Four factors to deal with long-term health conditions
02 October 2018
By Graeme Currie
The headlines in the mainstream media over the 2017-18 winter highlighted the scale of the challenge faced by the UK's National Health Service (NHS).
During a difficult flu season, accident and emergency services across the country were under severe and sustained pressure. Ambulances queued, patients waited on trolleys in corridors due to a lack of beds, waiting times stretched to six hours and beyond. Terms like "crisis", "disaster", and "breaking point" became synonymous with the state of the nation's healthcare provision.
Like many other healthcare systems across the world the NHS is facing a set of factors that make the delivery of effective affordable healthcare far more difficult than in the past.
A population that is both growing in numbers and living much longer, technological innovation that increases the healthcare options available, rising costs of treatment in many cases coupled with constrained resources, all of these factors mean that significant change is required to ensure a healthy NHS.
There are frequent calls for wholesale structural change, indeed major restructuring in order to make the NHS fit for the future seems to be permanently under discussion.
Rather than consider the transformation of the NHS in its entirety, though, a topic which could easily fill several books rather than a brief article, I want to focus on a specific area of care that presents one of the most difficult challenges for healthcare systems in developed nations: the way that we deal with long-term conditions.
Here I am referring both to conditions that may be physical such as diabetes, ulcerative colitis, or obesity, for example, and also some that are more specifically mental health related, such as dementia. These long-term conditions affect all age ranges, but many disproportionally affect older people.
The negative impact of poorly managed long-term conditions is huge. Care of some 15 million people with long-term conditions consumes 70 per cent of the NHS budget in England, that is £77 billion annually, as well as £10.9 billion of the £15.5 billion spent on social care in England.
Without the appropriate action on long-term conditions, for example, you will continue to get unnecessary acute admissions. Patients end up at Accident and Emergency (A&E), then being discharged unsafely back into the community, and then returning to A&E. It is a revolving door and unsustainable.
Yet, attention to a few distinct measures would make a considerable difference to the effectiveness of dealing with long-term conditions and, in doing so, to the overall effectiveness of the NHS.
Of course structural reform of the NHS is nothing new. Yet, despite the best efforts of policymakers the provision of care for long-term conditions remains inadequate. Much of the structural reform thus far, notwithstanding some recent reforms, has focused predominately on healthcare.
However, long-term conditions offer a different set of challenges from situations that take up a finite, short-term period of time, that might involve, for example, diagnosis, surgery, possibly a brief hospital stay and then being discharged home to recover fully. Instead, long-term conditions involve discontinuous intervention, in and out of different care settings, and across domain boundaries.
Someone might have a more preventative problem that could be dealt with in the community by the GP, around lifestyle and diet, for example. They may have an associated mental health problem. They may have issues relating to social care - a housing problem, perhaps. An education setting may be involved, given that many mental health issues increasingly affect young people, like eating disorders.
When an older person is discharged from hospital, there is often nowhere for them to go because it is not possible to put a social care package in place. You get admission problems due to 'bed blocking' but arguably these are social care rather than healthcare problems.
Long-term conditions need to be managed effectively by the different agencies that are involved. Reform has to be seen at an integrated system level, extending beyond just healthcare.
Unfortunately, though, measures such as separating the commissioners of healthcare from the providers of healthcare in Clinical Commissioning Groups (CCGs), following the Health and Social Care Act in 2012, or the increasingly competitive environment and marketisation of health and social care generally, have tended to fracture and fragment rather than integrate services.
The UK Government recognises many of the issues and has taken steps through various initiatives to try and address some of them. For example, it has supplemented markets with network arrangements, trying to encourage networks of care.
However, there has been a failure to align structural reform with pre-existing process and practice on the ground. If these networks are imposed in a way that ignores pre-existing collaboration across providers, which they often are, then they tend to fail. Children's care networks, such as that around paediatric nephrology, are a good example of this.
Elsewhere you have initiatives, such as that in Greater Manchester, where health and social care budgets have been put together and devolved to the local level to allow decisions about integrating care across health and social domains to be made locally.
An issue here, however, is the lack of additional money to help bring about the change. Merely combining and devolving budgets will not necessarily produce better integrated care because there are vested interests in the system.
Hospitals need to discharge people more effectively and safely if they want to solve their bed blocking problem. But, in reality, the hospital management may not easily be persuaded to hand over a proportion of its budget for social care.
And then there are Sustainability Transformation Plans (STPs), a system level approach to integrated care where providers and commissioners are brought together, including health, social care and other agencies, to devise an appropriate solution - it is "an accountable care system".
STPs are promising and gathering pace, but politics still gets in the way. The outcome from STP discussions may be that it makes sense to close, move, or concentrate certain services in a particular hospital.
However, resistance from local communities, and negative reports in the media, often means that the backlash can prevent progress. Hospitals are keen to retain prime position in the system, which commonly acts against integration.
What has been conspicuously lacking from the NHS reform initiatives is a focus on the processes that are needed in order to make any structural reforms a success. Structural reform on its own is not enough.
We need to think about building capacity in the system to make integration work at a process level. This is where organisational management expertise becomes invaluable.
There are four process issues, in particular, that are worth highlighting where action is possible and would make a significant difference: knowledge mobilisation; distributed leadership and accountability; collaborative strategy; and workforce development (each of these areas has been the subject of in-depth research within the Organising Healthcare Research Network, see further reading list below).
