Coping With More People With More Illness. Part 1 - The Nature of The Challenge and The Implications For Safety and Quality
Coping With More People With More Illness. Part 1 - The Nature of The Challenge and The Implications For Safety and Quality
Coping With More People With More Illness. Part 1 - The Nature of The Challenge and The Implications For Safety and Quality
doi: 10.1093/intqhc/mzy235
Advance Access Publication Date: 22 November 2018
Perspectives on Quality
Perspectives on Quality
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
© The Author(s) 2018. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved.
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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
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
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
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.