Healing healthcare 2: What’s missing?

Healing healthcare 2: What’s missing?

Healthcare is everybody’s business, but unfortunately the business of healthcare isn’t doing so well. Brooke Consultant Bryanna McDermott has been engaging with thought leaders and practitioners across the health industry to determine what is needed to create the best medicine for Australia’s healthcare. This second blog in her series Healing Healthcare will offer potential solutions to some of the issues raised in her first blog.

In Healing Healthcare 1: Operating costs I argued that crippling operating cost increases in the health sector are in large part due to self-inflicted structural problems, namely the funding imbalance between prevention and cure. The feedback on the blog was overwhelmingly positive, but split between two points of view. In one camp were those who believe that we continue to promulgate a reactive treatment culture in Australia where the bottom line shrinks while the workforce attempts to keep up with demands. In the second camp the view was that the state of affairs is in fact far more positive than it appears, with strong investment in digital and patient-centric technology reducing costs by pushing low complexity treatments out of hospitals and into community centres and homes.

There is no doubt that the health industry remains one of the most complex and highly dynamic industries in Australia, if not the world. With the relentless onward and upward march of operating costs, practitioners and health care leaders continue to play the investment tug-of-war between cost-effective preventative care measures and acute care treatment approaches.

So where should we invest? I would argue that the balance needs to move more to prevention since so many of the health problems we face are lifestyle related.  In the end of course, we have to do both, and no matter where the balance sits we have to get the most out of the resources we put into both prevention and cure.

An apple a day…

For preventative care the main challenge has been convincing government bodies, politicians and health care executives that investment in prevention is far more effective from a cost and patient perspective than investment in complex treatments of lifestyle-related illnesses. Part of the problem appears to be the seductiveness of management by crisis.  In a crisis there are fewer options, it’s easier to get people into action and it is easier to come out looking like a hero.  In most organisations, you are more likely to be rewarded when you ride to the rescue once an issue has turned into a crisis than if you managed to prevent it in the first place.  As a result, we lose our ability to distinguish between the urgent and the important.

Interestingly, one solution to the problem preventing prevention may be emerging from another of our human predilections – our love of gadgets.  New wearable technologies capable of monitoring our health both directly and indirectly are rapidly becoming available, and at prices that will allow them to impact health outcomes at a population level.  For example, a well-known brand of smart watch (you know the one I mean) has been credited with saving lives through monitoring heart rhythms and detecting falls.  It’s also rumoured to be developing a non-invasive way of measuring blood glucose levels, which would be truly life-changing for diabetics.  The longer-term health impacts of these devices through changing our lifestyles with simple prompts and feedback – like reminders to stand up, keeping count of our steps, tracking our sleep patterns – may be even greater.  Most importantly, these devices appear to be doing something which the health sector as a whole has not been able to do, which is make living a healthy lifestyle on trend.

Truly integrated care

On the ‘cure’ front, Australia’s hospital-centric health care environment is sharpening its focus on better triaging patients. This means that less complex ailments can be treated outside the high-cost hospital environment.  However, this approach seems to be mainly cost-driven, which falls well short of true integrated care.  We would do well to take a leaf from the book of those smart watch makers who work out what people want and then design their products and services accordingly (and know how to market them).

This means starting with patients and their communities to determine their needs, and then working out how to best deliver the services they need in an integrated way (from the patient perspective).  Unfortunately, our health system is structured the other way around and is more about meeting the needs of service providers.  Once again, it’s a question of balance.  Service providers do need to specialise, and some services may need to be provided centrally and others locally.  Integrated care models therefore often involve consortia of service providers and there have been some transformative success stories in Europe based on this approach.

However, consortia are notoriously difficult to manage and sustain over time.  This is sometimes because they were poorly set up (despite the large amounts of legal fees consumed in developing consortium agreements) or more often simply because things change over time.  For example, process improvements, new treatments and new technologies can render the initial division of accountabilities and activities obsolete.

Also, most consortia carry the seeds of their own destruction.  In theory the consortium exists to increase the size of the pie, which is in the best interests of each member (and hopefully their patients!).  However, once the consortium has been established, each member has an incentive to ‘cheat,’ to take a larger slice of the pie – just look at OPEC.

The missing piece

We believe that the missing piece of this puzzle is governance.  Sure, most consortia have governance rules and processes, but these are mostly used to defend or promote the interests of individual members.  Who stands for the success of the consortium as a whole?  We believe that an enduring integrated care model requires an independent party (i.e. one not involved in service delivery) whose role is simply to make the consortium successful. Their sole focus should be increasing the size of the pie and ensuring that it is shared equitably through the consortium’s governance processes.

The foundation for these governance processes is defining the outcomes (not the activities) that the consortium is committed to delivering and how to measure them, starting with patient and community outcomes then working back to commercial objectives.  The role of each consortium member in delivering these outcomes can then be determined, and performance measures agreed.  The governance process overseen by the independent party then consists of monitoring the achievement of the consortium outcomes and the performance of each consortium member in delivering them.  When deviations from plan or other issues arise, the role of the independent party is to convene joint problem-solving workshops between consortium members, rather than reverting to lawyers at ten paces.

It seems that this governance element is missing at the sector level as well. Andrew Peterson, CEO of Nexus Hospitals, relayed it to me quite simply: “We’re all sitting in opposite corners of the room not talking to one another. We have government and policy-makers in one corner, service providers in another, doctors in one and health insurers in the other. The patients aren’t even in the room. We can each have our own approach as to why and how preventative care or integrated care “should be done,” but if we’re not tackling the issues collaboratively we’ll never make material changes to the model of care to improve patient outcomes and remove unnecessary waste in the system”.

We believe that a customer-led, tech-savvy, systemic approach to prevention; and integrated patient care, driven by outcome-focused governance and aligned around a shared vision for the future, are missing links in Australia’s health ecosystem.

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20th December, 2018