The notion of health care, and in particular primary health care, being a public good was strongly expressed in the Declaration of Alma-Ata in 1978 [ 1 ] .
- Health System
- Simple Rule
- Health Workforce
- Complex Adaptive System
- Health Experience
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Bhutan seems to be the only exception; the country follows the Buddhist ideals that development of human society should benefit from the side-by-side development of material and spiritual growth, and that both aspects reinforce each other. Development is measured in “growth in national happiness” based on the principles of promotion of sustainable development, preservation and promotion of cultural values, conservation of the natural environment, and the establishment of good governance.
George Annas re-emphasised this: The “economic perspective” ignores the inability of the market to distribute goods and services whose supply and demand are unrelated to price.
See Chap. 39 by Seltman and Berry.
For more detail see, e.g. the training guides of the National Park Service (http://www.nps.gov), especially.
What are core values?http://www.nps.gov/training/uc/whcv.htm.
How Will Core Values be Used?http://www.nps.gov/training/uc/hwcvbu.htm.
National Leadership Council on Core Values. http://www.nps.gov/training/uc/tcv.htm.
These insights are not new as such, e.g. Dent & Holt described the application of complex adaptive systems thinking in the context of the US Air Force in the following terms: Its most powerful “attractors of meaning” are its core values: “integrity first,” “service before self,” and “excellence in all we do.” …
Successful organizations of the future will maximize its members’ understanding of the mission and vision, optimize the connections inside and outside the organization, and then seek to remove barriers to formal structural change. They will be identifiable by their core values, beliefs, and culture. An organization’s values will be the source of its self-referential stability and order. They will provide the organization with a strong anchor that will enable self-renewal without experiencing chaos. The emergence of informal structures within the organization will be encouraged and supported but not prescribed. Senior leadership will not insulate organizational members from the realities of the environment. Organizational change will be governed only by a few guiding principles or core values that are central to the identity of the organization .
See Chap. 15 by Sturmberg for more details.
With a growing total population, a steady proportion of the population requiring hospitalisation will still result in an increase in the absolute number requiring hospitalisation, significantly impacting on workloads and costs.
For more details, see Sturmberg, Chap. 15.
The therapeutic relationship—sometimes also referred to as the ‘doctor as a drug’—as a source of healing has been downgraded as a placebo effect, e.g. see Benson [33 35]. However the field of psychoneuroimmunology has provided the “scientific” explanations of the workings of the therapeutic relationship: the dampening of the pituitary–adrenal axis.
For somato-psycho-socio-semiotic nature of health, refer to Sturmberg, Chap. 15.
The importance of the patient experience, and the impact of harnessing this experience, has been demonstrated by Ben Heywood and colleagues from PatientsLikeMe(http://www.patientslikeme.com).
PatientsLikeMe was inspired by the personal experiences with an ultimately fatal condition in the co-founders family. PatientsLikeMe conceptualized and built a health data-sharing platform that … can transform the way patients manage their own conditions, change the way industry conducts research and improve patient care.
PatientsLikeMe followsfour core values: putting patients first, promoting transparency (“no surprises”), fostering openness and creating “wow.” We’re guided by these values as we continually enhance our platform, where patients can share and learn from real-world, outcome-based health data.
For a detailed discussion on PatientsLikeMe, see e.g. TEDxCambridge—Ben Heywood tells the story of PatientsLikeMe (http://www.youtube.com/watch?v=n3NVG-pVDIs)
For its impact, see e.g. Paul Wicks, Timothy E Vaughan, Michael P Massagli & James Heywood. Accelerated clinical discovery using self-reported patient data collected online and a patient-matching algorithm. Nat Biotechnol 2011;29(5):411–14.
For more details on this, refer to Chap. 4
The likelihood of death for patients treated in New York than those treated in Texas showed a hazard ratio of 0.87 (CI 0.78–0.98), the likelihood of suffering from angina amongst patients in Texas than New York was significantly higher (OR 1.41; CI 1.13–1.76), and the ability to NOT perform instrumental activities of daily living requiring ≥ 5 METs was significantly greater (OR 1.62; CI 1.26–2.07)
For a more detailed consideration of this aspect, see Stewart Mennin, Chap. 43
Suggested points 4 and 5 relate to the system dynamic behaviours, the one-to-many relationship of each agent, and the time delay common to inputs into a system.
