integrated care

Live webinar interview with Helen Bevan and Cathy Fooks

On November 22 at 2 pm, Cathy Fooks, CEO of The Change Foundation in Ontario, and Helen Bevan, Chief Transformation Officer of the National Health Service – Horizon Team in the U.K., will host a webinar on how to lead and support change in Ontario’s healthcare system. 

Providing a mix of local and international perspectives, Cathy and Helen will share their learnings and insights on how their respective organizations have evolved to support change and meaningful improvement within their health care systems. 

Are you interested in learning about small and large scale change? How people, organizations and communities can lead change? What conditions need to be in place for meaningful change?

Join us for this webinar hosted by two esteemed health system leaders.

Register now: http://bit.ly/2PVFp1O

Integrating the caregiver voice: Reflections on the IFIC Conference

Jodeme Goldhar, Executive Lead, Strategy and Innovation

In May 2018, Carole Ann Alloway, a family caregiver, and I partnered to develop and present a keynote address at the International Foundation for Integrated Care (IFIC) annual conference in Utrecht, The Netherlands. A few months after our presentation – Transformation through integration: The Answer is With Patients and Their Families – I asked Carole Ann to reflect on her experience.   

Jodeme:

First of all, Carole Ann, it was an honour to have the opportunity to co-present with you in Utrecht. It truly was a collaborative experience. What was your reaction when you were first asked to co-present at the IFIC conference?

Carole Ann:

It was overwhelming at first because there were so many things I wanted to say. But to get the most value for the audience, I realized we had to choose a key focus. With The Change Foundation’s knowledge, background and guidance, we started brainstorming our message — that the caregiver voice must underpin integration — and the best way to get it across. 

Jodeme:

We know that health systems around the world see integration as a major opportunity for transformation. But perspectives on how to go about this transformation vary. Can you share how we approached this?

Carole Ann:

Well, from my point of view, and from The Change Foundation’s point of view, patients and caregivers need to be partners every step of the way as this transformation happens.

Our goal for this presentation was to be provocative and inspire people to truly understand that patients and caregivers are the experts on the physical, emotional and spiritual aspects of their lives. It’s important for healthcare professionals, researchers and policymakers to recognize their value, and to work in partnership with them.IFIC slide

We used this idea, together with The Change Foundation’s expertise on integration and system change around the world, to create a storyline. Within this storyline, we thought about how best to build and think about our presentation to address the topic from many different angles: the system, research, policy and everyday practice.

It was a pleasure working as a true collaborator on this presentation with you.  

Jodeme

On that note, we know the importance of working in partnership with caregivers. As a caregiver involved in this project with us, how did you feel about our partnership?

Carole Ann

I felt heard and valued sharing my lived experience. Together, we were able to help get my message across in a way the audience would understand. I didn’t want to just tell my story, I wanted people to leave with a sense of urgency to truly reflect on their own work habits, cultures and see how they could respond to what was possible by including their own patients and caregivers in the decision-making process and as a member of the team.

Jodeme

It was important to us, as we made this presentation, to give the audience a real sense of the caregiver experience. How did you approach this? 

Carole Ann

I didn’t just give a play-by-play of my caregiver experience. I also told the story of what could have been. I imagined my experience as if my husband’s care had been integrated and if the team was focused on what’s most important to me and my husband. I shared my reflections on the problems that could have been avoided, healthcare dollars saved, outcomes that could have been improved, as well as how the experience for my husband and I would have been so much better. I also believe if my journey had played out in this imaginary way, healthcare professionals would have had more job satisfaction.

It was important to me that the audience leave knowing that it isn’t hard to do. The answer is simple and everyone has a role to play in making a difference, and could start tomorrow. 

For more simple ideas that can make a big difference, watch the Caregivers Wishlist videos created by The Change Foundation in partnership with Carole Ann.