1 Mobilising knowledge
To begin with, the provision of first-class integrated care for long-term conditions is not possible without the mobilisation of knowledge across organisational and professional boundaries.
Unfortunately, many people seem to equate the concept of knowledge mobilisation with the implementation of an IT system that facilitates data sharing. And that is part of the problem.
Knowledge is different from data. Knowledge is embedded in practice. This is about ensuring that the different professionals in organisations understand each other's perspective and are able to broker knowledge to each other in real time, in ways that make sense to the other party.
2 Making distributed leadership and accountability work
Work needs to be done on aligning performance. Typically, under the existing performance management systems different parts of the organisation point in different directions with respect to the performance indicators that they need to meet.
A classic example is targeted waiting times for A&E. If your job is likely to be at risk for not hitting a target you might, as a hospital manager, keep ambulances waiting outside A&E and not count them as coming into the hospital until you know that you can hit your target.
However, somebody in the ambulance trust will have their job linked to time targets for the ambulance service that is being provided. If the ambulances are stuck waiting outside at the hospital then there will not be enough ambulances to respond to calls.
Professionals will orientate towards their discrete professional indicators. A lack of performance indicators aligned to delivery of the overall service across domains, coupled with intense scrutiny and cost and quality pressures, creates incentives for organisations, or parts of an organisation, to act in dysfunctional ways that lead to inefficient and ineffective delivery of care.
It encourages gaming and fragmentation of the system. Instead we need broader, more sophisticated performance indicators that relate to overall service provision over the long term, rather than just the narrow and very direct performance indicators, such as waiting times at A&E.
In turn this will create the conditions to allow leadership to be distributed across organisations and professions, rather than having hospital medical leadership as the dominant force, for example. At the same time this must be supported by collective responsibility.
At present there tends to be a patchwork of discrete accountabilities, with each individual in the care provision chain feeling that their duty to the patient is discharged after their personal interaction with the patient.
Accountability is important, but we need to encourage a sense of collective responsibility for care of the patient over the longer term, focusing on long-term overall outcomes, particularly where care is discontinuous.
3 Collaborative strategies
In the current fragmented system individual service providers, whether in health, social care, education or another domain, develop their own strategies in isolation at an organisational level.
One reason that they do this, for example, is because marketisation and competition incentivises organisations to seek competitive advantage over other potential providers as they seek to sustain and develop the business.
However, although strategy needs to take place at an individual level, it also needs to take place in the context of the care ecosystem.
So while all these organisations have a local population to provide for, they need to engage in a strategy that is collaborative and that takes account of the other. There is some progress on this measure via STPs. Nevertheless, the hospital is always a disproportionally powerful player.
Similarly, within and across organisations, managerial and professional conflict must be mediated in order to encourage those in managerial and professional roles to work collaboratively towards shared objectives.
For example, there is a need to bring policy and delivery together. Otherwise, policy is developed without any reference to pre-existing process and practice.
Thus, we need to ensure that policymakers, and not just executives but also middle level managers with clinical experience, engage with those who are delivering the care.
4 Workforce development
Delivering integrated care requires a multi-disciplinary delivery system. It needs a local level multi-disciplinary team that pulls in people from different organisations and professions to address patients with long-term needs.
In addition, there should be a focus on hybrid roles - professionals who move into managerial roles. This ensures that there is both the knowledge about what is required in clinical and social care, for example, but also that there is a good understanding about the resources needed for implementation in the particular local context.
The answer is not simply providing more doctors or nurses, either, something that is likely to take many years to filter through to improvements. But instead, finding ways to enable doctors, nurses, social workers and other key professionals that deal with long-term conditions, to become competent managers.
Here it is worth acknowledging that workforce development is perhaps one element of process reform that the Government has paid attention to. This can be seen in initiatives such as the NHS Leadership Academy initiative.
It is clear then, that while structural reform of the NHS is inevitable, it is unlikely to be effective unless it is accompanied by the necessary process reform.
Furthermore, while reform of the NHS is a huge endeavour, there is much to be said for focusing on long-term conditions given its prevalence among the population and associated costs. Here, substantial improvements could be made by concentrating on four critical areas of process reform that support structural reform.
In addition, besides reducing the cost burden of mismanaging the treatment of long-term conditions, addressing these areas will undoubtedly encourage practices that are useful in NHS reform elsewhere.
The introduction of market competition into national healthcare systems is a global trend. The question being not whether healthcare systems will be marketised but rather the extent to which they will be marketised.
A major challenge, therefore, will be how to optimise both competition and integration across and within domains, as intuitively the two seem to counter each other.
But by focusing on long-term conditions it will be possible to develop practices that promote better integration of all parts of the NHS family, regardless of whether they are private sector firms, social enterprises, public sector organisations or from the voluntary sector.
Currie, G. & Spyridonidis, D. (2018 forthcoming). Sharing leadership for diffusion of innovation in professionalized settings. Human Relations.
Wiedner, R., Barrett, M., Oborn, E. (2017). The emergence of change in unexpected places: Resourcing across organizational practices in strategic change. Academy of Management Journal, 60, pp. 823-854.
Currie, G., Burgess, N., Hayton, J. (2015). HR practices and knowledge brokering by hybrid middle managers in hospital settings: the influence of professional hierarchy. Human Resource Management, Vol 54, No 5, pp. 793-812.