Coping With More People With More Illness. Part 1 - The Nature of The Challenge and The Implications For Safety and Quality

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International Journal for Quality in Health Care, 2019, 31(2), 154–158

doi: 10.1093/intqhc/mzy235
Advance Access Publication Date: 22 November 2018
Perspectives on Quality

Perspectives on Quality

Coping with more people with more illness.

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Part 1: the nature of the challenge and the
implications for safety and quality
RENÉ AMALBERTI1, CHARLES VINCENT2, WENDY NICKLIN3,4,5,
and JEFFREY BRAITHWAITE5,6
1
Haute Autorité de Santé, 5 Avenue du Stade de France, 93210 Saint-Denis, France, 2Department of Experimental
Psychology, University of Oxford, Anna Watts Building, Radcliffe Observatory Quarter, Woodstock Rd, Oxford, OX2
6HG, UK, 3Queen’s University, 99 University Ave, Kingston, ON K7L 3N6, Canada, 4University of Ottawa, 75 Laurier
Ave E, Ottawa, ON K1N 6N5, Canada, 5International Society for Quality in Health Care, 4th Floor, Huguenot House,
35-38 St Stephens Green, Dublin 2 D02 NY63, Ireland, and 6Australian Institute of Health Innovation, Macquarie
University, Level 6, 75 Talavera Road, North Ryde, NSW 2109, Australia

Address reprint requests to: Jeffrey Braithwaite, Centre for Healthcare Resilience and Implementation Science,
Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, North Ryde, NSW 2109,
Australia. Tel: +61-414-812-579; Fax: +61-298-502-499; E-mail: [email protected]
Editorial Decision 16 October 2018; Accepted 15 November 2015

Abstract
Health systems are under more pressure than ever before, and the challenges are multiplying and
accelerating. Economic forces, new technology, genomics, AI in medicine, increasing demands for
care—all are playing a part, or are predicted to increasingly do so. Above all, ageing populations
in many parts of the world are exacerbating the disease burden on the system and intensifying
the requirements to provide effective care equitably to citizens. In this first of two companion arti-
cles on behalf of the Innovation and Systems Change Working Group of the International Society
for Quality in Health Care (ISQua), in consultation with representatives from over 40 countries, we
assess this situation and discuss the implications for safety and quality. Health systems will need
to run ahead of the coming changes and learn how to cope better with more people with more
chronic and acute illnesses needing care. This will require collective ingenuity, and a deep desire
to reconfigure healthcare and re-engineer services. Chief amongst the successful strategies, we
argue, will be preventative approaches targeting both physical and psychological health, paying
attention to the determinants of health, keeping people at home longer, experimenting with new
governance and financial models, creating novel incentives, upskilling workforces to fit them for
the future, redesigning care teams and transitioning from a system delivering episodic care to one
that looks after people across the life cycle. There are opportunities for the international commu-
nity to learn together to revitalise their health systems in a time of change and upheaval.

Key words: massive ageing, ageing population, health system reform, elderly

Introduction Health Organization [1], the Organization for Economic Co-


The growing number of older people living with chronic conditions operation and Development [2], United Nations [3] and the World
is a major focus for international organisations such as the World Economic Forum [4]. Multiple books and reports have estimated the

© The Author(s) 2018. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved.
For permissions, please e-mail: [email protected] 154
Part 1: nature of challenge • Health system reform 155

escalating size of the ageing population relative to other age cohorts amongst this population will suffer one or more chronic conditions,
and described a cascade of social and economic consequences. such as musculoskeletal problems, heart disease, neurodegeneration
Many have taken a country-specific and a few, country-comparative or frailty [12]. By 2050, on the other side of the demographic curve,
approach [5–7]. Only a few nations and organisations have moved 1 or 2 billion younger people will be newly diagnosed and treated
beyond providing general warnings and offered implementable solu- for a chronic condition such as cancer, cardiovascular disease, back
tions to cope with ageing, frailty and long-term care needs. pain and diabetes, due in part to the rapid advances in personalised
Focusing on ageing alone understates the overall problem. New medicine [13].
technologies, genomics, personalised medicine and other advances We have tended until now to see these problems in terms of an
are also increasing the pressure on healthcare systems. Nevertheless, increasing number of older and sicker people; however, case com-
the ageing population is a core challenge confronting countries and plexity is intensifying as well. Multi-morbidity and polypharmacy

