Measures that matter should define accountability and governance frameworks

While the Royal Commission into Aged Care Quality and Safety has clearly identified the issues with our Australian residential aged care system, its recommendations-so far-have not been translated into policies that will ensure a framework in which nursing home operators and care staff are empowered to focus on what matters-ensuring vulnerable residents receive care that meets their needs and preserves their dignity. For this to be achievable the system requires measures that in the first instance reflect the system's purpose, and that all stakeholders can use to improve care. Such measures need to be easy to understand and implement, and most importantly reduce bureaucratic burden.

Surfing Corona waves - instead of breaking them: Rethinking the role of natural immunity in COVID-19 policy

In the first two years of the pandemic, COVID-19 response policies have aimed to break Corona waves through non-pharmaceutical interventions and mass vaccination. However, for long-term strategies to be effective and efficient, and to avoid massive disruption and social harms, it is crucial to introduce the role of natural immunity in our thinking about COVID-19  (or future "Disease-X") control and prevention. We argue that any Corona or similar virus control policy must appropriately balance five key elements simultaneously: balancing the various fundamental interests of the nation, as well as the various interventions within the health sector; tailoring the prevention measures and treatments to individual needs; limiting social interaction restrictions; and balancing the role of vaccinations against the role of naturally induced immunity. Given the high infectivity of SARS-CoV-2 and its differential impact on population segments, we examine this last element in more detail and argue that an important aspect of 'living with the virus' will be to better understand the role of naturally induced immunity in our overall COVID-19 policy response. In our eyes, a policy approach that factors natural immunity should be considered for persons without major comorbidities and those having 'encountered' the antigen in the past.

Perspectives of (/memorandum for) systems thinking on COVID-19 pandemic and pathology

Is data-driven analysis sufficient for understanding the COVID-19 pandemic and for justifying public health regulations? In this paper, we argue that such analysis is insufficient. Rather what is needed is the identification and implementation of over-arching hypothesis-related and/or theory-based rationales to conduct effective SARS-CoV2/COVID-19 (Corona) research. To that end, we analyse and compare several published recommendations for conceptual and methodological frameworks in medical research (e.g., public health, preventive medicine and health promotion) to current research approaches in medical Corona research. Although there were several efforts published in the literature to develop integrative conceptual frameworks before the COVID-19 pandemic, such as social ecology for public health issues and systems thinking in health care, only a few attempts to utilize these concepts can be found in medical Corona research. For this reason, we propose nested and integrative systemic modelling approaches to understand Corona pandemic and Corona pathology. We conclude that institutional efforts for knowledge integration and systemic thinking, but also for integrated science, are urgently needed to avoid or mitigate future pandemics and to resolve infection pathology.

The danger of the single storyline obfuscating the complexities of managing SARS-CoV-2/COVID-19

Chimamanda Ngozi Adichie showed how a single story is limited and thereby distorts the true nature of an issue. During this COVID-19 pandemic there have been, at least, three consecutive single stories-the 'lethal threat' story, followed by the 'economic threat' story, and finally the 'vaccine miracle' story. None of these single stories can convincingly and permanently capture the dynamics of the pandemic. This is because countries experienced different morbidity and mortality patterns, different socioeconomic disadvantage, age and vulnerability of population, timing and level of lockdown with economic variability, and, despite heavy promotion, vaccines were beset with a significant and variable degree of hesitancy. Lack of transparency, coherence and consistency of pandemic management-arising from holding on to single storylines-showed the global deficiency of public health policy and planning, an underfunding of (public) health and social services, and a growing distrust in governments' ability to manage crises effectively. Indeed, the global management has increased already large inequities, and little has been learnt to address the growing crises of more infectious and potentially more lethal virus mutations. Holding onto single stories prevents the necessary learnings to understand and manage the complexities of 'wicked' problems, whereas listening to the many stories provides insights and pathways to do so effectively as well as efficiently.

