A Complex Adaptive Health System Redesign from an Organisational Perspective

Abstract

The organisational literature considers an organisation’s function and structure at four different scales. The organisation of a health system involves at:

• The macro level policy and governance issues

• The meso level the organisation and coordination of regional health, community, social and infrastructure services

• The micro level the provision of local/individual care delivery in the local community

• The nano level issues of personal health, functional independence, and the self-management of one’s well-being and diseases

As outlined in the previous chapter a seamlessly integrated complex adaptive organisation needs to maintain its overarching focus on its purpose, goals, values, and “simple (operating) rules”.

From a complex adaptive systems perspective, a seamlessly integrated complex adaptive, equitable, and sustainable health system needs to:

• Develop its own value based systems, and translate them in its “organisational structures and interactions” (in the form of “simple rules”)

• Recognise that within a health system there are simple, complicated, and complex domains each necessitating different organisational and management approaches

• Have leaders that “direct without directives” and foster co-operation between all staff

• Have leaders that embrace the emergent nature of health systems and healthcare systems in their unique local contexts

• Accept that health system outcomes will inevitably vary depending on the conditions of the local environment

These principles do not prevent subsystems to adopt their own set of purpose, goals, values, and “simple (operating) rules”, however, these need to be consistent with those of the “health system as a whole”.

Appendices

Addendum 1

The Roles and Responsibilities of Agents at Each System Level followed by a red fragment

Macro or Policy-Level Policy and financial frameworks need to address population needs as well as the needs of vulnerable groups. The principle of optimal health for all citizens is central to policy innovations in any model of primary health care. Currently prescriptive, “top down”, hierarchical, and linear policy approaches predominate. In “bottom up” approaches, general practice may advocate for patients and lobby for strategies that provide considered multimodal frameworks in which all stakeholders work together to develop locally appropriate solutions.

Meso or Organizational and Local-Level Addressing health needs and health related determinants at a regional/local level requires coordinated responses from both health providers and administrators. In order to facilitate the evolution of new, locally relevant service models, it is important to allow key stakeholders to operate in an open rather than heavily prescriptive planning environment. For example, the general practitioner/family physician, thus has a developing organizational and knowledge brokerage role in interdisciplinary and intersectoral care, and in the uptake of new technologies, while at the same time maintaining the core principles of personalized care delivery. This requires the translation of research knowledge, ensuring patients’ equity and access to timely health care, and the sharing and coordinating of health care between the wide range of health care and non-health agencies.

Micro or Individual-Level Patients and their communities are the centre point around which care is provided and organized. The effectiveness of the roles and responsibilities of general practice rests in the consultation and the personalized interaction of the doctor/provider with an individual. The consultation is the basic “production unit” in medicine—here decisions about resource consumption are negotiated between the doctor and the patient. Yet roles and responsibilities in this area are evolving with care delegation, new patient expectations, electronic information systems, and internet medicine. Crucially there is an increasing advocacy and leadership role to keep the patient (not a disease, a cost, or a multidisciplinary team) central to the health system and to ensure their core care remains continuous, coordinated, relationship-based, and located in primary health care.

Nano or Organismic-Level The level of health—subjective as well as objective—reflects the entire impact of the forces influencing human health. Health perception, that is, the subjective experience of health or disease, is the result of the person’s interdependence (a term coined by Ban-Yar) with his/her environment. In other words, a patient’s experience of healthcare is an outcome reflecting the effectiveness of consultations—nature and nurture, and the workings of the health system at large. However, in the end it is the organism and its embodied experiences of mind, body, and emotion that we label “health”. This is where health care is directed and has its raison d’être. The judgement of primary health care success is ultimately located at this level. Increasingly this is where the role and responsibility of general practice lies.

Martin CM, Sturmberg JP. Rethinking General Practice—Part II: Strategies for the Future. Patient-Centred, Socially and Economically Responsible Primary Care and the Leadership Challenges [ 1 ].

