Paddling against the stream- dealing with the ‘prevention paradox’

Paper of the Week: 20th February 2020

This week’s blog is brought to you by: Dr Joe McManners

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Full reference and title from the journal:

Paddling against the stream- dealing with the ‘prevention paradox’, link to paper: click here

Authors conclusion

ACOs faced significant difficulties in integrating social services with medical care. First, the ACOs were frequently “flying blind,” lacking data on both their patients’ social needs and the capabilities of potential community partners. Additionally, partnerships between ACOs and community-based organizations were critical but were only in the early stages of development. Innovation was constrained by ACOs’ difficulties in determining how best to approach return on investment, given shorter funding cycles and longer time horizons to see returns on social determinants investments. Policies that could facilitate the integration of social determinants include providing sustainable funding, implementing local and regional networking initiatives to facilitate partnership development, and developing standardized data on community-based organizations’ services and quality to aid providers that seek partners.

3V bottom line

To get best outcomes for resources health systems need to be able to invest in the ‘up-stream’ causes of health problems. These may be the social determinants of health, or preventative health interventions (primary or secondary). The organization of systems (particularly financing systems) does not help in reallocating resources across time and organization. Collaborative networks with shared resources working with a culture of shared responsibility would help this problem.

3VH – Implications for value

We know that significant drivers of poor health are down to social factors, the paper quotes 40-90%.

To address the results of poor health, particularly the cost of it, we should be intervening ‘up-stream’. But typically we don’t, instead using the bulk of resources (workforce time as well as money) on secondary and tertiary care.

Truly looking at population health, and ‘programme budgets’ for population groups, should mean allocating resources towards services that give the best value. If providing transport costs to access community groups promotes independence, reduces ill health and is better value than waiting for hospital admission, then we should do. But we generally do not do this.

‘Integrated care’, and the attempts to facilitate this through different means such ‘Accountable Care Organisations’ in the US, ‘Integrated Care Systems’ in England etc, should if they are working correctly address this problem.

If the organisations or systems are integrated, they should be able to look at how to deliver the best value outcomes for their populations with their resources, agnostic to the services or institutions, be they traditional medical (hospitals, General Practice) or socially orientated (housing, transport, public health, social care).

This paper of week looks at why systems struggle with this, to slightly mix metaphors, why they are ‘paddling’ upstream against the current, ‘with a small paddle’. The lessons drawn are US specific but applicable to any system trying to achieve these ends.

The paper looks at progress in ‘integrating medical and social services’. By this they mean Accountable Care Organisations (ACOs) partnering and investing services to address social determinants of health, for example transportation, housing and more. The research qualitative, based on was interviews and visits with ACOs that were known to be more progressive in this area.

‘We found three major themes in our data related to why implementation of social service and medical care integration was so challenging for organizations that were committed to that integration and on the leading edge of integration efforts. First, the ACOs had few data related to social needs to use in making decisions. Second, partnerships between ACOs and community-based organizations were critical to developing programs but were often difficult to develop. Finally, implementation of innovations to address social needs was constrained by ACOs’ difficulties in determining how best to approach return on investment (ROI), given shorter funding cycles and longer time horizons to see returns on social determinants investments. We next explore each of these. ‘

Data availability, expressed as ‘flying blind’, is a familiar problem to the UK, although the availability of public health/’social needs’ data may be better here. Partnership working may also not be as much of a problem in the UK as described as in the paper, but clearly it is variable and needs work.

The most familiar problem identified is the third: the short-term funding cycles and the difficulty of investing ‘upstream’, with a nervousness of impact and difficulty to prove return on investment. This is the ‘counter-factual’ problem- it is difficult to show that something didn’t happen.

This last point is also critical if we are to crack the problem of (re)allocating resources to improve value. If organisational bottom lines and current budget silos remain the focus it will be harder to reduce to invest in preventive programmes and services:

‘Moreover, in the absence of robust program evaluation and ROI analysis, it will be difficult for ACOs to make a business case to continue early work on social service integration. Len Nichols and Lauren Taylor5 suggest that instead of evaluating social determinants investments in traditional ROI models, such investments should be understood as public goods better suited to a collaborative approach to financing ‘

‘Collaborative approach to financing’ would seem a way to address this sizeable problem, but is only touched upon here. The authors conclude that despite the ACOs interviewed were chosen as being ‘cutting edge’, their leaders recognised the need to address social determinants and there were clear needs, there was not a lot being done.

The problems described are common to health systems, the move towards Integrated Systems in England, and similar longer standing arrangements in the devolved nations, represent an opportunity here but they need to prioritise this problem. The shared and collaborative management of resources needs to happen at a system level, with a shared understanding and agreement of how to use the resources to achieve agreed population health outcomes.


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