Leadership for the future health system: where do medical leaders fit in?

There is widespread agreement that the people we serve must be at the centre of designing a health system for the future. In many ways it is astonishing that it has taken until now for this paradigm to diffuse across the levels and variety of clinical disciplines, including the most senior of doctors.

From this thinking an old idea has become ‘new’ again: that care should be integrated – across disciplines and settings, across public and private, health and non-health sectors. Questions being asked regard what qualities leaders in this re-design need, and the extent to which doctors have those qualities, or can be trained for leadership roles.

Graph: Whole of system cycle: the person-centred propeller. Source: rosemary.aldrich [at] calvarymater.org.au

In Australia we are also grappling with meeting the challenges of ageing population, constrained resources, increasing expectations of consumers, widening inequalities, increasing cost drivers, and the need for engaged transparency. This year I have travelled to Singapore, England, Scotland, and New Zealand to observe and learn about the experience of whole system integrated care models from the leaders of some of the world’s best health systems. I find it useful to think of what we are seeking to achieve in terms of X (outcome) = culture x structures x people (both the people we serve and the people providing the services); cultural, structural and people factors are key and common to effecting person-centred integrated care.

Culture – health culture leaders must:

• truly believe in the aims and reasons for going down the path of slow but necessary system transformation; leaders must listen to patients, clients and their carers about what works for them, support the workers trying to make it happen, and just get on with it
• put the individual and the community at the centre of thinking –  support clinicians to make the best decisions, referrals, and communications to most effectively and efficiently provide care for the people who need it
• focus on primary health care initiatives and options rather than a culture of hospital admission
• be careful about the language used to communicate strategy and purpose – language is vision, and
• permit and train others to be responsibly innovative without a strict command and control structure (‘permissive leadership’); this is a feature of the successes of the Canterbury Health System in New Zealand.

Structures – integrated care systems should:

• at all levels and through all clinical work units (no matter what size) address three aims: manage demand, optimise (patient) flow, and effect continuity of care, as represented in Figure 1; effort revolves around the “P” in the middle (for patient, person, people, or population)
• strengthen primary and community care,  and promote collaborations with non-health sector agencies to identify and address structural barriers to accessing or benefiting from health care, and to reduce the need for hospitalisation; as much as possible such systems move care out of hospitals and into or close to a person’s home, and
• identify ways to invest in primary and community care using the savings realised from managing the multiple causes of waste in secondary and tertiary care.

People we serve – partnering with consumers includes:

• identifying frequent re-presenters and re-admitters to hospital – at our facility we call such people VIPs (Very Intensive Patients) – and ask them why they have come to hospital and what they think would help them get the care they need where it can be given, and
• characterising at an individual level the social determinants drivers of care seeking, including social isolation and mental health issues, and form partnerships to find solutions.

People we have – growing a workforce for the future health system needs medical leaders who:

• acknowledge and respect the many equally important stakeholders in an integrated care system
• reflect on where medical leaders fit in; given our conventional role as directors of care and gatekeepers of care plans, it is critical that medical leaders are champions of whole system integration, and can lead clinical peers in system re-design by demonstrating innovation, leadership, use of evidence to inform models of care, understanding of system mechanics such as financing, and genuine collaboration, and
• understand and prepare themselves for the many challenges to being a health system leader; these include being willing to share ideas without regard for who gets credit, being prepared to relinquish “the way we do things around here” in favour of a more patient- or person-focused approach proposed by someone else, and being capable of self-reflection to examine personal behaviours which may or may not promote deep integration.

To effect integrated health care centred around the people we serve, medical leaders and managers will require numerous skills, including knowledge of how systems work, judgement to analyse and plan, and a capacity to lead and or be part of teams working to embed person-centred health care; both ‘teamship’ and leadership are crucial. Medical leaders can be system leaders, but not alone.