The role of leadership in times of systems disruption: a qualitative study of health and social care integration

OBJECTIVES

To understand whether and how effective integration of health and social care might occur in the context of major system disruption (the COVID-19 pandemic), with a focus on how the initiative may overcome past barriers to integration.

DESIGN

Rapid, descriptive case study approach with deviant case sampling to gather and analyse key informant interviews and relevant archival documents.

SETTING

The innovation ('COVID-19 Protect') took place in Norfolk and Waveney, UK, and aimed to foster integration across highly diverse organisations, capitalising on existing digital technology to proactively identify and support individuals most at risk of severe illness from COVID-19.

PARTICIPANTS

Twenty-six key informants directly involved with project conceptualisation and early implementation. Participants included clinicians, executives, digital/information technology leads, and others. Final sample size was determined by theoretical saturation.

RESULTS

Four primary recurrent themes characterised the experiences of diverse team members in the project: (1) ways of working that supported rapid collaboration, (2) leveraging diversity and clinician input for systems change, (3) allowing for both central control and local adaptation and (4) balancing risk taking and accountability.

CONCLUSIONS

This rapid case study underscores the role of leadership in large systems change efforts, particularly in times of major disruption. Project leadership overcame barriers to integration highlighted by prior studies, including engaging with aversion to clinical/safety risk, fostering distributed leadership and developing shared organisational practices for data sharing and service delivery. These insights offer considerations for future efforts to support strategic integration of health and social care.

Critical Factors Favoring Outward Physician Migration from an Affluent Gulf Country

Background

Physician retention is essential to creating a strong and stable healthcare system worldwide. The density of physicians and nurses significantly impacts important population health outcomes. Globalization has enabled the mobility of physicians, but the recruitment and retention of quality physicians have not been without challenges. The purpose of this study was to identify the outward migration factors affecting expatriate physicians who have resided and worked in the United Arab Emirates (UAE) for at least 5 years, as compared with newly emigrated physicians. This physician population has likely adapted to the local environment and actively contributed to the advancement of medical care in the country; their attrition is a significant loss to the UAE healthcare system.

Methods and Statistical Analysis

A 23-point validated survey questionnaire, consisting of four domains, was electronically administered to the participants (n = 374), and responses were statistically analyzed, using descriptive statistics and the Chi-square test.

Results

Our results indicate that all physicians considered a ten-year visa to be factor contributing to retention, more so for the recent physician migrants to the UAE. Professional development opportunities, career-specific plans and income promoted only short-term retention of physicians in the UAE. Non-financial factors related to living and working conditions prevented migration of physicians who lived in the country for more than five years.

Conclusion

Lifestyle-related factors are an important consideration in long-term retention of physicians in the UAE. Initiatives to promote career advancement and improve job satisfaction for mid- and late-career clinicians are necessary to set the foundation for a robust physician retention policy and to enhance the quality of the healthcare system. Long-term visas provide an additional factor for retention.

Evidence-informed health policy making in Canada: past, present, and future

Evidence-informed health policy making (EIHP) is becoming a necessary means to achieving health system reform. Although Canada has a rich and well documented history in the field of evidence-based medicine, a concerted effort to capture Canada's efforts to support EIHP in particular has yet to be realized. This paper reports on the development of EIHP in Canada, including promising approaches being used to support the use of evidence in policy making about complex health systems issues. In light of Canada's contributions, this paper suggests that scholars in Canada will continue engaging in the field of EIHP through further study of interventions underway, as well as by sharing knowledge within and beyond Canada's borders about approaches that support EIHP.

Health care frames - from Virchow to Obama and beyond: the changing frames in health care and their implications for patient care

RATIONALE, AIMS, OBJECTIVES AND METHODS

Framing allows us to highlight some aspects of an issue, thereby bringing them to the forefront of our thinking, talking and acting. As a consequence, framing also distracts our attention away from other issues. Over time, health care has used various frames to explain its activities. This paper traces the emergence of various health care frames since the 1850s to better understand how we reached current ways of thinking and practicing.

RESULTS AND CONCLUSIONS

The succession of the most prominent frames can be summarized as: medicine as a social science; the germ theory of disease; health care as a battleground (or the war metaphor); managing health care resources (or the market metaphor); Health for All (the social justice model); evidence-based medicine; and Obama Care. The focus of these frames is causal, instrumental, political/economic or social in nature. All remain relevant; however, recycling individual past frames in response to current problems will not achieve the outcomes we seek. Placing the individual and his/her needs at the centre (the attractor for the health system) of our thinking, as emphasized by the World Health Organization's International Classification of Function framework and the European Society of Person Centered Health Care, may provide the frame to refocus health and health care as interdependent experiences across individual, community and societal domains. Shifting beyond the entrenched instrumental and economic thinking will be challenging but necessary for the sake of patients, health professionals, society and the economy.

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.

Consumers' perspectives on national health insurance in South Africa: using a mobile health approach

BACKGROUND

Building an equitable health system is a cornerstone of the World Health Organization (WHO) health system building block framework. Public participation in any such reform process facilitates successful implementation. South Africa has embarked on a major reform in health policy that aims at redressing inequity and enabling all citizens to have equal access to efficient and quality health services.

OBJECTIVE

This research is based on a survey using Mxit as a mobile phone-based social media network. It was intended to encourage comments on the proposed National Health Insurance (NHI) and to raise awareness among South Africans about their rights to free and quality health care.

METHODS

Data were gathered by means of a public e-consultation, and following a qualitative approach, were then examined and grouped in a theme analysis. The WHO building blocks were used as the conceptual framework in analysis and discussion of the identified themes.

RESULTS

Major themes are the improvement of service delivery and patient-centered health care, enhanced accessibility of health care providers, and better health service surveillance. Furthermore, health care users demand stronger outcome-based rather than rule-based indicators of the health system's governance. Intersectoral solidarity and collaboration between private and public health care providers are suggested. Respondents also propose a code of ethical values for health care professionals to address corruption in the health care system. It is noteworthy that measures for dealing with corruption or implementing ethical values are neither described in the WHO building blocks nor in the NHI.

CONCLUSIONS

The policy makers of the new health system for South Africa should address the lack of trust in the health care system that this study has exposed. Furthermore, the study reveals discrepancies between the everyday lived reality of public health care consumers and the intended health policy reform.

Divergence of NHS choice policy in the UK: what difference has patient choice policy in England made?

OBJECTIVES

To examine the types of choices available to patients in the English NHS when being referred for acute hospital care in the light of the divergence of patient choice policy in the four countries of the UK.

METHODS

Case studies of eight local health economies in England, Scotland, Northern Ireland and Wales (two in each country); 125 semi-structured interviews with staff in acute services providers, purchasers and general practitioners (GPs).

RESULTS

GPs and providers in England both had a clear understanding of the choice of provider policy and the right of patients to choose a provider. Other referral choices potentially available to patients in all four countries were date and time of appointment, site and specialist. In practice, the availability of these choices differed between and within countries and was shaped by factors beyond choice policy, such as the number of providers in an area. There were similarities between the four countries in the way choices were offered to patients, namely lack of clarity about the options available, limited discussion of choices between referrers and patients, and tension between offering choice and managing waiting lists.

CONCLUSIONS

There are challenges in implementing pro-choice policy in health care systems where it has not traditionally existed. Differences between England and the other countries of the UK were limited in the way choice was offered to patients. A cultural shift is needed to ensure that patients are fully informed by GPs of the choices available to them.