care is expected to offer accessible and comprehensive health services with a continuity of care and a strong patient focus. It is supposed to be the foundation of the whole healthcare system with an orientation towards diseases of frequent occurrence and needs among major population groups, such as families with children, older people, and patients with chronic diseases. In spite of the ambitions to create an integrated delivery system on the local level, it is unusual to find a high degree of organisational cohesiveness in local care. Instead, it is common that the system is linked together through chains of care or other types of coordinated networks, many of them with a focus on older patients with multiple diseases. In this sense, chains of care may have a renaissance, after being high on policy agendas for almost 20 years but with modest development results. Thus,

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Health and Social Care Issue 31 - Integration, not fragmentation - Public Service

8/29/13 17:22 PM

there seems to be a mutual relationship between local care and chains of care. Local care needs chains of care as integrating mechanisms, and the chains of care are strengthened by the integrative context of local care, which, in turn, create feasible paths out from the Patient Bermuda Triangle. At the same time, a new system of free choice for patients in primary healthcare has been introduced. The choice generates a capitation payment to the chosen primary care centre. Policymakers believe that, as a result of competition between health centres, strong providers will survive while unprofitable ones will be eliminated. In order to implement the new system, different models of patient choice have been developed. In some models the patients can choose among comprehensive local care arrangements, whereas in others they register for a specific general practitioner. There is a great challenge for the health authorities to simultaneously manage both competition and provider integration, although it is easier when patients choose among networks of integrated healthcare and not among individual healthcare providers. Models of the latter kind tend to fragment the provision of health services and will thereby likely establish a Patient Bermuda Triangle or reinforce an existing one.

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