Monday, October 27, 2014

The Role of Health Care Professionals in Health Service Innovation

On Friday 24th October 2014 we held a Public Management and Governance Special Interest Group workshop on the Role of Health Care Professionals in Health Service Innovation at the British Academy of Management (BAM) office in London. The workshop was funded by BAM Researcher Development Grant as part of our research project on CCGs and telehealth. Panel discussions with eminent experts in the field triggered engaging and productive discussions among all participants. As we know health care professionals are faced with challenges in the innovation of the health service  to increase efficiencies and improve patients’ outcomes. Their valuable set of skills and pool of knowledge can contribute towards workable solutions in health service innovation. Yet, health care professionals are very busy people, overstretched with resources. They require will, effort, breaking cultural barriers and changing routines to implement and make health service innovations work effectively. The workshop offered the opportunity to learn about recent advancements in professional studies of health service innovation and share and discuss research experience and ideas on how to advance research agenda in the field. The workshop discussions focused on three main themes: the implications of IT-enabled integrated care for inter- and intra-professional collaboration; how knowledge sharing across professional boundaries within and outside the health sector (e.g. universities) can contribute to health service innovation; the role of professional power and identities in health service innovation. Many ideas were discussed in the workshop and this post just summarizes a few.

Starting with integration, one theme that emerged in the discussion is that of a socio-collaborative approach to integration where integration is seen as a socio-technical infrastructure with any one working on it knowing not only their bit but also how the whole integrated system works. The cost-driver of integration does not seem to bring any good to the cause. Driving integration with a focus on patients' needs can be more effective. A debatable issue was that of the role of professional integration vs. organizational integration. In other words, are barriers to health care integration mainly organizational (e.g. competition among health care professionals, fragmented patients pathways)? Or is poor inter-professional collaboration due to strong boundaries between health care professionals one of the major challenges to health care integration?

Moving to knowledge sharing across professional boundaries, the discussion opened with a focus on the collaboration between academia and health care organisations in co-producing innovation and research sponsored by such programs as the National Institute of Health Research (NIHR) Knowledge Mobilization Research Fellowship Scheme and Collaboration for Leadership in Applied Health Research and Care (CLAHRC). It came out that misaligned incentive schemes and interests between professionals and academics constitute one of the major barriers to their collaboration. While a Clinical Commissioning Group (CCG) may be interested in collaborating with a researcher for the evaluation of a telehealth project, researchers may question whether the type of data collected in an evaluation can be worth good academic publications. Difficulties in collaboration also exist between clinical and social researchers, the former more interested in the effectiveness of an innovation and less interested than social researchers in the social and normative dimension of an innovation. Brokers with multiple background of experience emerged to play a significant role in  bridging healthcare with academic communities. In this respect, the broker does not necessarily need to be a senior person. Fundamental is the role of interconnected brokers that engage in boundary work by communicating with other brokers in other teams. There were mixed opinions about whether more collaboration and knowledge sharing opportunities could lead to increased innovation. Co-production models can work, they produce innovation but at a very low pace. By contrast, Multidisciplinary Teams (MDTs) have not always proven very effective in terms of knowledge sharing and innovation. These teams may take the form of institutional rational myths because of the use that one group would do to direct and plan other members action. These considerations have led to question the role of organizations and institutions in limiting boundary work and co-production of innovation across professions. Taking the example of the UK, most innovation and change management programs in the NHS are driven by the top-management. Very little is done at the top, whereas professionals are not empowered and entrusted to do more. This top-down approach stifles innovation from the grassroots  and bars clinical ownership. 

Finally, talking about professional power and identities in relation to health service innovation, we discussed new collaborative and hybrid forms of professionalism matching clinical and managerial roles. Public reporting of performance has gained the legitimacy among health care professionals as ways of proving their clinical excellence to their peers and secure public trust without losing their autonomy. One question is whether these mechanisms of professional accountability can work as a catalyst of innovation or, by contrast, may have the opposite effect of stifling innovation. For example, excessive reporting may have the downside effect of diverting time away from creativity. Linked to this, it is worth questioning whether and how new hybrid forms of professionalism can be conducive of innovation in the health sector. This is particularly important in relation to those episodes where health care professionals can challenge innovation if they feel it can threaten their identity. Can clinical managers overcome these resistances? The importance of health care professional identities is even stronger in those circumstances where the implementation of one innovation does not lead to variation but uniformity across multiple sites, such as diverse hospitals. Not everyone in the health sector views innovation as a threat to their professional identity and social status. There are also instances where innovation can be perceived as a source of empowerment. IT systems like EPRs (Electronic Patients Records) can enlarge the role of nurses, for example, by giving them more clinical tasks and responsibilities. IT-enabled changes in professional practice relate to the extent to which an IT innovation fits in the professional culture of a specific category  of staff.

Sunday, July 20, 2014

Health Care Integration through Telehealth

In the past few years there has been a lot of emphasis on integrated health care provision. This goes along side patient-centred care whereby health and social care teams work closely together in the community to provide a more holistic care plan to patients with multiple Long Term Conditions (LTC). By integrating health and social care services, commissioners hope to reduce avoidable admissions and outpatients’ services utilization.

