People-centred and integrated health services.

Abstract

Someone once said that travel broadens the mind and it would be harder to think about a broader set of responsibilities or challenges than those faced by the World Health Organisation (WHO) who addresses the broadest definition of health and well-being for the broadest range of countries, ethnicities and contexts. The Director of Service Delivery and Safety, Dr Edward Kelly, launched the interim report of a global strategy on people-centred and integrated care in Edinburgh on Friday 27 March 2015 which will be presented to the World Health Assembly alongside a global health workforce strategy in 2016.1 The report starts from the premise that the case for integrated care is sound and the benefits include: increased service efficiency, decreased costs, improved equity in service uptake, better health literacy and self-care, increased satisfaction with care, improved relationships between patients and their providers and an improved ability to respond to health care crises such as Ebola. The choice of Scotland for the launch was timely since the following week, 1 April, marked the implementation of legislation2 to reallocate a minimum two thirds of the entire spending for adult health and social services to Integration Joint Boards. These boards have equal representation of National Health Service (NHS) and Local Authority members and will instruct NHS and Local Authority executives on strategies to achieve people-centred and integrated care. The Integrated Joint Boards have responsibility for a defined area (coterminosity), and are expected to engage with patients and community stakeholders to identify and plan to meet the needs of their populations through joined-up services. A number of interesting observations can be made. This is not another pilot, small-scale intervention in integrated care. At a minimum, it includes 60% of the total revenue for adult health and social services. It would not be possible without bi-partisan political support in the Scottish parliament. It applies to rural as well as metropolitan areas and builds on agreements and systems for the sharing of information when it is needed. It builds upon sensible decisions about service and community boundaries and upon long-term and more recent investments in information and related systems. Perhaps most importantly, it recognises that doing nothing in health system development is a prescription for more beds, more specialist services, fewer satisfied patients and more unhappy tax payers. Countries with broadly unitary health systems in which preventive, primary, secondary and tertiary services are funded from the same purse have the advantage in integrating care. It is no surprise that the leading international services such as Kaiser Permanente, the US Department of Veterans Administration and Clalit Health Services in Israel have registered clients, capitation payment systems and operate in contexts where dissatisfied consumers can switch to another provider who will be more responsive to their wants or needs. These organisations have been successful in moving care from hospitals to primary and community care settings and then to the home, making use of telephone and Internet as well as face-to-face consultations. In doing so they have made progress towards the triple aim of population health improvements, better patient care and reduced costs of care. Countries and health care providers who accept responsibility for the quality and cost of services pay particular attention to the roles and performance of preventive and primary health services since they seek to address health risks before they become health conditions and require expensive secondary and tertiary interventions. Reorienting health care systems away from an inpatient and acute focus requires improved engagement with populations and communities. This may imply moving beyond traditional town hall meetings to engagement using the web, smart phone apps and other social media. All this seems a tall order for an Australian health care system that could best be described as provider centred and fragmented. The challenge is to focus on the goal of population-centred and integrated care in which rural communities may have the advantage of scale: in some instance, small scale may prove helpful with fewer providers to engage. If rural communities can lead, we will all benefit whether as providers, patients, citizens or indeed all three.