Complexity is part of our contemporary experience and mind-bogglingly complicated health systems make even small changes difficult and broad reform almost impossible.
Take the challenge of coordinating the elements of care needed by patients with complex, often long-term, illnesses.
In Australia, we lament the separation of hospital and community-based care. We wish that unified funding and management would bridge the gap. The cultures and traditions of different care providers – hospital and general practice to name two – turn out to be seriously disparate. Denmark, often hailed as an exemplar of innovative and humane care, has, largely this reason, struggled to establish sustainable integrated care systems (ICSs).
Australia has the added challenge of huge distances and wide variety from one city and town to another. If we are to meet this challenge successfully, in my opinion we must accept a decentralised, local approach. These services seem, from what I have seen, to work when they are locally inspired and equipped. They cannot be mandated.
In England, integrating the providers of care in the service of people with serious and continuing illness was formalised recently in new statutory ICSs. It will be interesting to see whether such a major change to the way NHS pounds are distributed and spent really works. While England clearly does not have huge distances like ours to consider, other divisions – north/south, ethnic, and economic – make it essential for health services to be varied and locally defined. Entrenched practitioner tribal behaviours will make this tricky.
Dr Anna Charles, a doctor and health ethicist who has advised government on community care, and Richard Murray, an economist and academic and previously chief analyst at NHS England, and now Chief Executive of The King’s Fund, a London health think-tank, are “working closely with system leaders developing ICSs in England”. They write in a recent newsletter from the King’s Fund that:
Many of the greatest issues in health and care today – staffing shortages, long waiting lists, deepening health inequalities – require solutions that span many parts of the system.
We don’t doubt that the will and commitment exist to improve population health and reduce inequalities through cementing new ways of working based on partnership and collaboration. But we also don’t underestimate how challenging it will be to make a reality of those ambitions or the risks of them being derailed by wider system pressures and the gravitational pull towards entrenched ways of working.
We would hope to see ICSs and their partner organisations pulling all the levers they collectively have available. This could include making it easier for staff to move across organisational boundaries, growing attractive and flexible career opportunities and making the best use of broader support available through the contributions of voluntary, community and social enterprise organisations and volunteers and communities themselves.
ICSs could foster a workforce strategy for the future that enhanced the match between the values and aspirations of practitioners and the need for integrated care.
Much has been considered thoughtfully and published in Australia about integrated care – especially in South Australia with a very active group at Flinders University. The Royal Australian College of General Practitioners has also been taken an interest.
In my years associated with Westmead Hospital and from connections throughout NSW, I have seen several ICSs develop, often against the odds, in fields such as paediatric and aged care, diabetes, respiratory and cardiovascular disease. They have sprung from local interest. Clinicians and managers have seen the need for them. They have grown from ‘the ground up’ rather than from ‘the top down.’
For many years, geriatric care has benefitted from multidisciplinary approaches. Aged Care Assessment Teams were part of this approach. Similarly, Diabetes Education and Care programs have been operated to the benefit of thousands of patients, often including a variety of therapists and educators. In relation to child health, care that involves hospitals and community practitioners and services has flourished and is now the norm.
Initially when Jillian Skinner was minister for health, pilot integrated care demonstrator programs were established in western NSW, western Sydney, and the NSW central coast. They ran from 2014 to 2017.
The design of each of the three programs was left to the local health authorities and communities to determine. In western Sydney, integrated care programs were created to assist patients with chronic respiratory problems, cardiovascular disease, and diabetes. This meant establishing networks with local general practitioners, Primary Care Networks, hospital clinicians and patients.
An evaluation of the program conducted by Steven Trankle and colleagues from the University of Western Sydney. Their findings were mixed:
Shared patient-care plans and specialist action-plans improved communication and gave patients more confidence. Whereas relationships between GPs and hospital staff improved and disease-specific teamwork was demonstrated, inter-specialty collaboration did not improve as greatly.
Although GPs were, at times, difficult to engage, they reported improved access to hospital specialist advice through telephone support, and improvements in clinical care as a result of practice-based education where specialists helped GPs and vice versa. Health Pathways assisted with evidence-based care, though some GPs found the on-line platform challenging.
Information technology (IT) difficulties limited the use of shared records. Enrolment criteria were contentious. Many in need were excluded. Lack of transport and hospital parking were barriers, especially for the disabled. The fact of this being a short-term trial significantly impeded engagement with WSICP, staff recruitment and staff retention.
This realistic assessment emphasises the effort needed to institute integrated care and how widely one must cast the net – to parking, transport, and IT literacy for example. (Trankle et al. BMC Health Services Research (2019) 19:95.
Luca Tiratelli, a policy worker at the King’s Fund, has experience with locally-inspired initiatives. He writes:
[Top-down initiatives] can have negative effects on staff, and lead to them feeling pressurised, disempowered, and ignored.
Initiatives that focus [instead] on culture, and efforts to cultivate bottom-up change that empowers frontline staff, are far more effective in bringing about the types of improvements we all want to see.
There are copious examples in contemporary health care of service integration that can guide our planning. Many major hospitals, for example Sydney’s Royal Prince Alfred Hospital and St Vincent’s Hospital, now offer substantial extensions of their services into the community, with notable success. These had special salience during the worst of the covid epidemic, in which hospital in-patient services were severely stressed.
Integrated care is an important element of health care of the future given the need of ever more patients with serious and continuing illnesses. It is by no means the only component of health care for the future, nor is it path to salvation for health care financing. It costs money. But it can harness the interest of clinicians of all persuasions and patients. That is a good reason to support it.
COI: I chaired the evaluation committee for the Western Sydney Demonstrator Pilot Projects.
Stephen Leeder is an Emeritus Professor of public health and community medicine at the University of Sydney. Steve has 45 years of experience in epidemiological research, medical education reform and in mentoring young investigators and is currently Co-Editor-in-Chief of the International Journal of Epidemiology. He held the position of Chair of the Western Sydney Local Health District Board from 2011 until 2016 and was Editor-in-Chief of the Medical Journal of Australia from January 2013 until April 2015.
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