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systems. This is why we, the Innovations and Systems Change are on the rise. The reality that healthcare faces is not so much the
Working Group (I&SCWG) of the International Society for Quality problems of the very old, but the sheer number of people living with
in Health Care (ISQua) suggested that ISQua use the ageing popula- illness on the planet. By the 2050s, >50% of the global population
tion as the platform and starting point from which to assess the will be living with a chronic illness, compared to <20% in 2000.
potential tsunami of consequences for our current approaches to Dementia and mental illness such as anxiety and depression are very
conceptualising, assessing and improving the safety and quality of large burdens on individuals and societies, too [14].
healthcare. As yet the necessary innovations required—in delivery Recent studies have reinforced the challenge and tragedy of loneli-
systems, quality and safety standards and care provision—are at a ness and social isolation in both urban and rural areas, associated
very early stage. We believe that the rate of progress is too slow and with poor health outcomes [15, 16]. In many countries, older adults
that current initiatives are too narrow in scope. live alone, women in particular, because of the differences in the life
The I&SCWG on behalf of ISQua, having consulted over the expectancy of sexes. It is more difficult to provide health and social
last 4 years at each annual conference with some 40 countries, has care services and resources to this population [17], particularly in
been grappling with this problem on behalf of the institutional and remote areas. This problem needs specific recognition and attention by
individual members of its international community. This work has healthcare providers and should be reflected in prevailing standards.
led us to frame the problem thus: nations need to address the grow- This represents not just a healthcare and social test of our
ing challenge inherent in the increasing ageing population with cost- ingenuity but a substantial economic one. Governments will find it
effective solutions, in parallel with confronting the health of children increasingly hard to allocate sufficient funding for education, trans-
and youth, as chronic diseases accelerate, with a focus on improving port and security as a proportion of gross domestic product (GDP),
quality and safety of health and care. alongside the growing demands for more spending on healthcare
In this, the first of two companion articles, we outline the impli- and social care. In addition, the available funds must be divided
cations for safety and quality of an ageing population and share across a greater spectrum of healthcare requirements including gen-
ideas generated from ISQua’s international community. We provide eral practice, acute care, aged care, rehabilitation and community
an account of the challenges to healthcare systems, the range of services, with other specific demands, such as for assistive technolo-
potential solutions and the broad implications for patient safety and gies. Addressing wider social determinants of health, such as income
quality of care. There are multiple difficulties ahead, but our present equality, will also be critical [18].
aim is to address a particular role and mission of ISQua, namely the
definition, provision and accreditation of healthcare organisations
and standards. In our second article, we provide a more detailed
proposal for the new type of standards that will be required, the
The present path
extension of standards to deal with the entire patient journey and The primary goals of transforming the system related to massive age-
the challenges for leaders in tackling this issue. ing are preserving the autonomy and physical and psychological
well-being of the elderly as long as possible, respecting and mitigating
against the risks of increasing frailty (such as injuries due to falls)
How we got here and addressing the rapid increase in cognitive disorders (principally
In the last 60 years progress in hygiene, improvement in access to Alzheimer’s disease and other dementias). Simultaneously, we must
clean water and nutritious food, the relative absence of war, pre- respond to the health and social needs of the growing population at
ventative strategies in public health and continuous improvement in end of life stages and the concomitant implications for palliative care.
diagnostic and treatment modalities (especially for infectious dis- What can we do to tackle this thorniest of problems?
eases and maternal and child mortality) have combined to create Traditionally, healthcare systems were designed to heal recurring,
huge reductions in premature deaths in the under 50s [8]. Living to acute diseases affecting younger citizens and to treat a few seniors
over 90 years or age is becoming the norm in Western countries. For affected by aggressive diseases, in turn by delaying death or simply
several decades, now people have, on average, gained 3 months providing palliative care [19, 20]. Such healthcare systems have sim-
extra life for each passing year, in many countries [9]. This degree ply not been designed for the new reality, our emerging future and
of years of life gain is unprecedented in human history. Although the exponential increase in people with chronic conditions [21].
they have previously lagged behind high-income countries, this Sophisticated and costly diagnostics, long-term treatments and
acceleration of increased lifespan can be even greater in low- and needed aged care could, if extrapolated over decades, lead nations
middle-income countries [10]. Survival for its own sake is not the to the brink of unaffordability. On the present path, universal health
goal; however, reduction of disabilities, better quality life years and coverage (UHC) may become increasingly difficult to achieve despite
supporting outcomes, which patients favour, are key. WHO efforts and international support, or UHC may become
The world had 200 million people over 60 in 1950; this will embedded as a part of the solution, as an enabler of population
increase to 1 billion by 2020 and 2 billion in 2050 [11]. Many healthiness. We do not yet know which.
156 Amalberti et al.