Leadership is key, and other lessons learned from the UK’s Helen Bevan

Cathy Fooks, President & CEO

The way to get stronger is to let go of power, according to what Helen Bevan of England’s National Health System told a group of leaders in Ontario health care at The Change Foundation recently.

That seemingly paradoxical notion made sense to those of us gathered there once we grasped Bevan’s argument that only by shifting to different kinds of power, finding it in the hands of different people and using it in different ways will health systems be sustainable and provide the care patients deserve.

Bevan, the Chief Transformation Officer for the National Health Service (NHS) was the third speaker in a series on integrating care 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. The goal is to create a learning lab of ideas that will help leaders in Ontario integrate care, and we’re sharing insights from these important conversations more broadly through blog posts, to be followed by more in-depth articles in Healthcare Quarterly.

Bevan, who gave her presentation by video link, had three lessons about introducing large-scale change for the three dozen people watching her from The Change Foundation’s board room. The first was on the importance of the language and narratives we use when proposing change; the second, on shifting power and the new approach to leadership that requires; the third was on the choice between structure and agency as the means of bringing about change.

Bevan did not shy away from using the example of a big mistake the NHS made in the use of language for their current redesign. Their choice of the phrase “accountable care organization,” originally used in Obamacare, to describe new local partnerships of health and social services triggered an immediate backlash. Critics warned of “American-style” healthcare and privatization. Some of their work was put on hold as a result and the new name will be integrated care organizations.

Bevan said the incident was a compelling reminder of something she had long known — that to win support for large-scale change, you need to connect with people’s values and emotions, in this case through language and labels that are meaningful for people.

“You know if we had kind of stood back and thought about it, we should never have used the labelling ACO or accountable care, because it’s got connotations around U.S. health care privatization,” Bevan said, adding “You will smile at this, but the new labelling — rather than being an accountable care organization — will be an integrated care organization.”

I was more inclined to sigh than smile, because the incident was such a prime example of what happens when we don’t involve the public in what we’re doing. That’s a failure we’re often guilty of in health care, whether it’s in how we treat one individual or family, or responding to broader public needs.

The second lesson Bevan offered the meeting was that integrated care requires a different approach to leadership. She began by talking about old power, the norm in hierarchical organizations, including health care. She defined it as positional authority, based on commands and focused on meeting goals and standards. New power, by contrast, is based on collaborative relationships and the sharing of goals and ideas.

2 kinds of power

Old power clearly leaves little room for public input, or even the involvement of staff and providers. Moreover, since early efforts to reform the NHS actually put health organizations in competition with each other, moving to new power will require big shifts in leadership thinking, but they are essential.

“There can’t be winners and losers,” Bevan said. “The system has got to win.” Integration will only succeed, she added, if it’s built on relationships based on trust, which make it possible for people at all levels to work together to bring about change.

Bevan’s third lesson was that system-wide change is accomplished not only by structural means such as rewriting rules, setting new standards, or imposing top-down plans for restructuring, but also through agency (empowering people and groups to make positive changes).

Public sector reform over the past 20 years has focused on structural mechanisms, but giving people (or groups) agency to make changes is increasingly popular around the world. It’s faster, for one thing. Also, it brings many more minds to bear on an issue — ideally, the minds of people who work on or near the frontlines and know what the real issues are and what solutions make the most sense.

“We know that diverse groups of people will consistently make better decisions than small groups of senior leaders or experts,” Bevan said. “If we start doing things in different ways, if we start opening up our decision-making processes and we have different kinds of conversations with people, I think we can almost talk ourselves and think ourselves into different ways of doing things.”

This was an idea more likely to draw a smile than a sigh from me — because it shows how patients and families, as well as providers, can be change agents, if systems welcome and encourage them. Bevan called it “building power to make a difference,” and it’s done, she told us, by activating people, by improving their ability to make choices and building capability. If we do that, she said, we can build leaders everywhere.

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.”

