Systems not Structures: shaping the future of health and social care in NI
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1 Systems not Structures: shaping the future of health and social care in NI Professor Deirdre Heenan Professor Rafael Bengoa Date 9 May 2017 ulster.ac.uk
2 Systems not Structures This paper will cover: Context of health and social care in NI Principles for reform Delivery of reform
3 Systems not structures Northern Ireland population 1.8 million Health and Social Care integrated since 1972 Health and Social Care accounts for 4.6 Billion or 46% of the entire budget. Systems for delivering health outcomes fragmented Resources tied up in acute care which would have greater impact elsewhere. Striking and growing health inequalities.
4 Systems not Structures In common with countries across Western world attempts to transform care in context of: Increasing demands Growing population Ageing population Increasing co-morbidities Shrinking resources Technological advances Rising patient expectations
5 Systems not Structures 2011 Transforming Your Care (TYC) set out 99 proposals for change. The Right Time the Right Place (Donaldson Report) Systems, Not Structures: Changing Health and Social Care. (Bengoa Review) Health and Wellbeing 2026 Delivering Together (Minister s Vision) Broad political agreement that a need to embrace transformation and create a modern sustainable service. Although review fatigue reviews have created a context for change.
6 Systems not Structures System at breaking point and unsustainable Budgetary requirement set to double by 2026 Resources concentrated in acute sector Striking and growing health inequalities ED struggling to meet demand Waiting lists highest in UK Cannot fund innovation due to fire fighting Heavily reliant on locum and agency staff
7 Systems not structures The Bengoa Report made 14 recommendations based on a new model of care. Quadruple aim Improving the patient experience of care Improving the health of the population Achieving better value Improving life of those who deliver care
8 Systems not Structures Accountable care systems linked to population care planning needed to improve outcomes for patients. Elements of this already exist in ICPs and GP federations. Those who provide care enabled to take responsibility for a given population with a capitated budget linked to population based outcomes. Change must be evidence- base, clinically led resulting in better outcomes for patients.
9 Systems not Structures Health and Wellbeing 2026 New model of care and new way of working Person-centred Focused on prevention Early intervention Supporting Independence Co-production and co-design
10 Systems not Structures Departmental Report 4 areas of change. Build capacity in communities Provide more support in Primary Care Reform community and hospital services, only those needing acute care in hospital Emphasis on working together and planning and management of new HSC services Focus on integration, improvement and collaboration Real time evaluation to assist policymakers
11 Systems not Structures WE know the WHAT but HOW is key question. Research reveals the following are predictors of success Shared vision between clinicians an administrators Strong leadership committed to quality Routine measurement of quality and costs of care Emphasis on primary care and integration Evidence based care linked to performance based management Rapid evaluation of new ways of working IT systems that support and facilitate
12 POLICY LEVEL PERSPECTIVE GET BEYOND FRAGMENTATION OF CARE. MOVE TO SYSTEM MANAGEMENT/INTEGRATED CARE TARGET BETTER CHRONIC CONDITIONS MANAGEMENT IMPROVE PATIENT-CENTEREDNESS & EMPOWERMENT MOVE TOWARDS POPULATION HEALTH MANAGEMENT. EXPAND USE OF INFORMATION AND COMMUNICATION TECHNOLOGY. EXPLORE AND ADAPT OUTCOME BASED PAYMENT MODELS TO ENCOURAGE VALUE VERSUS ACTIVITY SI-HEALTH 2016
13 MANAGE INTEGRATED SYSTEMS RATHER THAN MANAGING STRUCTURES STRUCTURES COMMUNITY SYSTEM Vs. PATIENT SI-HEALTH 2016
14 NEED TO MANAGE TWO AGENDAS SIMULTANEOUSLY & REINFORCES A RESIST CULTURE DOES NOT CHANGE MODEL OF CARE SOME LOW HANGING FRUIT STILL AVAILABLE ( WASTE ) LAUNCHES A TRANSFORMATIVE CULTURE REACH UP FOR THE HIGH HANGING FRUIT TOUGH BUT DOES CHANGE THE MODEL OF CARE ENGAGE ALL RELEVANT ACTORS Bengoa/Arratibel. SI Health
15 SYSTEM FRAMEWORKS
16 Management Arsenal for Transformation! ALL INTEGRATORS! Electronic Medical Record Electronic prescription Digital Health/Telemedicine Risk Stratification New payment models Integrated care Coordination Health & Social Care New professional roles (nursing) Patient Empowerment (selfmanagement) Third sector Engagement Patient pathways Engagement of health professionals New forms of distributive/facilitator leadership. SI-HEALTH 2016
17 So, what is stopping us from a systematic move to integrated care? POLICY MAKER SI-HEALTH 2016
18 Politics? Kingdon Policy Streams
19 ENGAGING POLICY MAKERS STREAM Politically Hard rationalizing hospital infrastructure Hard shifting resources to community/phc Hard to integrate health & social care
20 INTEGRATORS ACORDING TO POLITICAL RISK MORE RISK LOW RISK Shifting Resources to community and PHC Hospital infrastructure rationalization Health & Social Care integration New value based payment models MANAGING POLITICAL RISK EMR Risk stratification Digital Health Integrated Pathways Engaging professionals Empowering patients Less top down leadership SI-HEALTH 2016
21 INTEGRATORS ACCORDING TO POLITICAL RISK MORE RISK LESS RISK Shifting Resources to community and PHC EMR Risk stratification EXPERIMENT Hospital infrastructure rationalization Health & Social Care integration MANAGING POLITICAL RISK Digital Health Integrated Pathways Engaging professionals DO IT New value based payment models Empowering patients Distributive leadership REAL TIME EVALUATION LOCAL ACCOUNTABLE HEALTH SYSTEMS SI-Health. Bilbao, 2017
22 ENGAGING POLITICIANS OBJECTIVE : GET BEYOND POLITICAL CYCLES : REFORMS NEED TIME. BUILD A BURNING PLATFORM. SCENARIOS ( WHY REFORM ). BRING ALL POLITICAL GROUPS TOGETHER GET AGREEMENT ON THE BURNING PLATFORM AGREE PRINCIPLES E.G. COLLABORATION RATHER THAN COMPETITION, SOME RATIONALIZATION REQUIRED, ATTACK WASTE, DRIVE TOWARDS HEALTH & SOCIAL INTEGRATION, INTRODUCE VALUE BASED CARE. LAUNCH A NATIONAL/ INTERNATIONAL TECNICAL PANEL ENGAGE ALL STAKEHOLDERS. ESPECIALLY INCLUDE CLINICIANS, NURSING AND SOCIAL CARE RE-ENGAGE POLITICAL INTEREST WHENEVER POSSIBLE ENGAGE PARLIAMENTARY COMITTEE ON HEALTH SEEK GOVERNMENT COMMITMENT TO THE MAIN RECOMENDATIONS ENSURE A TRANSFORMATION FUND & DECIDE ON A TRANSFORMATION TEAM GO FAST SI-Health. 2016
23 ! IMPLEMENTATION! MORE RESOURCES & TRANSFORMATION MORE RESOURCES & NO TRANSFORMATION NO RESOURCES & TRANSFORMATION NO RESOURCES NO TRANSFORMATION SI-HEALTH 2016
24 Conclusions Enormous pressures on healthcare systems worldwide. Healthcare complex with large number of stakeholders Reform is medium to long term (10 years) Need to develop a favourable policy environment Financial systems aligned to outcomes Shared leadership Top down and bottom- up Need to find balance between managing in austerity and transforming
25 The Institute for Health & Strategy Bilbao, Spain
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