Over the past three years, ISQua’s Innovation and Systems Change Working Group has been assessing how health systems cope with current and impending ageing populations. The group's work compliments studies undertaken by the World Health Organisation (WHO), European Union and World Economic Forum (WEF).
Our aim is to facilitate a global collaborative approach to address this challenge. The group published a white paper last year on this subject. Now undertaking an in-depth analysis of literature and opinion on this topic, the group is working on its next open access resource, providing a pragmatic update on current and future strategies.
During 2015, the Innovation & Systems Change Working Group began focusing on the global issue of ageing populations, the increasing pressure worldwide on health care systems and the transformation of care needed. Health care systems must continuously innovate and adapt if they are to meet the challenge of delivering safer, better care to more complex patients within limited health care budgets. In October 2015, a one day seminar was held in Doha, Qatar where representatives from sixteen countries shared their vision, diagnosis and further challenges to address their ageing populations. An editorial based on the discussions held in Doha was published in the International Journal for Quality in Health Care in March 2016. On Monday 17th October 2016 Professor Cliff Hughes officially launched the first white paper - Health Systems and Their Sustainability.
On 24th July 2017 Prof René Amalberti, MD, PhD, Senior advisor to the French Patient Safety Accreditation Agency (HAS - Haute Autorité de Santé) and Chair of ISQua's Innovative System Change Working Group gave a webinar on massive population ageing and the major effect this has on health care.
During the 2017 ISQua Conference, in London, delegates were invited to participate in an interactive session facilitated by Prof René Amalberti, Ms Wendy Nicklin and Prof Jeffrey Braithwaite. The workshop was divided into two exercises, the verbatim of which we have published below.
The Innovations and System Change Working Group are currently working on their second paper which will focus on the need for revisiting the basic principles of quality and safety in health care in the face of ageing populations.
London Conference - PreConference - Exercise 1
Focusing on the impacts of massive ageing on the very nature of the health care system, and how we define and provide care to all citizens, whether they are already aged, or they are younger but will need a better care system as they age, cite potential transformations of quality of care and safety standards and methods developed over decades that could cascade from the effects of massive aging in the next twenty years.
We agree to shift care to the community because acute care is quite costly and we want to be sure that the patients take care of themselves outside of the hospital.
The second thing we are looking at is the way we fund healthcare, because right now it is mainly a fee-for-service, and to address a good funding model we have to make sure that it is based on a value-based payment; we saw very interesting models in the US like bundled care and also capitation. These models are probably good to fund patients for what they value most.
Another thing interesting at our table was the input from the private system, since it is quite different from what the government is looking at. They prefer care to be in the hospital for maintaining profits.
We listed some key problems associated with the ageing process: attitudes to ageing, geographic and financial accessibility of the ageing population, political competing interests about financing and educating and making reforms all over the world.
To overcome all these things, our health system should be reformed, addressing and keeping at its center the ageing population. We know that this ageing population is suffering from chronic disorders, which are very costly and it is not possible for many countries, especially in Asia, to give all these people the services at the right specialised level.
The treatments have to be given at home or at the community level.
So community level and home base reforms of the healthcare system could be the most cost effective reforms/weapons to help this ageing population.
The first thing that came to mind is prevention - to prevent people from getting sick, from entering the disease process and from needing to look for health services. Secondly, we want to move the doctors away from the process; in other words we want to empower nurses, other therapists and allied aiding persons and families. We agree with the colleagues from Singapore; moving away from fee-for-services because it provides the wrong incentives. Third, work on education at school, this empowers patients to ask questions on their treatments.
We talked about four different areas: (a) patient responsibility, (b) the ability to navigate through the healthcare system, (c) preventive medicine… we have a dentist in our group who pointed out that very few people actually lose their teeth because preventive dental care has been brilliant over the last few years. If we extrapolate that to many other conditions that ultimately result in chronic illness, preventive medicine should begin in childhood, (d) We talked about data and technologies and the impact that it's going to have on the way we deliver systems. Finally, we spent most of the time talking on structures and process out of the hospitals, which is a point that comes out at all tables. The question we ask: how can we decentralize and maintain quality and safety? Three ideas came forth: education, communication and standards.
We agreed that in 20 years, most of the elderly people will be in their own homes. Given that, we have some problems. We want the nurses to be here, but we have a lack of resources for nurses in our countries; The second problem is that when you send people home from the hospital, you send them home to less qualified staff, but they are more sick; we have to change the competences to be able to take care of these patients.
