Paper of the Week: 30th January 2020
This week’s blog is brought to you by: Dr Joe McManners
Full reference and title from the journal:
Managing the performance of general practitioners and specialists referral networks: A system for evaluating the heart failure pathway.
SabinaNutiaFrancescaFerréaChiaraSeghieriaElisaForesiaTherese A.Stukelb Health Policy Volume 124, Issue 1, January 2020, Pages 44-51
Web link to paper
https://www.sciencedirect.com/science/article/pii/S0168851019302581
Authors conclusion
The aim of this paper is to identify and evaluate the performance of naturally occurring networks of GP’s and hospital-based specialists providing care for congestive heart failure (CHF) patients in Tuscany, Italy. They demonstrate the existence of informal links between GP’s and hospitals based on patterns of patient flow. An integrated approach to evaluation and performance management that considers the naturally occurring links between professionals working in different settings may enable more efficient, integrated care and quality improvements.
3V bottom line
If healthcare systems are to enter the ‘network century’, there are a number of changes that need to be made:
- Clear professional networks based around patient populations
- Access to meaningful data to measure outcomes
- Accountability of the network to achieve the evidence based outcomes
- Public visibility of the outcomes and resource
- Network control of resources
3VH – Implications for value
If the 20th century can be thought of as the age of bureaucracies and hierarchies, the 21st century is looking like the century of networks. Complex systems such as health systems are hard to manage by a traditional hierarchical structure with bureaucratic mechanisms, organising around natural networks maybe more effective, but how can they be made accountable and manage resources?
In this paper the authors demonstrate the existent of mainly informal clinical networks around patients with congestive heart failure (CHF) in Tuscany. These networks span primary and secondary care and have developed ‘organically’ rather than through structural bureaucracy.
The authors found that the quality of care provided by these networks and the outcomes are variable. Despite this, considering these networks as almost an accountable delivery team is a move forward as they reflect the need of patients with chronic conditions to have an integrated service, and they are a way of breaking down the barrier between primary and secondary care.
We have described ‘2D care’ and ‘3D’ care. 2D care is institutionally based and is seen in the historic divide between primary and secondary care. 3D care is a much more population and patient focused way of organising healthcare, as it bases services around the need of a population and the patients within. Considering clinical networks centred around subgroups of the population rather than institutions for CHF is 3D care.
In the paper, Nuti et al describe how improved coordination of care across organisational ‘silos’ has been shown to reduce deaths, reduce hospital admissions, improve quality of care and improve sustainability of health services. Yet despite this, communication and integration is limited and critically organisations are managed and held accountable by performance frameworks that encourage internal targets and do not encourage collaboration and patient centred outcomes.
The authors found that outcomes of the 38 ‘network’s examined are highly variable: three fold variation in post admission follow up (28%-87%), three fold variation in 30 day post admission death rate (3.8%-16.8%). This is not surprising considering that the networks are informal and these outcomes are not managed across networks. The variation is a ‘symptom’ of care not be organised and funded towards achieving patient outcomes, rather than organisational priorities. The NHS in the UK shows similar patterns.
The authors conclude that:
‘From a health system perspective, several features should be redesigned to incentivize and optimize integration: funding, regulatory mechanisms, management systems such as performance evaluation tools, and financial and human resources management systems. In some healthcare systems, including the Italian, professionals lack commonly defined objectives, information systems capable of following the patient across different care settings, and mechanisms of joint accountability to monitor outcomes and appropriateness of care’.
They point out that publically available performance measures would allow professionals to compare themselves and ‘compete’ for better outcomes, and be accountable to the public.
To be able to make meaningful changes to the outcomes the networks would also need to manage the resources (money, workforce, time, carbon, leadership priorities).
If healthcare systems are to enter the ‘network century’, therefore there are a number of changes that need to be made:
- Clear professional networks based around patient populations
- Access to meaningful data to measure outcomes
- Accountability of the network to achieve the evidence based outcomes
- Public visibility of the outcomes and resource
- Network control of resources