The current model of diabetes care, with patients moving between primary, community and specialist care, does not always support clinicians’ aims of delivering high quality, patient-centred care with the effective and efficient use of resources. Patients’ complex needs may not be fully addressed, care is fragmented, and interventions may be delayed or duplicated. Integrating services across traditional boundaries provides a solution.
Closer working between primary and secondary care
Integration is best delivered using an evidence-based approach, supported by a statutory duty. However, the best level and extent of integration is not always obvious.
Attempts to integrate care by encouraging closer working between primary and specialist healthcare professionals are numerous. However, without the right organisational support, there is a risk of improving care in a way that makes it unsustainable and not available to all patients.
One example of the barriers that can be experienced is the delivery of virtual diabetes clinics in a CCG locality in Oxfordshire, where a multidisciplinary team is tasked with identifying and reviewing the care of patients at risk of developing complications from diabetes. Working across institutional and professional boundaries, the efforts of the team are often hindered because of a lack of workforce planning and poor flow of information. The sharing of data, organisational-level engagement, and appropriate funding of such developments is necessary for longer term success.
The need for a comprehensive and multilevel approach to change
Ferlie and Shortell (2001), experts on strategic change in the health sector and the organisational factors that affect quality and outcomes of care, suggest an approach that may be useful when planning service transformation. Their approach is based on an understanding of the health care system as four interdependent levels, and an appreciation of the dynamics of each level to identify the levers of change:
· the individual
· groups and teams
· the organization
· the larger system and environment.
Address the levels simultaneously
As Ferlie and Shortell observe, it is possible to achieve a small and limited impact by focusing on one of the four levels of change. However, the greatest and longest-lasting impact is achieved by considering all levels simultaneously. The multilevel approach to change means that change effort is directed to all four levels simultaneously, or, more often, a change aimed at one level is considered within the context of the other three levels.
An example may help to illustrate the point. In order to improve clinical performance, it is not enough to use strategies focusing on individuals alone. As Ferlie and Shortell note, medicine is largely practiced as part of a group or team embedded within a complex organisational structure. The comprehensive and multilevel approach to change explains why addressing clinical education only at the level of the individual may not bring about the expected change. Traditional medical education and dissemination of guidelines or protocols does not deliver as great an impact as an overall staged intervention that first identifies opinion leaders within the organization.
Both policy-makers and practitioners are encouraged to apply a more comprehensive and multilevel approach to avoid their efforts to improve the quality and outcomes of care failing to realise their potential.
(Ferlie and Shortell, 2001)
Anticipating the barriers to change
Considering the four levels helps to plan and manage change in a way that ensures it will be most effective. Ferlie and Shortell recommend analysing potential barriers within and between each level of change in order to identify possible causes of resistance and develop effective strategies for dealing with them. In the case of the virtual diabetes clinics, the possible barriers at organisational level could include:
· inadequate information systems
· the lack of physician involvement
· insufficient senior management leadership and support.
Four essential factors
It is important to note that addressing all four levels of change is not enough on its own to guarantee successful change. Ferlie and Shortell not only warn about the danger of ignoring the complexity and interdependence within the health sector, but also highlight the risk of not securing:
· leadership at all levels of change
· a pervasive culture that supports learning throughout the care process
· an emphasis on the development of effective teams
· greater use of technologies for continuous improvement work and external accountability.
When all of these factors are in place, transformative change, such as that involved in service integration, stands a much greater chance of success.
References:
Ferlie, E.B. and Shortell, S.M. (2001) Improving the quality of health care in the United Kingdom and the United States: a framework for change. The Milbank Quarterly, 79(2), pp.281-315. Link