A key lesson, summarised by Peter Allen, Prof of Management at the Cranfield University School of Management, is: No learning if agents cannot read the feedback!, Centralised organizations will stop Local learning, and theNeed to design Organizations that allow learning.
WHO. Declaration of Alma-Ata. International Conference on Primary Health Care, Alma-Ata, USSR, 6-12 September 1978. Geneva: World Health Organisation1978.
Lakoff G, Johnsen M. Metaphors we live by. London: The University of Chicago Press; 2003.
Annas GJ. Reframing the debate on health care reform by replacing our metaphors. N Engl J Med. 1995; 332(11):745–8.
Moynihan R. Key opinion leaders: independent experts or drug representatives in disguise? Br Med J. 2008;336(7658):1402–3.
Astra Zeneca. Patient groups. Astra Zeneca International; [cited 2012 05-Jan-2012].
Mintzes B. Should patient groups accept money from drug companies? No. Br Med J. 2007;334(7600):935.
Herxheimer A. Relationships between the pharmaceutical industry and patients’ organisations. Br Med J. 2003;326(7400):1208–10.
Ball D, Tisocki K, Herxheimer A. Advertising and disclosure of funding on patient organisation websites: a cross-sectional survey. BMC Public Health. 2006;6(1):201.
Kent A. Should patient groups accept money from drug companies? Yes. Br Med J. 2007;334(7600):934.
Donohue JM, Cevasco M, Rosenthal MB. A decade of direct-to-consumer advertising of prescription drugs. N Engl J Med. 2007;357(7):673–81.
Heylighen F. Complexity and Self-organization. In: Bates MJ, Maack MN, editors. Encyclopedia of Library and Information Sciences. New York: Taylor & Francis; 2008.
Gell-Mann M. Complex adaptive systems. In: Cowan GA, Pines D, Meltzer D, editors. Complexity: metaphors, models, and reality, Santa Fe Institute studies in the sciences of complexity, Proc Vol XIX. Reading, MA: Addison-Wesley; 1994. p. 17–45.
Eisenhardt KM, Sull DN. Strategy as simple rules. Harv Bus Rev. 2001;79(1):107–16.
Capra F. The web of life. London: HarperCollins Publishers; 1996.
Dooley KJ. A complex adaptive systems model of organization change. Nonlinear Dynam Psych Life Sci. 1997;1(1):69–97.
Sturmberg JP. The personal nature of health. J Eval Clin Pract. 2009;15(4):766–9.
Sturmberg JP. The Foundations of Primary Care. Daring to be Different. Oxford San Francisco: Radcliffe Medical Press; 2007.
Sturmberg JP, Martin CM, Moes M. Health at the centre of health systems reform—how philosophy can inform policy. Perspect Biol Med. 2010; 53(3):341–56.
Batalden P, Ogrinc G, Batalden M. From one to many. J Interprof Care. 2006;20(5):549–51.
White K, Williams F, Greenberg B. The ecology of medical care. N Engl J Med. 1961;265(18):885–92.
Green L, Fryer G, Yawn B, Lanier D, Dovey S. The ecology of medical care revisited. N Engl J Med. 2001;344(26):2021–5.
Institute of Medicine. The Healthcare Imperative: Lowering Costs and Improving Outcomes—Workshop Series Summary2011: Available from: http://iom.edu/Reports/2011/The-Healthcare-Imperative-Lowering-Costs-and-Improving-Outcomes.aspx.
Starfield B, Shi L. Policy relevant determinants of health: an international perspective. Health Policy. 2002;60(3):201–18.
Macinko J, Starfield B, Shi L. The Contribution of Primary Care Systems to Health Outcomes within Organization for Economic Cooperation and Development (OECD) Countries, 1970–1998. Health Serv Res. 2003;38(3):831–65.
Starfield B, Is US. Health really the best in the world? J Am Med Assoc. 2000;284(4):483–5.
Macinko J, Starfield B, Shi L. Quantifying the health benefits of primary care physician supply in the United States. Int J Health Serv. [10.2190/3431-G6T7-37M8-P224]. 2007;37(1):111–26.
