Ctl-Alt-Del:
It’s time for health and care leaders to hit the reset button and come together as one system, one team
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"Realising the true value of integrated care: Beyond COVID-19", is thought leadership report published by the Foundation which states that Covid19 presents an opportunity to reset our fragmented health and care systems so that they are integrated, driven by people and communities and resilient in the face of future systemic shocks.
COVID-19 is changing what we value as a society – we are redefining the meaning of ‘community’, realising that we cannot get through difficult times on our own. We are discovering the importance of undervalued care work. We are now painfully aware of how the social, economic and health inequities, entrenched in the past decades through austerity measures, exacerbate and are exacerbated by the pandemic.
Seizing the opportunity to transform how we think about and design our systems will lead to improving population health and wellbeing and ensure we are better equipped to respond to future crises. This requires unprecedented levels of collective action. It requires tackling the social determinants of health and reducing health inequalities. It requires shifting our focus from hospital-centric, disease-specific approaches to assuming accountability towards a territorially defined population, taking as a start point people’s and communities’ strengths.
IFIC proposes nine building blocks to help steer health and care system leaders towards a radically different future where we as one team, one system can achieve a stronger and more resilient society. In shifting sands, Integrated Care provides solid foundations.
The current crisis represents an opportunity to do things better and speed up integration of our health and care systems so that they are more resilient in the future. This report, which brought together many global perspectives from across IFIC's network, was written and collated by Leo Lewis, Director for Research and Development and Nieves Ehrenberg, Senior Researcher, and describes the issues with and opportunities for strengthening the enablers of integration.
Nine key pillars underpin our position and vision for the future of a resilient (global) integrated care system.
Shared values and vision
Improving population health and wellbeing requires collective action to address the social determinants of health and reduce health inequalities. This is a system-wide responsibility that is heavily influenced by what our societies and organisations value and the extent to which we are prepared to work together to achieve our shared vision. A good example on a national level is New Zealand’s National Wellbeing Budget and Strategy (2019) which shifted New Zealand’s economic goal from increasing gross domestic product (GDP) to improving the welfare of New Zealand’s citizens.
Population health and local context
In most places, attempts to achieve better population health and wellbeing fall short because efforts tend not to focus on addressing the root causes - the determinants of health and the reduction of health disparities. It is for this reason that we need to shift our focus from problem solving, disease-specific approaches to assuming accountability towards a territorially defined population. The current pandemic has led governments to increase spending in areas that have suffered cuts in past years in much of Europe. Governments have been exploring with keener interest policy instruments like Universal Basic Income. We would go beyond this to suggest that we need to take advantage of the current appetite for more radical options to transform and properly fund public services – improving livelihoods through free transport, childcare, internet and housing is increasingly being considered as potentially more efficient and longer-lasting in terms of value for money.
People as partners in care
People are living longer, but not healthier lives. The burden of care is increasing and, with it, complexity, as many people live with multiple chronic conditions. There is a growing imperative to place people and communities, and what matter to them, at the centre of health and care services. The design of our health and care systems needs to be a process that is shared with citizens and patients. It is time for a shift in power - to make the voices and choices of all, not just a few, count. To leave nobody behind, we must reach out to the underserved and those facing barriers to having their rights and dignity respected.
Resilient communities and new alliances
There is growing evidence to demonstrate that empowering local communities is essential for citizens’ wellbeing and for the care system to function effectively . Crucial to success is a shift to genuine ‘co-production’ with people and communities. There are several examples from around the world of how this works in practice. The TransForm initiative (Transnational Forum for Integrated Community Care) that IFIC has partnered with has collected and described a range of case studies to illustrate this new philosophy and social movement that has been gaining traction in international policy and practice agendas.
Workforce capacity and capability
The current pandemic has stretched our workforce beyond what we could have imagined. They have stepped up by extending scope of practice, blurring roles to support each other, and rapidly acquiring new caring and remote consultation skills to offer the best possible care and support in extremely difficult circumstance. The current innovative and risk enabled interprofessional ethos augurs well for workforce reform. We have a unique opportunity to test integrated workforce solutions that will strengthen our systems and lead to better health, better care and better value.
System wide governance and leadership
The pandemic has forced us to reflect on the nature and effectiveness of our governance systems and go beyond just health and care to look more broadly at the governance of our societies and their globalised nature. The spread of the virus and our disjointed efforts to contain it has evidenced on the one hand the lack of systems thinking (reflecting the complex and interconnected characteristics of our world) and as a consequence, the lack of foresight . The pandemic presents an opportunity to do things differently, to be better prepared next time – to create more global, collective and coordinated governance mechanisms, including for example a global health security system.
Far from command and control leadership, the current crisis is teaching us that successful leaders are those leading in a compassionate, inclusive and dynamic manner.
Digital solutions
Due to the unprecedented drive to keep people out of hospital on a global scale, there is a new sense of urgency to find the right balance between keeping people at home and in the community as much as possible, without adversely deferring necessary health services for those who need it. Digital solutions can support alternative options for delivery and can help harness the best of community and hospital services. We need to ensure our leaders understand the strategic place of digital solutions in the post COVID-19 world, whilst ensuring appropriate privacy measures are put in place. The evidence of how digital solutions can help deliver care with greater scale, flexibility and sustainability is there for everyone to see and we have a responsibility to act now to ensure we all continue to benefit.