India is a young society, but even in India the social system is changing and it is getting more difficult for families to take care of the aged population; this is a challenge for all of us.
The speed of ageing is also very high in all of our countries, not only in Japan, but also in Korea, Hong Kong, and now China has just joined the group. In South-Korea and Japan we set up a long term care insurance, in addition to the health care insurance system, and one issue is how to coordinate and integrate these two systems and to make a more efficient system.
We actually cannot say that we can spend more money on health care. In Australia the population is ageing. That means that we have more patients, with the same amount of money. We have to accept that our pocket money is smaller, so the discussion needs to be about not just the amount of money but about how we divide the pie.
Three things we talked about. The first thing is our system which likes to spend money on opening new hospitals, but does not talk very much about humans. We have not got great community engagement and without that community engagement, we cannot have the cultural and community discussion and a robust decision. The second thing on a practical level is that the political circle has a big impact: every three years we have an election. The important thing is that our leaders who make decisions on how the money is spent are unable to be long term strategists. The third point we spoke about was the ethical dilemma. Within Australia, we have people struggling, trying to find food and a place to sleep and yet we have also many that are rich enough and sleep and eat very well. So the ethical dilemma is how do we make a decision on how the money is spent. As an aside, we also have an international issue; we know that Australia attracts physicians from poor countries … do we have a global ethical responsibility?
For us, a modern health care system should focus on patient empowerment, a population based approach and what these two themes bring to integrated care. Another point is to change the payment system. It would be good to have a value-based payment system, but it could be difficult without perfect data, and difficult to measure.
Another ethical dilemma is the high cost of some medical treatment, especially cancer. How to prioritize problems.
London Conference - PreConference - Exercise 2
Of the challenges listed below, choose the two top challenges that make sense as priorities for your region within the next decade. For these two challenges, develop:
- What changes could be considered
- How your region consider steps to definitively advance progress.
- What initiatives are necessary to truly advance the agenda?
- Who are the key drivers and partnerships that will accelerate change/transformation?
- How do we accelerate change?
- CHALLENGE 1 Adapting basic Q&S definition and concepts
- CHALLENGE 2 Adapting Q&S principles for a ‘just-in-time’ logic in acute hospitals
- CHALLENGE 3 Adapting Q&S principles to home care/aiding persons
- CHALLENGE 4 Adapting Q&S principles to patients living alone
- CHALLENGE 5 Adapting Q&S principles to the growing number of cognitive impairment
- CHALLENGE 6 Adapting Q&S principles to the digital revolution
- CHALLENGE 7 New governance: impact on leadership, measurement and accreditation
We have two priority choices, challenge 7 is our number one choice, and challenge 3 is our second choice. Why we chose the governance? Because the ageing population is not a local problem; it is a global problem and to address the issue, we need to address both global governance, and local governance. So, we think that it is not only the local government to reduce for example the use of tobacco, but there is also a link with the WTO, World Bank, IMF, these kinds of things. So then what is the impact on the local government or national government? If we consider the local government, this issue of ageing should be prioritised, defined and motivated by local and national governance, and in our vision, at least, we think that ageing is not a prioritised issue because the governments have other competing interests and have limited human and financial resources. We are not very interested in governance however we need to learn to replace this term with stewardship that includes leadership and regulations. Policy should come before regulation, and both regulations and policies should influence public and private sectors. All public and private sectors should come together because private sectors are in all health sectors since globalisation in the 1980s. We see that in both public-private, it is only in finance but not in regulations, so it is not working. So we propose that both the public and private should come together to make policies and to prioritise the issue of global ageing populations. The leadership became popular in Bangladesh in 1978 but it has big competition with the effect of globalisation, because primary care health care has 4 main principles; social equity, community participation, multi-sectoral approach and appropriate technology. This does not work very well because of competition in the private market – a consequence of privatisation and marketisation of health care and a rise in the age of the population. We think that the leadership should include all the components of the country, including the ministries, public sector, private sector, the market and also civil society. These components could come together and do something better, using a very life-based approach for this ageing community. Their voice should be heard, because at one time they did something very productive for society, but now they are aged and have a right to get a return from society.
If I go to the second challenge, marketisation is only interested in investments and returns and not in prevention. We propose that prevention should be addressed in terms of sustainable development and that because of industrialisation and urbanisation, development is not sustainable. This is because there are no biking parks, green spaces and playgrounds in our surroundings or in our urban areas. We think these should be integrated into our policies for prevention of diseases. People who are 20 or 30 years old will be 60 or so in 30 years’ time and will have a good environment for exercise and good knowledge and information about better health. So a sustainable policy should involve all sectors of the society and include community participation. In short, I would say that civil society should come forward and play a role; there is a big part to play for society.