But we do know that if we continue on the present path, in which Priorities for system transformation: the
the focus is primarily on acute healthcare and UHC is not in place, perspective of the ISQua community
healthcare systems will become progressively unsuited to the popula-
To date, the actions taken are important and necessary but are not
tions they need to serve. Health systems will need to be transformed
yet sufficient. They represent the beginnings of the journey rather
in ways that support more preventative healthcare, primary and sec-
than the destination. Providing integrated care to all citizens, for any
ondary services and integrated care [22]. The current silo-oriented
age, requires radical changes to health and social care systems. The
structures, disjunctions between health and social systems and divi-
challenge is to redefine, rethink and re-orientate the vision of health-
sions between acute and community services represent major barriers
care; health, not defined by a series of episodes but, in terms of a
to progress. The task is to control costs, increase efficiencies, introduce
person’s health journey, an all-encompassing lifespan solution. To
and adapt new organisation structures and initiate new models of

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support this, needs-based research conducted in close collaboration
care, all supported by relevant policy frameworks, structural altera-
with knowledge users becomes important.
tions, change models and education of all involved [13, 23]. Reducing
We took the opportunity at the 2017 ISQua London conference
the amount of low-value care, including overdiagnosis, over prescrip-
to ask a panel of 50 world leaders in quality and safety to consider
tion and unnecessary or poor value clinical practices, is a key part of
the implications of an ageing population for healthcare systems and
this equation.
in particular for our current approach to safety and quality stan-
dards and principles. Members of the group ranged from policy-
makers and managers to quality improvement and patient safety
The response to date from healthcare and
officers, clinicians and patients and their representative groups. We
society asked them to prioritise potential initiatives to guide us in develop-
By the way of response to date, academic and community medicine, ing these twin positioning articles and to ensure that the issues
healthcare organisations, government and selected healthcare leaders addressed were genuine priorities in an international context
have begun the task of moving in four complementary directions: (Table 1).
The rise in digital capacities was seen as an essential part of the
• An ‘increase in awareness, training and competence’ in the care
solution but is not without its challenges. Standardisation and inte-
of older and frail people in all specialties, including preventive
gration of e-health platforms were seen as major issues. The work-
and personalised medicine, support for the role of caregivers and
shop considered that, although harnessing technology is critical,
innovations that specifically apply to the long-term care of the
emphasis should also be placed on education and developing new
elderly, including rehabilitation [1, 2].
standards for primary care professionals, patients and families. The
• ‘System-wide reform initiatives are underway’ to improve the
roles of patients and families are central to the delivery of many
quality of care whilst concurrently attempting to reduce and con-
forms of healthcare. Widespread consultation about the proposed
trol costs; this has been progressing for several decades, leading
and the co-creation of new forms of care was seen as critical.
to decreased hospital length of stay, with savings ideally reallo-
The London experts made further points in relation to systems
cated to rehabilitation, primary, preventative, mental health,
governance. Countries have not signalled a willingness to increase
community and home care [5, 6].
the proportion of GDP currently spent on health and social care. So,
• ‘Increased utilisation of information technology’. Electronic
there is a need for substantial reallocation of resources within health
health records, practice networks, telehealth, low cost mobiles
and social care systems, with a consequential risk of creating ‘win-
and widespread data applications can provide healthcare
ners’ and ‘losers’ whilst the realignment of funding takes place.
remotely, bolster physician–patient co-decision making, enhance
Finally, the group emphasised the interlinked nature of all these pri-
communication amongst the health and social care providers
orities and the need to consider these developments in a holistic
and support people at home for longer [7].
manner.
• ‘Reconsider the concept of retirement’. Many governments have
made changes to retirement ages, pensions, medical coverage
and insurance programmes, to reflect the reality of an ageing
population and the increased responsibilities of carers [24–26].
A reconfigured health and social care system
Some have in addition put long-term economic drivers in place The London priorities fall into two broad categories: first, the grow-
to prioritise the support for an ageing population [27–29]. ing desirability of keeping people psychologically and physically well