Gulliford MC. Availability of primary care doctors and population health in England: is there an association? J Public Health. 2002;24(4):252–4.
Roetzheim RG, Pal N, Gonzalez EC, Ferrante JM, Van Durme DJ, Ayanian JZ, et al. The effects of physician supply on the early detection of colorectal cancer. J Fam Pract. 1999;48(11):850.
Ferrante JMMD, Gonzalez ECMD, Pal NMPH, Roetzheim RGMDM. Effects of physician supply on early detection of breast cancer. J Am Board Fam Pract. 2000;13(6):408–14.
Campbell RJ, Ramirez AM, Perez K, Roetzheim RG. Cervical cancer rates and the supply of primary care physicians in Florida. Fam Med. 2003;35(1):60–4.
Roetzheim RG, Pal N, Van Durme DJ, Wathington D, Ferrante JM, Gonzalez EC, et al. Increasing supplies of dermatologists and family physicians are associated with earlier stage of melanoma detection. J Am Acad Dermatol. 2000;43(2):211–8.
Skinner JS, Staiger DO, Fisher ES. Is technological change in medicine always worth it? The case of acute myocardial infarction. Health Aff (Millwood). 2006;25(2):w34–47.
Benson H, Epstein M. The Placebo Effect. A Neglected Asset in the Care of Patients. JAMA. 1975;232:1225–1227.
Stange KC, Ferrer RL. The paradox of primary care. Ann Fam Med. 2009;7(4):293–9.
Rosenberg CE. The tyranny of diagnosis: specific entities and individual experience. Milbank Q. 2002;80(2):237–60.
McWhinney IR. The Importance of being different. William Pickles Lecture 1996. Br J Gen Pract. 1996; 46(7):433–6.
Hjortdahl P. Continuity of care: general practitioners’ knowledge about, and sense of responsibility toward their patients. Fam Pract. 1992;9(1):3–8.
Fugelli P. Trust—in general practice. Br J Gen Pract. 2001;51(468):575–9.
Freeman G, Olesen F, Hjortdahl P. Continuity of care: an essential element of modern general practice? Fam Pract. 2003;20(6):623–7.
Hjortdahl P, Lærum E. Continuity of care in general practice: effect on patient satisfaction. Br Med J. 1992;304:1287–90.
Hjortdahl P. The influence of general practitioners’ knowledge about their patients on the clinical decision-making process. Scand J Prim Health Care. 1992;10:290–4.
Sturmberg JP, Schattner P. Personal doctoring. Its impact on continuity of care as measured by the comprehensiveness of care score. Aust Fam Physician. 2001;30(5):513–8.
Saultz JW, Lochner J. Interpersonal continuity of care and care outcomes: a critical review. Ann Fam Med. 2005;3(2):159–66.
Guthrie B, Saultz JW, Freeman GK, Haggerty JL. Continuity of care matters. Br Med J. 2008; 337(aug07_1):a867.
Freeman G, Hughes J. Continuity of care and the patient experience. London: The Kings’s Fund; 2010.
Sweeney K, Gray D. Patients who do not receive continuity of care from their general practitioner—are they a vulnerable group? Br J Gen Pract. 1995;45:133–5.
Stewart AL, Greenfield S, Hays RD, Wells K, Rogers WH, Berry SD, et al. Functional status and well-being of patients with chronic conditions. Results from the Medical Outcomes Study. J Am Med Assoc. 1989; 262(7):907–13.
Fortin M, Dionne J, Pinho G, Gignac J, Almirall J, Lapointe L. Randomized controlled trials: do they have external validity for patients with multiple comorbidities? Ann Fam Med. 2006;4(2):104–8.
Greenfield S, Nelson E, Zubkoff M, Manning W, Rogers W, Kravitz R, et al. Variations in resource utilization among medical specialties and systems of care. J Am Med Assoc. 1992;267(12):1624–30.
Greenfield S, Rogers W, Mangotich M, Carney M, Tarlov A. Outcomes of patients with hypertension and non-insulin-dependent diabetes mellitus treated by different systems and specialties. J Am Med Assoc. 1995;274(18):1436–44.