Challenge 3 should be integrated in this policy. It is not possible to give efficient treatment in a hospital that is not working – somebody can go to the hospital and then invest his own money and may leave to sell his own property. What is the consequence of this? Because of this we propose that home-based care and community-based health workers, skilled health workers, should be improved and in place. This would reduce the harm in the society.
Basically we are looking at challenge 7 as our top priority – governance and leadership. And challenge 3 as our 2nd priority – moving to the home care setting. In our context, we have these slogans of moving from health care to health but we don’t really have any financial support from top down. Therefore we would like to see a change – increased budget, more financial support. For us, the move from acute care into the home care setting can relieve some of the pressure on the caregivers. We can utilise some of the technologies like tele-health or vital signs monitoring, in the future once we have a budget. In our context for home care the main challenge is a lack of trust between the doctors and the caregivers. The doctors will be held liable if they discharge their patients before they are ready; it may be the doctor has a problem or the caregiver has a problem. We have to have some budget for training of caregivers in the home to ensure they have certain knowledge of what to do during a medical emergency.
One of the concepts that we discussed was the concept of the sharp edge and the blunt edge. We ranked challenge 1 as the top priority because that’s what’s happening at the sharp edge – where the doctors, nurses, support workers are, the people who deliver health care are at the sharp edge of the system. What things are important to them going forward? Firstly, health care is changing rapidly. In fact, it is estimated that medical knowledge doubles every 4 years. Because of this we need new metrics, we need dynamic metrics. We need to change them essentially as we go along. We also need to define what is quality – I think everyone in this room would agree that our definition of quality changes from time to time. We agree with the statement that we need to manage, but not control risk. I think Jeffrey made the point that 95% of the time we are successful and 5% of the time we are not. Why are we successful 95% of the time? That is extremely important.
With all that, we need to define what the standards are in a dynamic and ever-changing universe, so we need to develop a process. We feel it’s extremely important at the coal face that patients must be consulted, so they should form part of the decision making group. The key drivers here are stakeholders – patient, family, caregivers, health care providers, champions within the team and support groups.
Our 2nd priority was governance, because this is the blunt edge. This is where the government works and where we find the people who are establishing the regulations and framework within which we work in health care. We felt that therefore this should be the 2nd most important priority. We recognise that governance can be at national level, regional level, state governments, provincial governments etc. and perhaps most importantly at the local level. That obviously provides a feedback loop to the sharp edge, That is, the group of people who are regulating the system or responsible for the system who are closest to those at the sharp edge. An example that we discussed was of a transplant committee, which works very much locally but on the other hand it has to feed into a number of different areas. We agree that input from patients and families is extremely important.
Finally we talked about – what is the health care system going to look like in 30 years? We believe that much of the care will occur at home, that assisted living will be extremely important - and you could divide that into nursing homes and long-term/hospice care and also hospital care. So the model isn’t going to change dramatically but the balance will change over the next 30 years.
We think that challenge 1 is an over-arching challenge, so we discussed the challenge relating to home care and the challenge related to cognitive impairment. The changes we discussed relating to healthcare is 1, in Brazil and we have a colleague in our group from South Korea who noted that most of the challenges also apply to her context. 1) is to have target funding, especially from public and private in the case of Brazil, to do with health care 2) to establish national policies and most importantly 3) to improve coordination across the continuum of care and also integration with primary care in the home care setting, and 4) better legislation and regulation and also a definition of what services home care provide and does not provide. Also there should be some form of alignment of expectations between health care providers and families, as to what to expect in terms of outcome in home care. Partnerships, patients and families with the health services and policy makers and how to move the agenda forward – I will discuss these two together.
In terms of cognitive impairment, the first idea is to raise awareness among health care providers and families about the burden of cognitive impairment now and in the future, and 2) to better equip the primary care teams and all the other care teams with a true multidisciplinary team including psychologists, behavioural therapists, eventually psychiatrists, to deal with the cognitively impaired patients and also to improve our diagnostic ability. Again, partnership with patients, families, perhaps special needs societies and the local healthcare authorities is important how do we move the agenda forward? One of the things we really need to try will to move this forward, perhaps doing this step by step, moving it forward at a small scale as step one, a health care unit in one region, and then scaling up to the State and to the country. Also, we can only move the agenda forward if we truly engage the community, patients and families. So the change comes from the grassroots, from the bottom, because if we wait for those at the top to make the changes, we will go nowhere.