Telehealth can enable better health and social care services integration and out-of-hospital strategies by empowering patients to manage their health better and by providing health and social care teams in the community with the capability to monitor patients’ conditions in their homes. The idea behind telehealth is to implement a continuous care plan that prevents patients from entering a critical stage, which would then require no other means but hospitalization.

Effective care plans of patients with complex health conditions also require specialist medical skills that from the hospital need to be deployed in the community.  Thus, telehealth can work as a powerful tool of integration between secondary and primary care services. Taking the example of Heart Failure (HF), telehealth can be used as an enabler of an integrated cardiology pathway whereby skills of specialist nurses and consultants at the hospitals can be used in the community. For GPs this means working closely with both hospitals and community services for a better care plan of their patients.

Yet, in recent years, the gap between hospitals and primary care services has widened due to competition among providers. Many hospitals are big powerful organizations that take most of the health budget. Commissioners often need to purchase services from more than one hospital to provide their patients with enough choice for their treatment. Therefore, the design and implementation of a cost-effective telehealth pathway require commissioners to work closely with GPs, primary care and secondary care providers. These actors should work together towards an integrated  health care service delivery model, whereby both specialist and generic medical services are provided to patients affected by LTC in the community

Thursday, July 10, 2014

Telehealth: opportunities and challenges for clinicians 

Recent studies suggest that GPs can view telehealth as a threat to their identity as “gateways” to health care (e.g. Segar et al. 2013). This is because, after referral or hospital discharge, patients mainly deal with a telehealth centre. Yet, GPs can also see telehealth as a means of empowerment by giving them more responsibilities in managing such conditions as Heart Failure (HF) early enough to avoid hospitalisations. That is the case when, for example, GPs go for a specialist pathway, such as cardiology, and become GP with Special Interests (GPsIS). Even though some GPs may see the role of GPsIS as undermining their autonomy and identity as general medical professionals (Currie et al. 2012), some GPs may view these new specialisms as an opportunity to enhance their knowledge and their professional status.

Yet, often General Practices do not have the capacity to lead a telehealth project. Their major involvement would require a considerable investment of resources on primary care. Yet, this does not seem to be much different from the resource needs that the hosting of a telehealth centre in a health care community centre involves. Therefore, we can conclude that, if GPs buy into telehealth and they are given enough resources, their level of engagement in the successful implementation of telehealth may be related to how telehealth impacts on their professional status. Such impact may not necessarily be negative but also positive for the sustainable and scalable adoption of telehealth.

Thus, the issue at stake is to understand how GPs can be enrolled into the innovation process enabled by telehealth. GPs can actually influence the course of an innovation in the health service. For example, GPs’ members representatives bodies and other forms of organizations such as clinical advisory groups can have a say in CCG Governing Bodies’ decisions on whether and how an innovation should be put in place.  It is in these circumstances that the role of CCGs in health care IT innovation takes prominence. Given that GPs have a high representation in their governing bodies, it is legitimate to ask how the interplay between their roles of “commissioners” and “medical professionals” influences the quality of relationships with key health service stakeholders affected by telehealth implementation. 

Wednesday, June 25, 2014

Telehealth Commissioning in the UK

Our journey starts with telehealth in the UK. Thanks to a research grant from the British Academy of Management (BAM), we are conducting a research project on the role of Clinical Commissioning Groups (CCGs) in the implementation of telehealth. For those of you who are not familiar with the health sector in the UK, CCGs are NHS (National Health Service) organizations in charge of commissioning health care services in their local area. CCGs were created in 2012 with the latest health sector reforms. The majority of their members are General Practitioners (GPs), who, together with their major health care partners, such as local councils, are responsible for the design and planning of health care services for their communities.

Simplified model of telehealth pathway

In particular, CCGs are now faced with the paramount responsibility of bringing health services closer to patients. It is within the patient-centred care agenda that telehealth constitutes a key strategic resource for commissioners, thereby stressing the importance of learning more about how commissioners can roll out telehealth services successfully. That is because telehealth has the potential of reducing avoidable admissions and outpatients services utilization as well as enhance the delivery of primary care services to patients. 

Yet, there are mixed results on the cost-effectiveness of telehealth. Some would say it is worth the money, particularly, because it enhances the patient experience in terms of self-disease management, thereby reducing the number of contacts with GPs and outpatients visits. Others would argue that there is not enough evidence that telehealth can meet expected efficiency and cost-saving targets.

Let us not forget that small telehealth pilots or projects cannot create the necessary critical mass of users to deliver expected results in terms of cost gains. In addition, telehealth is much more than a toolkit; it is a complete new health service pathway requiring a certain amount of effort in the reorganization of the health service. The responsibility of how telehealth can be embedded within full stream service delivery rests with CCGs, who, in consultation with their local partners, decide what are the best and most sustainable pathways for their patients. Having this in mind, the research project we are leading aims to  produce evidence on the main issues that are most likely to affect the adoption and scalability of telehealth services.