Viewing the global health system as a complex adaptive system - implications for research and practice

The global health system (GHS) is ill-equipped to deal with the increasing number of transnational challenges. The GHS needs reform to enhance global resilience to future risks to health. In this article we argue that the starting point for any reform must be conceptualizing and studying the GHS as a complex adaptive system (CAS) with a large and escalating number of interconnected global health actors that learn and adapt their behaviours in response to each other and changes in their environment. The GHS can be viewed as a multi-scalar, nested health system comprising all national health systems together with the global health architecture, in which behaviours are influenced by cross-scale interactions. However, current methods cannot adequately capture the dynamism or complexity of the GHS or quantify the effects of challenges or potential reform options. We provide an overview of a selection of systems thinking and complexity science methods available to researchers and highlight the numerous policy insights their application could yield.   We also discuss the challenges for researchers of applying these methods and for policy makers of digesting and acting upon them. We encourage application of a CAS approach to GHS research and policy making to help bolster resilience to future risks that transcend national boundaries and system scales.

There is More to 'Making Connections to Improve Health Outcomes'

Langevin¹ rightly points to the reductionist mindset being the stumbling block for providing person-centered care. While considering the interconnections between the various domains underpinning health is a necessary first step towards more person-centered care, it ultimately is not sufficient. Person-centered care arises from the appreciation of the interdependencies and interactions between the various domains across its large-scale supersystems as much as its small-scale subsystems. Viewed with a complex-adaptive systems mindset health and disease are the phenotypical outcome categorisations of a person’s whole-of-systems dynamics across all scales of organisation.^2,3

'False accountability': The harmful consequences of bureaucratic rigour for aged care residents

BACKGROUND

Public outrage about the treatment of aged care residents in some nursing homes has its origins in a failure in each facility's accountability framework. There is an overwhelming focus on documentation of organisational structures and care processes, detracting from what really matters - whether the wellbeing of residents has been achieved.

OBJECTIVE

This article examines process- or action-oriented versus outcomes- or interaction-oriented accountability principles and their impacts on aged care residents' care.

DISCUSSION

A 'performance outcomes approach' provides a more effective and efficient way to achieve high levels of care in aged care facilities. These findings are important in the context of potential recommendations arising from the Royal Commission into Aged Care Quality and Safety.

Evidence-based medicine: is it a bridge too far?

AIMS

This paper aims to describe the contextual factors that gave rise to evidence-based medicine (EBM), as well as its controversies and limitations in the current health context. Our analysis utilizes two frameworks: (1) a complex adaptive view of health that sees both health and healthcare as non-linear phenomena emerging from their different components; and (2) the unified approach to the philosophy of science that provides a new background for understanding the differences between the phases of discovery, corroboration, and implementation in science.

RESULTS

The need for standardization, the development of clinical epidemiology, concerns about the economic sustainability of health systems and increasing numbers of clinical trials, together with the increase in the computer's ability to handle large amounts of data, have paved the way for the development of the EBM movement. It was quickly adopted on the basis of authoritative knowledge rather than evidence of its own capacity to improve the efficiency and equity of health systems. The main problem with the EBM approach is the restricted and simplistic approach to scientific knowledge, which prioritizes internal validity as the major quality of the studies to be included in clinical guidelines. As a corollary, the preferred method for generating evidence is the explanatory randomized controlled trial. This method can be useful in the phase of discovery but is inadequate in the field of implementation, which needs to incorporate additional information including expert knowledge, patients' values and the context.

CONCLUSION

EBM needs to move forward and perceive health and healthcare as a complex interaction, i.e. an interconnected, non-linear phenomenon that may be better analysed using a variety of complexity science techniques.

Framing of scientific knowledge as a new category of health care research

RATIONALE

The new area of health system research requires a revision of the taxonomy of scientific knowledge that may facilitate a better understanding and representation of complex health phenomena in research discovery, corroboration and implementation.

METHOD

A position paper by an expert group following and iterative approach.

