Command and control not the way to integrated care
Jodeme Goldhar, Executive Lead, Strategy & Innovation
It’s a good thing the meeting room at the Change Foundation has big windows, considering the rate at which Geoff Huggins was throwing accepted wisdom out of them during his recent visit. Huggins is director for health and social care integration in Scotland. He described his role as one of strategic and policy responsibility — but added “both of those are really quite outdated concepts.” So that was the first idea of how to bring about change that got tossed.
Huggins was the second health leader from the United Kingdom to speak on integrating care at a series organized by The Change Foundation with partners from the University of Toronto — the Institute of Health Policy Management and Evaluation, the Health System Performance Research Network, and the Dalla Lana School of Public Health. We’re sharing ideas from these important conversations more broadly through blog posts, to be followed by more in-depth coverage in Healthcare Quarterly in the new year.
Scotland officially launched integrated health and social care with legislation that came into effect in April 2016. It created 32 “Integration Authorities,” (similar to LHIN sub-regions in Ontario) and put heavy emphasis on local action for local needs. (More detail on Scotland’s integrated approach to health and social care is available at: http://www.gov.scot/Topics/Health/Policy/Health-Social-Care-Integration)
Huggins told the meeting the move to integration was driven by the need to rethink a healthcare system that was unsustainable in the face of people living longer, even into very old age, often with chronic conditions.
Historically, he told us, Scotland would have taken a highly centralized approach to the issue.
“Our previous model was to publish guidance, to have budgets, to have projects…and to set targets, then expect the system, by doing all those things which we had centrally mandated, would produce benefits. That model doesn’t seem to be working.”
There went another piece of accepted wisdom out the window — that centralized policy and planning, firmly mandated from on high and carefully tracked and measured, is the essence of keeping healthcare sustainable.
Scotland is also bucking current thought on standardization. Where Ontario and most other jurisdictions strive to scale up good ideas and spread them, Huggins embraces variation. There is no guarantee that patients in each Integration Authority will get the same services as patients elsewhere; in a country with 300 per cent variation in hospitalization rates for seniors, one size will definitely not fit all.
Instead, Scotland set nine health and social care goals for the country, then asked each locality what it needed to achieve those goals, in the belief the government’s role is to remove barriers and enable change, not to dictate how goals are to be achieved. Each locality’s different mix of providers and population needs local solutions backed by government support.
Now, health officials are free to act locally — although not in isolation. “What we expect is that you know what everybody else is doing, how people are approaching the same problem, you know what the evidence base says, and you find the best solution for your area,” Huggins explained. “Whether it’s something somebody else has done, or something you build yourself, you then track it against outcomes and you evaluate it appropriately.”
It’s a big change for governments, Huggins said. They like holding on to power, telling people what to do and how to do it, because being in charge makes them look committed and effective, but it comes at a price.
“At the point where we become involved in being directive and controlling and monitoring, then we begin to suck the life out of people,” he said. “All of this reduces the ability of the system to do the things it needs to do. We have great people — we need to treat them as great people.”
Most healthcare systems try to control any change that occurs, so it was clearly energizing for Huggins’ audience to hear a high-up official of another country’s healthcare bureaucracy say categorically that relinquishing control and learning to support people making changes yields greater improvement than central planning.
In fact, when Huggins remarked “The role of government is to promote that capability and to support that system rather than to direct that system and tell it what it needs to do,” he was echoing the words of the speaker at the first meeting, Chris Ham, who said the goal of government and planning bodies in integrating healthcare should be “do no harm.”
There were other echoes as well. Both Ham and Huggins said integration must focus on people, not organizations. And both noted that integration requires surrendering power, and acting altruistically to put the patient or the team or the system ahead of the self, or the organization, or the professional silo.
It can be done — and according to Huggins works best on the front line. “At the point where you give teams of people the opportunity to work together and differently, they will generally find good and sensible things to do and our challenge is to be out of the way and not try to overly manage it.”