In first place we chose challenge 7, and in the second place we chose challenge 3. On challenge 7, we talked about the need for long term planning and systems that - in spite of having elections every 4 years - so that one government can’t change what the other has done. We also think that we should put a lot of effort into education at both high and low levels. We think that we need accreditation programmes. It is very important to have interaction analysis so that we can find out where we are good and where we need improvements. With number 3 we think education is very important for both patients and for the next of kin.
Empowerment is also a key word - empowerment with patients and the families. Also, it is important to understand transitions of care and practicalities and nutrition aids for the families. We need to have technologies there as well. It is important to aid communication between patients and the families because sometimes the patient and the families don’t agree on where to die – in hospital or in community care. And also communication between acute care and community care.
Without leadership, nothing can be achieved. In huge countries like ours, leadership makes policies, they allocate resources, they decide how the system works, so the impact of leadership we have placed as our number 1. Make leadership and various people in it aware of the minutiae of the problem. Develop indicators related to the health of senior citizens and include them in the routine monitoring of health systems. Put this in the system of accreditation, include it in government statistics regularly. It will help them to change health care policies and to use accreditation as a tool on various things related to health care systems, attending to old age problems.
Our second challenge was number 6, the digitalisation. Multiple platforms are being used and systems don’t talk to each other. It’s not regulatory so much as it is industry decided. Secondly, using the internet for things for health care monitoring, more and more interfacing of health professionals with industry so that new innovative tools can be developed. Impact of tele-medicine – whether we can improve that further. Robotics – how it can be used, domestic robotics. We can use robotics for communication challenges, robotic recognition of communication challenges, to identify whether there is depression, what kind of communication is going on with human beings – can it be used to monitor? And of course, health information literacy among the health professionals.These are some of the things we feel are important.
We chose challenge 3 and challenge 4 as our top two priorities. We realise for Australia this is a major transformational change in moving from a hospital environment to a community, home care environment and that would require an enormous number of things to happen. We believe it needs to be a government led strategy with a long term view and certainly we have had some other strategies, particularly one called living well and living longer that has been able to achieve that, but it’s very much a long term view. We believe that it needs active partnership with multiple organisations that have capacity and capability to deliver those types of models of care. We tossed around the idea of removing it from ‘anything-for-profit’ view, as it needed to be something that was seen to have a well-being agenda as opposed to an opportunity to make profit out of it. We also decided it might need to have a view and approach to the way we obtain funding including a co-payment from consumers based on their capacity to do so. We realise that changes to the funding models have enormous implications in terms of associated state and federal funding models. It requires a broad consultation process across the political sectors and also the not-for-profit sectors and the other community sectors including the various professions involved in it. Once the direction has been chosen – and this might be the cart before the horse, but we don’t think so – it’s the identification of qualitative and quantitative outcome models
We picked challenge 3 and challenge 5. I think these two challenges are related to each other. When you are getting old your cognitive ability is impaired so these two are our top two.
In Taiwan we have 23 million people and 14% of them are aged over 65 so we are quite an old country. In 2026 the aged people will be over 20% so it’s a big problem. In Chinese culture, we like to age at home so we have to plan our services to deliver this. We are facing this challenge now. A couple of months ago we passed the Long-Term Care Act, version 2 – so we divided the long-term care service into 3 sections, a, b and c. If we want to fulfil the 3 parts we do not have sufficient money and not enough personnel. The system is not well developed yet. So what do we have to do? In this a, b, c system, it all starts from acute care in hospital – if a patient is admitted to hospital we have to do discharge planning. If the patient is aged over 65 then we have to plan everything for them. It’s a heavy load for the nurses because the discharge planning is performed by the nurses. So the nurses are facing a lot of work. If we find the person is in long term care, we have 11 tasks and then we have to fill a 27 page questionnaire for the patient. So that is the first challenge for us.
The second challenge is that not many people in Taiwan are aware of the details of the long term care services and we don’t have money. How can we overcome and close that gap? In our hospitals we try to simplify the discharge planning because, as I mentioned, we have 11 items to perform as a first line screening and then have 27 page questionnaire. We are using technology to automatically extract data from our nursing information systems, so we can streamline our work. There was a lot of education for the people who were willing to join long term care services, so we could get enough personnel. We also advertised a lot to inform the public about long term care services.