RESULTS

'Scientific evidence' should be differentiated from 'elicited knowledge' of experts and users, and this latter typology should be described beyond the traditional qualitative framework. Within this context 'framing of scientific knowledge' (FSK) is defined as a group of studies of prior expert knowledge specifically aimed at generating formal scientific frames. To be distinguished from other unstructured frames, FSK must be explicit, standardized, based on the available evidence, agreed by a group of experts and subdued to the principles of commensurability, transparency for corroboration and transferability that characterize scientific research. A preliminary typology of scientific framing studies is presented. This typology includes, among others, health declarations, position papers, expert-based clinical guides, conceptual maps, classifications, expert-driven health atlases and expert-driven studies of costs and burden of illness.

CONCLUSIONS

This grouping of expert-based studies constitutes a different kind of scientific knowledge and should be clearly differentiated from 'evidence' gathered from experimental and observational studies in health system research.

Validation of a non-linear model of health

PURPOSE

The purpose of this study was to evaluate the veracity of a theoretically derived model of health that describes a non-linear trajectory of health from birth to death with available population data sets.

METHODS

The distribution of mortality by age is directly related to health at that age, thus health approximates 1/mortality. The inverse of available all-cause mortality data from various time periods and populations was used as proxy data to compare with the theoretically derived non-linear health model predictions, using both qualitative approaches and quantitative one-sample Kolmogorov-Smirnov analysis with Monte Carlo simulation.

RESULTS

The mortality data's inverse resembles a log-normal distribution as predicted by the proposed health model. The curves have identical slopes from birth and follow a logarithmic decline from peak health in young adulthood. A majority of the sampled populations had a good to excellent quantitative fit to a log-normal distribution, supporting the underlying model assumptions. Post hoc manipulation showed the model predictions to be stable.

CONCLUSIONS

This is a first theory of health to be validated by proxy data, namely the inverse of all-cause mortality. This non-linear model, derived from the notion of the interaction of physical, environmental, mental, emotional, social and sense-making domains of health, gives physicians a more rigorous basis to direct health care services and resources away from disease-focused elder care towards broad-based biopsychosocial interventions earlier in life.

Understanding health care delivery as a complex system: achieving best possible health outcomes for individuals and communities by focusing on interdependencies

RATIONALE, AIMS AND OBJECTIVES

The concept of emergence offers a new way of thinking about multimorbidity and chronic disease.

RESULTS AND CONCLUSIONS

Multimorbidity and chronic disease are the end results of ongoing perturbations and interconnected activities of simpler substructures that collectively constitute the complex adaptive superstructure known as us, the person or patient. Medical interventions cause perturbations of many different subsystems within the patient, hence they are not limited to the person's bodily function, but also affect his general health perception and his interactions with his external environments. Changes in these domains inevitably have consequences on body function, and close the feedback loop of illness/disease, recovery and regained health.

For every complex problem, there is an answer that is clear, simple and wrong: and other aphorisms about medical statistical fallacies

RATIONALE, METHOD

This essay examines the notions of knowledge, truth and certainty as they apply to medical research and patient care. The human body does not behave in mechanistic but rather complex adaptive ways; thus, its behaviour to challenges is non-deterministic. This insight has important ramifications for experimental studies in health care and their statistical interrogation that are described in detail.

RESULTS AND CONCLUSIONS

Four implications are highlighted: one, there is an urgent need to develop a greater awareness of uncertainties and how to respond to them in clinical practice, namely, what is important and what is not in the context of this patient; two, there is an equally urgent need for health professionals to understand some basic statistical terms and their meanings, specifically absolute risk, its reciprocal, numbers needed to treat and its inverse, index of therapeutic impotence, as well as seeking out the effect size of an intervention rather than blindly accepting P-values; three, there is an urgent need to accurately present the known in comprehensible ways through the use of visual tools; and four, there is a need to overcome the perception, that errors of commission are less troublesome than errors of omission as neither's consequences are predictable.

Complex adaptive chronic care

BACKGROUND

The Chronic Care Model (CCM) is widely taken up as the universal operational framework for redesigning health systems to address the increasing chronic disease burden of an ageing population. Chronic care encompasses health promotion, prevention, self management, disease control, treatment and palliation to address 'chronicity' of long journeys through disease, illness and care in the varying contexts of complex health systems. Yet at an operational level, CCM activities are predominantly based on an evidence-base of discreet chronic disease interventions in specific settings; and their demonstrable impact is limited to processes of select disease management such as diabetes in specific disease management programs.