Table 1 Seven quality and safety priorities, ranked from the most to least urgent as seen by 50 world leaders at ISQua’s 2017 Pre-
conference Workshop on Massive Ageing in London, England

Priority 1 Write standards and principles to reflect the health trajectory with the emphasis on home and community as the primary location for
receiving care
Priority 2 Develop new governance and leadership structures to reflect the transformed health and social care system, including measures of
effectiveness and external evaluation
Priority 3 Adapt quality and safety principles to reflect the growing number of people with cognitive impairment living at home
Priority 4 Design quality and safety standards relevant to those living alone and smaller healthcare organisations located in isolated regions
Priority 5 Develop quality and safety standards and principles for information technology to reflect and anticipate the digital revolution
Priority 6 Conceptualise safety and quality differently to reflect the vision of health across the continuum and throughout the health journey. Orient
standards toward living longer and healthier
Priority 7 Adapt quality and safety principles within hospitals to reflect their responsibility for effective transitions and support for later care in
community settings
Part 1: nature of challenge • Health system reform 157

for as long as possible in the home setting and anticipating the learning and success, has multiple downstream consequences for
reforms needed to all parts of the health and social care systems. adverse event analysis, evaluation of risk, regulation and the
Second, the need for new systems of governance to energise and then accreditation processes.
monitor the evolving health and social care systems over the next 30 Existing standards, which tend to be disease or sector based, will
years. These two priorities echo other international consensus groups need to be gradually revised to reflect a much longer term health
and are supported by data from the WHO [1] and OECD [2], and social care perspective. We will also need to develop standards
amongst others. The ISQua group further developed a number of in areas where regulation and accreditation have previously been
additional points which broadened our perspectives on these issues. weak or absent. There are thousands of quality and safety standards
With respect to home care, professional roles and related disci- for acute care; in contrast, very few standards apply to population
plines (particularly in the psychological and social areas) need to be health and to home and community care. These standards will need