Guadagnoli E, Hauptman P, Ayanian J, Pashos C, McNeil B, Cleary P. Variation in the use of cardiac procedures after acute myocardial infarction. N Engl J Med. 1995;333(9):573–8.
The Dartmouth Institute for Health Policy and Clinical Practice. Tracking the care of patients with severe chronic illness: Copyright 2008 The Trustees of Dartmouth College; 2008.
Tuijn SM, Robben PBM, Janssens FJG, van den Bergh H. Evaluating instruments for regulation of health care in the Netherlands. J Evaluat Clin Pract. 2011:no-no.
Doran T, Campbell S, Fullwood C, Kontopantelis E, Roland M. Performance of small general practices under the UK’s quality and outcomes framework. Br J Gen Pract. 2010;60(578):e335–44.
AHRQ. Value-Based Payments2012: Available from: http://www.ahrq.gov/qual/meyerrpt.htm#head3.
Jarousse LA. Value-based purchasing and bundled payments. Hosp Health Netw. 2011;85(5):6. following 32, 2.
Cashin C. United Kingdom: Quality and Outcomes Framework (QOF). 2011 [cited 2012 February 26th]; Available from: http://www.rbfhealth.org/rbfhealth/system/files/Case%20study%20UK%20QOF.pdf.
Kjellstrand CM, Kovithavongs C, Szabo E. On the success, cost and efficiency of modern medicine: an international comparison. J Intern Med. 1998; 243(1): 3–14.
Weinberger M, Kirkman M, Samsa G, Cowper P, Shortliffe E, Simel D, et al. The relationship between glycemic control and health-related quality of life in patients with non-insulin-dependent diabetes mellitus. Med Care. 1994;32(12):1173–81.
Nicolucci A, Carinci F, Ciampi A. On behalf of the SID-AMD Italian Study Group for the Implementation of the St. Vincent Declaration. Stratifying patients at risk of diabetes complications: an integrated look at clinical, socioeconomic, and care-related factors. Diabetes Care. 1998;21(9):1439–44.
Bauer A. “Die Medicin ist eine sociale Wissenschaft”—Rudolf Virchow (1821–1902) als Pathologe, Politiker und Publizist. Medicine—Bibliothek—Information. 2005;5(1):16–20.
Editors and Affiliations
47.6 Appendix 1: Core Value Statements of Government Health Departments
1.1 47.6.1 Secretary of State for Health, UK, July 2010
It is our privilege to be custodians of the NHS, its values and principles. We believe that the NHS is an integral part of a Big Society, reflecting the social solidarity of shared access to collective healthcare, and a shared responsibility to use resources effectively to deliver better health.
We are committed to an NHS that is available to all, free at the point of use, and based on need, not the ability to pay. We will increase health spending in real terms in each year of this Parliament.
The NHS is about fairness for everyone in our society. It is about this country doing the right thing for those who need help. We are committed to promoting equality and will implement the ban on age discrimination in NHS services and social care to take effect from 2012. The NHS Commissioning Board will have an explicit duty to address inequalities in outcomes from healthcare services.
We will uphold the NHS Constitution, the development of which enjoyed cross-party support. By 2012, the Government will publish the first statement of how well organisations are living by its letter and spirit. The NHS Constitution codifies NHS principles and values, and the rights and responsibilities of patients and staff. It is about mutuality; and our proposals in Chap. 2 for shared decision-making by patients, their carers, and clinicians will give better effect to this principle. It is also about NHS-funded organisations being good employers; and our plans in Chap. 4 will give organisations and professionals greater freedoms, leading to better staff engagement and better patient care.
Current statutory arrangements allow the Secretary of State a large amount of discretion to micromanage parts of the NHS. We will be clear about what the NHS should achieve; we will not prescribe how it should be achieved. We will legislate to establish more autonomous NHS institutions, with greater freedoms, clear duties, and transparency in their responsibilities to patients and their accountabilities. We will use our powers in order to devolve them.
1.2 Health Canada, Canada, October 2011
Core Values—Our Values in Action
The Dialogue on Values and Ethics resulted in the identification and description of the following core values for Health Canada. In pursuing and fulfilling our vision and mission, we achieve personal, organizational and public good by:
Taking Pride in What We Do
We are motivated and guided by our personal integrity.