AIMS

This paper proposes a framework that makes sense of the nature of chronicity and its multiple dimensions beyond disease and argues for a set of building blocks and leverage points that should constitute the starting points for 'redesign'?

FINDINGS

Complex Adaptive Chronic Care is proposed as an idea for an explanatory and implementation framework for addressing chronicity in existing and future chronic care models. Chronicity is overtly conceptualized to encompass the phenomena of an individual journey, with simple and complicated, complex and chaotic phases, through long term asymptomatic disease to bodily dysfunction and illness, located in family and communities. Chronicity encompasses trajectories of self-care and health care, as health, illness and disease co-exist and co-evolve in the setting of primary care, local care networks and at times institutions. A systems approach to individuals in their multi-layered networks making sense of and optimizing experiences of their chronic illness would build on core values and agency around a local vision of health, empowerment of individuals and adaptive leadership, and it responds in line with the local values inherent in the community's disease-based knowledge and the local service's history and dynamics. Complex Adaptive Chronic Care exceeds the current notions of disease management as an endpoint. Primary care team members are system adaptors in partnership with individuals constructing their care and system leadership in response to chronic illness, and enable healthy resilience as well as personal healing and support. Outcomes of complex adaptive chronic care are the emergence of health in individuals and communities through adaptability, self-organization and empowerment.

DISCUSSION

Chronic care reform from within a complex adaptive system framework is bottom up and emergent and stands in stark contrast to (but has to co-exist with) the prevailing protocol based disease care rewarding selective surrogate indicators of disease control. Frameworks such as the Chronic Care Model provide guidance, but do not replace individual experience, local adaptive leadership and responsiveness. The awareness of complexity means opening up problems to a different reality demanding different set of questions and approaches to answer them.

User-driven health care - answering multidimensional information needs in individual patients utilizing post-EBM approaches: a conceptual model

Evidence based on average patient data, which occupies most of our present day information databases, does not fulfil the needs of individual patient-centred health care. In spite of the unprecedented expansion in medical information we still do not have the types of information required to allow us to tailor optimal care for a given individual patient. As our current information is chiefly provided in disconnected silos, we need an information system that can seamlessly integrate different types of information to meet diverse user group needs. Groups of certain individual medical learners namely patients, medical students and health professionals share the patient's need to increasingly interact with and seek knowledge and solutions offered by others (individual medical learners) who have the lived experiences that they would benefit to access and learn from. A web-based user-driven learning solution may be a stepping-stone to address the present problem of information oversupply in medicine that mostly remains underutilized, as it doesn't meet the needs of the individual patient and health professional user. The key to its success would be to relax central control and make local trust and strategic health workers feel more engaged in the project such that it is truly user-driven.

Impact of Master of Family Medicine degree by distance learning on general practitioners' career options

INTRODUCTION

This study investigated the impact of a Master of Family Medicine degree (via distance education) on GPs' career options, and in particular, whether they were more likely to adopt university positions after the course. A secondary aim was to examine whether those who undertook a research project as part of their Masters took up different career options than Masters graduates who undertook a more clinically orientated course.

METHODS

A questionnaire survey was posted to all 192 graduates of the Master of Family Medicine degree. Approximately one fifth of these resided overseas, with the majority in Hong Kong.

RESULTS

The response rate was 68%. Graduates stated that they benefited from the course, particularly in the areas of clinical knowledge and improvement in 'academic' skills. Changes in careers, with increases in non-clinical appointments, did occur after the course for both the Research and Clinical Masters graduates.

DISCUSSION

Responses to the survey indicated that graduates benefited in completing the course and changes in their career direction following graduation. However, whether the Masters course provided new skills to enable career change, or the GPs were in the process of change anyway, cannot be determined with certainty. Further studies, including interviews, are required to establish the impact of a distance education higher degree.