Addendum 2

The Divergent Interests of Agents in the Health System followed by a red fragment

Level	Agents of influence	Agents’ interests
Macro	• Government policymakers  – Health  – Social services  – Social infrastructure  – Economics and finance  – others—education, work employment, housing, etc.	• Resource allocation  – Determined by perceived priorities  – Has financial control over health  – Currently “Balanced Budgets”
	• Private enterprise  – Pharmaceutical industry  – Device makers  – Medical associations  – Health insurance industry	• Market share and profits  – Getting new drugs developed and  – accepted on formularies  – Financial interest of members  – Growing membership and market share from public health system
	• Citizen lobby groups  – Health consumer forum  – Disease-specific support groups	• Getting greater resources for their specific interests
	• Non-government Organisations  – Research councils	• Getting greater resources for their specific interests organisations
Meso	• Local community infrastructure/ environment  – Work  – Education  – Housing  – Roads  – Social infrastructure  – Open spaces  – Others	• Dependent on cooperation with other interests • Resource constraints • Focused on specific tasks • Shifting priorities with shifting government agendas
	• Public hospital care  – Hospital departments  – Community outreach services	• Resource constraints  – Compartmentalised according to  – organ-system or technology  – Unstable workforce  – Staffing shortages  – High level of bureaucracy  – Performance based on throughput and reported safety
	• Private hospital care	• Return on investments  – Customer focus: doctors and specialists  – Performance based on maximizing revenue per patient day
Micro	• Health service delivery • Primary care  – GP-practice team, incl. reception staff, nurses, psychologists, indigenous health workers, others • Pathology/Radiology • Partialist (Specialist) • Community  – Community nursing  – Physiotherapy  – Psychology  – Other allied health professionals  – Family, friends, and social networks	• Private enterprise concerns  – FFS-system of remuneration  – Competition between practices  – Resourcing according to income generation potential  – Over-servicing incentive  – Time = money, referral an easy option  – Fragmentatory care  – Limited liaison with other health professional providers  – Limited evaluation of health outcomes  – Financial constraints  – Limited knowledge about patient care and support  – Difficulties accessing community support services
Nano	• The person	• Concerned about their health experience, does it limit desired levels of activity • Safety of self-management • Financial constraints • Difficulties accessing community support services

Addendum 3

The Focus and Actions of Agents in a Person-Centred, Equitable, and Sustainable Complex Adaptive Health System followed by a red fragment

Level	Agents of influence	Agents’ focus based on the health system’s purpose, goals, values, and “simple rules”
Macro	• Government policymakers  – Health  – Social services  – Social infrastructure  – Economics and finance  – others—education, work and employment, housing, etc.	• Leadership  – Promote values of the system  – Facilitate the necessary adaptive work that needs to be done  – Ensure they have the resource required  – Collaborate across other portfolios
	• Private enterprise  – Pharmaceutical industry  – Device makers  – Medical associations  – Health insurance industry
	• Citizen lobby groups  – Health consumer forum  – Disease-specific support groups
Meso	• Local community infrastructure/environment	• Community engagement • Think about long-term changes (10-year time frame)  – Work  – Education  – Housing  – Roads  – Social infrastructure  – Open spaces • Willing to understand multiple, perspectives work with complexity in all its challenging messiness, and recognise the importance of both local detail and the over-arching big picture. It’s no small task in this age of the quick fix and the sound bite.
	• Hospital level care
micro	• Health service delivery • Primary care  – GP-practice team, incl. reception staff, nurses, psychologists, indigenous health workers, others • Pathology/Radiology • Partialist (Specialist) • Community  – Community nursing  – Physiotherapy  – Psychology  – Other allied health professionals • Family, friends, and social networks	• Person/patient-centredness • Simultaneous focus on the physical, social, emotional, and cognitive/ sense-making domains of the illness • Joint decision-making taking into account  – Personal choices  – Acceptance of uncertainty and risk  – Impact of environmental factors on health and well-being • Engagement with community advocacy and development • Focus on strengthening linkage with  – Family  – Friends  – Difficulties accessing community support services
Nano	• The person	• Focus on strengthening  – Self-care  – Stress management  – Healthy food, exercise, medication adherence  – Engagement with family and social networks • Focus on prevention in light of  – Family history (genetics)  – Significant life events (epigenetics)  – Harmful environmental exposures—air and other environmental pollutants, poor housing, work place hazards