We recognise our potential
We take the initiative to improve ourselves and the way we do things
We act with sound judgment
Building a Workplace Community
We respect each other and work together in a healthy environment.
We embrace diversity and nurture empowering relationships
We communicate honestly and effectively
We create an environment that promotes learning and innovation
Caring for the People of Canada
We advance the public good with purpose and passion while honouring democratic values.
We provide credible information, reliable advice and quality services
We establish and maintain good working relationships with our stakeholders
We responsibly and wisely manage resources entrusted to us
By being accountable for our values and their integration in our work, we lay the foundation for excellence at Health Canada.
1.3 Department of Health and Ageing, Annual Report 2010–2011, Australia
An apolitical, impartial and professional environment.
The importance of achieving results for the Government and the community.
Delivering services to the public fairly, effectively and impartially.
Transparency, accountability and responsiveness.
A workplace that is fair and free of discrimination.
Diversity and equity in employment.
The highest ethical standards.
These principles reflect the Australian Public Service Values in the Public Service Act 1999 (Section 10) and the department’s People Strategy.
1.4 Office of Public Health and Science, 2011, USA
The OPHS has identified and defined five core values, which are listed below.
Put People First
Honor the public’s trust and confidence
Respect for colleagues and the public health professions
Recognise the invaluable contributions of OPHS staff
Adhere to the highest ethical standards
Ensure products and services are truthful, accurate, and comprehensive
Assure health research conforms to scientific norms
Recognise that privacy and safety of human participants is paramount
Conduct programs and activities guided by science and driven by results
Delineate clear and enforce consistent accountability for program outcomes
Design programs and activities so that rigorous program evaluations can and will be performed
Promote public health that is effective, efficient, and community-delivered
Embrace the richness of OPHS’ diversity and seek to strengthen it
Value the diversity of our Nation and the perspectives brought by differences in race
Ethnicity, gender, age, and socio-economic status
Believe that all Americans should benefit from advances in health promotion
Leadership through collaboration
Commit to disease prevention and health promotion
Believe that collaboration and coordination builds effective, efficient, responsive
Sustainable public health systems
Foster input from all relevant partners and stakeholders in program operations
Appendix 2: Core Value Statements of Health Institutions
2.1 Institute of Health Improvement, USA
These operating values are core principles for work in IHI. They guide the behaviour and choices of all staff, faculty, and the Board of Directors.
Without Boundaries: The people of the IHI compose a single organization, with common systems, common knowledge, and unconditional teamwork.
Speed and Agility: We change our own work and respond as quickly as the health care systems we serve need us to. Our past work need not ever be our future work. We are always willing to change.
Focus on Subject Matter: Our concerns are health and health care; we are not wedded to specific methodologies. We remain always open to new approaches to the continual improvement of care. Results for patients and communities define our success.
Valuing Volunteers: We network together people who have expertise and knowledge, so that they can teach each other, help others, and improve the work of IHI. These people are our “faculty.” Their work is the lifeblood of the IHI. We will make their experience with IHI the most satisfying of their professional lives.
Customer Focus: To achieve our mission, we must serve and delight those who shape and deliver health care. Their satisfaction—100% satisfaction—is our uncompromising aim, in everything that we do.
Honesty: To achieve our mission, we must earn and preserve the trust of those we attempt to help. To do so, we must tell the absolute truth about ourselves and our work, reporting both failures and successes with equal discipline, and seeking the views and opinions of people outside our organization.
Transparency: We are an institute without walls. Those who work with us, no matter where or when, should feel informed and welcomed. We work always in daylight.
Orderliness: Disorder is waste, which neither we nor health care can afford. We will be lean in our work, and continually reduce waste and disorder. We practice what we teach.
Celebration and Thankfulness: Our mission is long, and our work is not easy. We take time to look back, as well as forward, to thank each other, and to take pride in what we do.
2.2 Centre for Disease Control, Atlanta, USA
CDC Core Values
Accountability—As diligent stewards of public trust and public funds, we act decisively and compassionately in service to the people’s health. We ensure that our research and our services are based on sound science and meet real public needs to achieve our public health goals.
Respect—We respect and understand our interdependence with all people, both inside the agency and throughout the world, treating them and their contributions with dignity and valuing individual and cultural diversity. We are committed to achieving a diverse workforce at all levels of the organization.