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enhanced. Expert teams providing care in the community will incorp- to be more flexible than institutional standards, reflecting the needs
orate a wider range of disciplines. Care teams may include specialist of those living independently and autonomously at home, managing
focus such as psychologists, behavioural therapists and consultant psy- their conditions with multiple variables impacting their health. This
chiatrists, to handle the assessment and treatment of the growing num- in turn means we have to develop new indicators for safety and
ber of cognitively impaired patients. Nurses, other therapists, families quality across settings, which more closely reflect the lives and
and carers will take on new responsibilities. Carers, whether paid or healthcare of those ageing well, or frail people with complex health
unpaid, will need to be sufficiently skilled; otherwise, we will promote problems.
a cycle of insufficient care and continual readmission. Leaders of regulatory organisations and related bodies will have
Governance of health and social care systems resides at national to adapt to new approaches and potentially to the problems of set-
levels, regional levels and at local levels. Local governance, close to ting standards in a time of rapid change and considerable systems
the frontlines of care, will be a particularly critical guarantor of turbulence. In a time of transformative change, it may not be feas-
safety and quality standards, both during and after the transform- ible for organisations to meet all newly established standards and,
ation of services. Although the whole system needs to be trans- therefore, allowance may need to be made for individuals and orga-
formed, this does not mean that all changes will occur through nisations whilst they adapt to and embed new standards. Rapid
large-scale top-down reorganisation [30]. The changes are more innovation with new technology and techniques can create better
likely to occur initially at a local level and increase in scale, such as care but can lead to new adverse events; what was acceptable five
a regional healthcare initiative that broadens out to the national years ago may be an adverse event today. In healthcare, more-so
level [5]. We can only move the agenda forward if we truly engage than many other industries, patient safety is a moving target [36].
local communities, patients, families and all relevant stakeholders.

Conclusion
Re-conceptualising safety and quality for We need therefore to develop systems that reflect quality of care fol-
personal health journeys within the new health lowing the person’s health journey throughout life. This necessitates
and social care systems a fundamental re-conceptualisation of quality and safety to reflect
this new reality, with many implications for standards and
Healthcare systems will clearly need to transition from a primarily
accreditation.
event-focused, acute system to a longitudinal, life-course perspective
We have outlined the scope of the challenge and proposed
including the measurement of improvement. The central aim of
broad-based systems changes. In the second article in this two-part
health and social care will shift towards preventing disease and ill-
contribution, we will move to examine in more depth the kinds of
ness and extending the quality of life of people over the long term
standards needed in the future and the consequences a changing
rather than resolving short-term acute crises. Different solutions will
health system poses for the design of new, more flexible standards—
be needed for low-, middle- and high-income settings, based on
and vice versa.
need, context, culture and resource availability.
These changes will have profound consequences for how we con-
ceptualise safety and quality. For instance, safety will no longer be
Acknowledgements
described in terms of episodic risk suppression but in terms of control-
ling acceptable risk over time in both the short term and the long term. We are grateful to Ms Claire Boyling and Ms Meagan Warwick for their edi-
torial assistance with this manuscript. We appreciate, too, the work of the
The calculation of the risks and benefits of care will need to move
representatives of countries attending our consultations at the ISQua meetings
from an assessment of a single episode to an evaluation reflecting mul-
over the years.
tiple episodes alongside their interactions and social consequences.
This long-term perspective also has consequences for the analysis of
safety and adverse events [31]. Patient and family inputs and perspec-
Funding
tives are increasingly required to identify adverse events and enhance
analysis and inclusion of extensive patient information across the entire J.B. is the Professor of Health Systems Research and Founding Director of the
Australian Institute of Health Innovation at Macquarie University, Sydney,
health and social system with which the person has interacted.
Australia. This work was supported by the Australian Institute of Health
We must also incorporate the lessons of resilient healthcare, giv-
Innovation, which receives 80% of its core funding from category one, peer-
ing weight to how safety is achieved, both by individuals and sys-
reviewed grants, chiefly, the National Health and Medical Research Council
tems, and to how it is lost [32–35]. This suggests enhanced (NHMRC) and Australian Research Council (ARC) funding, which includes,
capacities in learning from the successes of everyday care and of most recently, the NHMRC Partnership Grant for Health Systems
rapid detection of problems, including in the home. The evolution of Sustainability (ID: 9100002). Funding support from Macquarie University is
safety risk suppression to risk management, with a parallel focus on gratefully acknowledged.
158 Amalberti et al.

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