Implementing Universal Healthcare implies Integrated Care Design - findings from a systematic review of the organisational challenges of implementing UHC policy

Abstract

Politicians in Ireland aim to radically transform access to healthcare by changing the current two-tiered system to a single-tier, universal healthcare service ensuring access to healthcare on the basis of medical need; not ability to pay. Successful implementation of this vision requires enabling a health system with the capacity to deliver in fact. Bedevilled with long waiting lists , emergency department bottlenecks, path dependent fragmentation and chronic under-resourcing of the primary and community care domains (to name a few of the challenges apparent), the Irish health system needs to forge practical paths to a level of integration greater than (although encompassing) the integrated care programmes already in train. This paper, based on initial findings of a systematic review of the 'organisational challenges of implementing universal healthcare policies in countries with a GDP per capita greater than $22,000' is oriented towards policy-makers, health system designers, enablers and providers - particularly those working in a context where health reform is focussed on implementing universal and integrated care models. Our initial search identified 1,784 papers (having removed duplicates) and after 5 screening stages resulted in 9 papers for review. These include a range of study types, and report findings from the USA, Australia, Canada, UK, Italy and Taiwan. Findings highlight the variety of policy instruments used to deliver universal healthcare, these include legislation, social health insurance and Medicare subsidies at the policy level; they also note service implementation processes, design, performance evaluation and leadership programmes aimed at greater system cohesion and integration at the practice level. The challenges and opportunities identified from our analysis relate primarily to provider practice and collaboration - both themes central to the development of integrated care. We find that providers experience better continuity of care and hence job satisfaction in some universal access settings, but also come up against systemic barriers to the shared decision-making, information flows and new role requirements necessary for integrated and universal access to care. The difficulty of changing role definitions and expectations is also apparent in our theme of collaboration. Getting stakeholders to engage in transparent peer-review, shifting fixed mind-sets and behaviours, optimum pacing of policy implementation for engagement, and systemic constraints that disable the renegotiation of professional differences on teams (for example) are also identified as important challenges. These findings can inform politicians and policy-makers as they express a vision and plan for the 'Future of Healthcare in Ireland' over the next 10 years (http://www.oireachtas.ie/parliament/oireachtasbusiness/committees_list/future-of-healthcare/). More broadly they offer pertinent evidence for those eager to better understand the processes of health system transition and transformation through a practical lens. We conclude on the basis of our review that universal healthcare implies a health system designed for integrated care. Making the explicit link between universal healthcare and integrated care on the basis of the organisational challenges and opportunities inherent to both policy directions is innovative and useful for health system reformers generally.