Integrity—We are honest and ethical in all we do. We will do what we say. We prize scientific integrity and professional excellence.
2.3 Cancer Council Western Australia
We will serve the people of Western Australia to reduce the impact of cancer.
We will improve our services to the people of Western Australia based on the best available evidence and practice.
We will respect and value the community, volunteers and our staff.
We will work toward our vision and mission through teamwork and collaboration.
We will act with integrity and honesty.
We will strive to achieve equity in the provision of programs and services.
We will manage and apply funds entrusted to us by the community in the most effective way.
Appendix 3: Core Value Statements of Professional Associations
3.1 American Medical Association, USA
Integrity and ethical behaviour
3.2 Canadian Medical Association, Canada
Our values describe what is important to us and outline the behaviours required to make us successful.
Excellence: We strive to be the best in everything we do for physicians and their patients and we are committed to continuous learning and improvement.
Professionalism: We strive to unite physicians around the fundamental tenets of high quality standards, patient safety, professional autonomy, accountability, responsiveness and physician health and well-being.
Integrity: We uncompromisingly adhere to the highest ethical standards and honesty in representing our members and conducting our business.
Compassion: We foster an individual and corporate culture of caring for physicians, their patients and each other.
Rassembleur: We strive to bring together diverse communities of interest in the pursuit of common goals.
3.3 Royal College of General Practitioners (RCGP), UK
The RCGP is the heart and voice of General Practice and as such:
We protect the principle of holistic generalist care which is integrated around the needs of and partnership with patients.
We are committed to equitable access to, and delivery of, high quality and effective primary healthcare for all.
We are committed to the theoretical and practical development of general practice.
3.4 American Association of Family Physicians (AAFP), USA
AAFP and its Members are Committed to Care that is…
Equitable for all people
Centered on the whole person within the context of family and community
Based on science, technology, and best available evidence
Supported by lifelong professional learning
Grounded in respect and compassion for the individual
3.5 Royal Australian College of General Practitioners (RACGP), Australia
RACGP values statement
“we serve with integrity, strive for excellence, foster GP unity, advocate for health equity and embrace the diversity of our profession”
Appendix 4: Core Value Statements of Clinical Institutions
4.1 Mayo Clinic, Rochester, USA
The needs of the patient come first.
These values, which guide Mayo Clinic’s mission to this day, are an expression of the vision and intent of our founders, the original Mayo physicians and the Sisters of Saint Francis.
Treat everyone in our diverse community, including patients, their families and colleagues, with dignity.
Provide the best care, treating patients and family members with sensitivity and empathy.
Adhere to the highest standards of professionalism, ethics and personal responsibility, worthy of the trust our patients place in us.
Inspire hope and nurture the well-being of the whole person, respecting physical, emotional and spiritual needs.
Value the contributions of all, blending the skills of individual staff members in unsurpassed collaboration.
Deliver the best outcomes and highest quality service through the dedicated effort of every team member.
Infuse and energise the organization, enhancing the lives of those we serve, through the creative ideas and unique talents of each employee.
Sustain and reinvest in our mission and extended communities by wisely managing our human, natural and material resources.
4.2 Central Coast Health, July 2008, Australia
Integrity × Teamwork × Best Practice
Accountability × Social Justice
4.3 Brigham and Women’s Hospital, Boston, USA
Quality Patient Care: Delivering quality patient care is the center of everything we do.
Teaching Excellence: We seek to uphold the highest standards in training health care professionals.
Research Leadership: We continuously seek new ways to demonstrate our leadership role in research.
Customer Focus: Our focus is to serve our customers.
Respect for the Individual: We recognise and value the contributions of every individual.
Teamwork: We work toward a unified approach to developing health care solutions.
Embracing Change: Embracing change will help us to be successful.
Operational Efficiency: We strive for efficient and effective delivery of services.
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Sturmberg, J.P., O’Halloran, D.M., Martin, C.M. (2013). Healthcare Reform: The Need for a Complex Adaptive Systems Approach. In: Sturmberg, J., Martin, C. (eds) Handbook of Systems and Complexity in Health. Springer, New York, NY. https://doi.org/10.1007/978-1-4614-4998-0_47
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