Aligned payment systems
Payment mechanisms tend to reward volume and provide little incentive for providers to collaborate but many countries have started moving to value-based rather than volume-based care. This recognises the need for integration of health and social services to ensure the overall wellbeing of the population. However, evidence suggests that successful integrated care arrangements can be achieved without integration of financial flows if the necessary structures to sustain and institutionalise collaborative arrangements are in place. The impact of COVID-19 tells us that “where there’s a will, there’s a way” to solving problems, including to long-established policies and fragmentations in financing. Perhaps the most significant legacy of COVID-19 might be the recognition that financial flows need to be significantly streamlined and changed to support effective supply chains of equipment and drugs.
Transparency of progress, results and impact
Each integrated care initiative needs to define and understand what success will look like and when for the many different stakeholders involved as many outcomes and benefits will only be realised in the medium to long term. In recent years, the Quadruple Aim and Value-based Health and Care have both emerged as a more rounded way of ensuring that the cross-organisational nature of integrated care is also reflected when measuring and reporting on progress, results and impact.
This means that data and information from health, social care and support organisations’ care delivery, care outcomes, workforce wellbeing and satisfaction, together with patient and citizen outcomes and experiences is required for inclusion in such a comprehensive approach. New and exciting approaches to evaluation of complex and adaptive systems such as Developmental Evaluation, are also being increasingly employed.
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Comments from contributors:
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Commenting on the launch of the report, IFIC board member Dr Jason Yap, Director, Public Health Translation, Saw Swee Hock School of Public Health said "The world-wide responses to COVID-19 have demonstrated that integration really does go so much further than just ‘joining the dots’. The ‘one team’ approach to building alliances of stakeholder organisations, people and communities we have seen must not be allowed to ‘wither on the vine’. It offers an opportunity to go beyond a narrow focus on the individual dots, or the patchwork linking of selected dots, to one that truly understands and assesses the changes that have taken place to enable the benefits to be sustained and lead to greater impact. These are unprecedented times for which there is no clear guidance or best practice to follow."
IFIC Treasurer and Director of IFIC Canada, Jodeme Goldhar from The Change Foundation says "Working as one system, one integrated system, has never been more important. This is not the time to retreat to working independently across health and social care as can often happen when individuals and organisations feel under threat and when we think of our organisations rather than the community. This is a call to action to work together and accelerate our ‘one team’ response. This is also not the time to retreat from co-designing with patients and caregivers. In fact, this is more important than ever. Only by sharing power between us, to design, deliver and learn as a system can a true, compassionate connected system emerge that will we be able to realize the potential that integrated care has to offer. Integrated care is NOT a project or an initiative, it is a redesigned system that places people, families, communities and the people who provide health and social care at the centre."
Asked about the leadership required during crisis Professor Áine Carroll, IFIC Board Member and Director of IFIC Ireland responded that "Leadership is hard at the best of times but never more so in a time of crisis. It is increasingly recognised that health and social care and integrated care are complex adaptive systems and that necessitates a different type of leadership that nurtures innovation facilitates adaptation and adoption. We are at an epoch in our history and for those of us passionate about integrated care - the time is now, for us to rise together to embrace share and shape our new future and this document is our first step."
Professor Anne Hendry, Director, IFIC Scotland, Deputy Honorary Secretary, British Geriatrics Society and Honorary Professor, University of the West of Scotland commented that "This new report offers hope and inspiration for designing a better future through people-centred integrated care that improves lives and opportunities for all. I commend it as a call to action for citizens, practitioners, and leaders at all levels - let’s not waste this opportunity to create a new reality together!"
The gravitas and timeliness of the report was resonated in Professor Nick Goodwin's reflection that "The COVID19 pandemic has brought into sharp relief the difficulties that fragmented care systems face when responding to a public health crisis. The lack of effective collaboration and coordination, both within and between care systems globally, is a fundamental weakness. The scramble to meet the challenges of the pandemic must lead to heroic action, demonstrating the underlying willingness of care professionals and the community to come together. History tells us that integrated care solutions are often created in response to a crisis. IFIC’s Call to Action, focusing on the core principles of effective integrated care systems, provides a vision for the future where collaboration must become the new normal. Such principles should be at the centre of our thinking as we all adjust to a new reality in the coming months and years"
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Acknowledgements
The report was developed through a collaborative process of collating a wide range of perspectives from across our network.
We are grateful in particular for the valuable insights and contributions from IFIC Board Members (past and present) and IFIC Hub Leads: Nick Goodwin, Anne Hendry, Jodeme Goldhar, Aine Carroll, Lourdes Ferrer, Galileo Pérez-Hernández, Donata Kurpas, Mirella Minkman, Jason Yap, Frank Tracey, Chad Boult, Albert Alonso and Walter Wodchis.
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