Integrated care: reach across, don’t dictate down

Cathy Fooks, President & CEO

There’s broad agreement that integrated healthcare serves patients better, eases the burden on caregivers and improves system accountability and efficiency. There are excellent examples of it in many countries and multiple efforts to create it here in Canada. Yet progress toward it remains frustratingly slow.

For that reason, The Change Foundation is working 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 — to organize a series of discussions on accelerating integrated care.

Our idea was to create a kind of learning lab: over the meetings, the same group of Ontario health-system leaders would hear from experts on how integration is developing in other countries. Their responses to the first discussion would shape the second, and the third would build on that. We’ll have more complete articles coming out about the discussions, but I wanted to share briefly the gist of our September meeting.

Chris Ham, chief executive of England’s King’s Fund think tank, was our guest speaker at the first session. He opened his remarks by showing a video the King’s Fund uses to illustrate the concept of integrated care. It’s a useful primer, but by now the concepts of integrated care are well known, without being well-used.

That failure to spread, according to Ham, is because the vast majority of attempts to integrate care go about it the wrong way. Successful integrated care, he said, is fundamentally about people and their families and carers—how we can best meet their needs and how we can give them the skills required to focus on relationships. Our efforts tend to flounder because we forget that, and focus our energies on institutions, professions and jurisdictions, as Ham illustrated in this slide: 

Challanges slides_the kings fund

It was easy to recognize the point Ham’s slide was illustrating: we’ve all been part of the strategizing and planning the column of technical challenges represents. Our efforts to integrate healthcare often, perhaps usually, boil down to debates over affordability and territory.

In a strongly centralized, government-controlled system, that’s no surprise. Healthcare is structured around budgets and institutions. But that is Ham’s point: it should be about people. People are not technical challenges. And that’s why successful integration shifts the focus to the second column, relational challenges.

That simple list was clearly revelatory for the people at the meeting. The idea that we need to focus on systems and collaboration to transform healthcare is not new, of course. What caught people’s attention was Ham’s firm belief that government needs to “stay out of the way” and let local groups draw on and build relationships in order to make care work for the people in their area. More specifically, government should create the right environment to allow local organizations to come up with the right solutions for them based on their populations, culture and resources.

Ham’s recipe for success, based on what he’s seen so far, suggests integrated care cannot be introduced in a system-wide, top-down way. The best efforts he knows start small scale, in neighbourhoods or communities, perhaps serving as many as 30,000 to 50,000 people. Small enough, in any case, that providers are used to working together, and building links among services is not too unwieldy.

Ham’s first example of that small-scale personal approach was the remarkable shift to integrated care in the English retirement area of Torbay. Change there was triggered by a failing grade given to the town’s social services system by government inspectors, he said, but the change itself was not dictated by government; rather, local healthcare providers, led by family doctors, got together to improve their patients’ lives.

He also described how the District Health Board for Canterbury, the region surrounding Christchurch on New Zealand’s South Island, undertook radical changes to its care services beginning in 2007, when demand on the system was mounting to the point where it looked unsustainable.

Key to that success, Ham said, was Canterbury’s close-knit community, where people already knew and trusted each other. But it was also about true and meaningful engagement of those who would have to implement the change at the frontlines. He believes real change cannot be dictated or transactional — it must be bottom up and developed at the person-to-person level. I’d add that it must also involve patients and caregivers to be meaningful, which is an aspect of engagement Ham admits has often been neglected.

Ham added a caution as he described these successful examples of integrated care. Because it depends on relationships and local community reality, he said, there is no single right way to do it, and one community’s successful model cannot simply be grafted onto another community. We should not look for shortcuts.

WHAT’S BEING SAID

All three hospitals in our first case studies report understood the power of stories to unite patients, families and professionals & remind them of the reasons they want to improve care. Learn more about the hospitals profiled in the case studies: bit.ly/2Stemsl pic.twitter.com/qXkJiPW1ep