CONCLUSION

The research output of general practice remains behind that of its specialist colleagues. Higher degrees for GPs might encourage them to undertake more academic pursuits, but the precise relationship still remains uncertain.

How to teach holistic care--meeting the challenge of complexity in clinical practice

CONTEXT

Removal of underlying pathologies through the application of science and technology alone will not restore a patient's health; that will require connecting with the person behind the disease. Being ill changes physical and social functioning, emotional well-being, and last but not least, it affects one's self-concept. It invariably leads to questions of the meaning and understanding of being ill, hence Pauli et al. (2000) termed the notion of a somato-psycho-socio-semiotic paradigm of health.

OBJECTIVE

Understanding health in this context allows the conceptualization of health as a balance between these four domains.

METHODS AND CONCLUSIONS

This paper describes, through a systems-based methodology, the translation of the somato-psycho-socio-semiotic understanding of health into a flexible teaching approach for students and in a postgraduate setting for registrars. This teaching mode, by making the different dimensions that affect a person's health transparent, has helped learners to rapidly progress towards our goal of becoming holistically practicing clinicians.

Approaching the future of general practice--how systems thinking might help

General practice in Australia is facing an uncertain future leaving many general practitioners to wonder if it is still worthwhile to stay in practice. At the 2003 Royal Australian College of General Practitioners (RACGP) Convention Forum, GPs identified retention of the workforce to be of primary importance to their profession. This article argues that understanding and finding solutions to the complexities inherent in the workforce issue requires a systems approach; simple linear approaches to 'fixing' a particular aspect are dangerous and invariably will lead to unforseen--usually detrimental--consequences.

General practice education in Australia. Current issues

General practice education is rapidly changing. Medical students now have exposure to general practice at most year levels, vocational training has been opened to competition, and continuing professional development is a mandatory requirement for maintenance of Health Insurance Commission recognition, and increasingly for state registration. This article outlines the foundations for, and challenge to, building a framework for quality general practice education in Australia.

Continuity of care: towards a definition based on experiences of practising GPs

BACKGROUND

The traditional concept of continuity of care, i.e. care from the cradle to the grave, is no longer sustainable in modern society.

OBJECTIVE

The aim of this study was to propose a definition of 'continuity of care' based on the experiences of a group of practising Australian GPs.

METHOD

Five focus group discussions were conducted to explore the understanding and practice of continuity of care, the individual's measurement of having achieved continuity of care in his/her practice and the advantages/disadvantages of providing continuity of care. Results and conclusions. The experiences of this group of GPs points towards three essential aspects to help with a definition of continuity of care. Firstly it requires a stable care environment, secondly good communication to build a responsible doctor-patient relationship and thirdly the goal of achieving an improvement of the patient's overall health.

Learning relevant procedural skills. Are supervisors providing opportunities?

OBJECTIVE

The aim of this study is to assess general practice registrars' (GPRs) learning needs in relation to their procedural skills development and compare these with the learning opportunities offered by their general practice supervisors (GPSs).

METHOD

A 43 item questionnaire was designed to assess the procedural skills development needs of GPRs. The questionnaire was administered to GPSs and GPRs.

RESULTS

GPRs can expect to consolidate their skills in the areas of joint injections. ENT procedures and some small surgical procedures. They are unlikely to gain experience in the areas of proctology, the use of the microscope as a diagnostic tool, cardiac stress testing, hearing assessment and some less frequently needed procedures. Respondents identified spinal mobilisation manipulation, flexible sigmoidoscopy, colposcopy and fine needle aspiration biopsy as procedures they would like to see performed in general practice.

CONCLUSION

GPRs are keen to enhance their procedural skills in a wide range of areas. They cannot necessarily expect that their general practice attachment will provide the opportunities to develop all skills desired. The Royal Australian College of General Practitioners (RACGP) Training Program needs to provide registrars with a list of core skills that are expected of every general practitioner (GP). To ensure this objective is achieved, innovative learning opportunities for GPSs and GPRs in the domain of psychomotor competencies need to be developed.