6.7. Risks and unintended consequences
6.7.3. Change fatigue
A common unintended consequence of health care reform is resistance to change, conflict, tension and turnover of staff resulting from change fatigue (Nutting et al., 2011, Doocey and Reddy, 2010, Maruthappu et al., 2010, Coombe, 2008). There is an expectation to implement a raft of changes, often without consultation or explanation to those required to adopt the changes or manage the consequences. As a result, the receptivity and commitment to change is low, cost is high and progress is slowed.
7 General summary
Factors that differentiate the models across Australia/internationally are:
Governance
Funding
Incentives
Partnerships where plans, providers, services remain separate but have arrangements around exclusive and interdependent contracts (i.e. MoUs or contractual arrangements)
Co-location
Performance indicators/ benchmarking.
The research literature in this review recognises the complexity of health care systems and
impediments to integration (e.g. convoluted funding and finance arrangements, competition, multi- layered organisational structures, cultural differences). Consequently, evidence suggests that attempts to introduce new structures and mechanisms to promote and enable integration should strive to not introduce additional complexity, but rather to work within a few minimum
specifications to create an environment in which innovative and complex behaviours can emerge (Plsek and Greenhalgh, 2001). These specifications, or conditions, include setting directions, establishing the boundaries of roles and responsibilities, allocating resources, and providing permission/legitimacy for new behaviours and relationships. The specifications need to have
intuitive appeal (‘face validity’) for the new set of ‘rules’ of engagement and integration to work and stakeholders should have direct input into establishing these minimum specifications and conditions for integrated health care. This process, however, is very dependent on the strength of existing networks amongst all the players and where the organisational and service ties are weak, much effort on strengthening networks is warranted (Fisher et al., 2012). The approach can make change attractive, enhance motivation, and reduce resistance to change and is in stark contrast to
generating a new set of protocols to be imposed within a detailed plan, which often results in non- compliance and cynicism.
A corollary of this approach to complex systems is “that it is often better to try multiple approaches and let directions arise by gradually shifting time and attention towards those things that seem to be working best” (Plsek and Greenhalgh, 2001). Plsek and Greenhalgh suggest that this ‘best-fit’
perspective may, paradoxically, result in far quicker and more pronounced change for the better than any attempt at rolling out a “Rolls-Royce” fix within complex scenarios. Attendant on this approach is the need for evaluation to be built into any complex system change from the outset, with ongoing measurement and review; otherwise a descent into chaos and failure, always hovering at the margins of complex systems, is likely (Plsek and Greenhalgh, 2001). It is evident across the models for integration that have been reviewed in this report that better outcomes have been reported where considerable effort was directed at getting providers to communicate directly with each other, whereas complex restructures often lead to a new set of challenges and problems, even when making some gains.
Five key findings
Integration of organisations at the meso-level does not guarantee integrated health service delivery; however, some of the leading models (i.e. Integrated Delivery Systems) show significantly improved health outcomes, cost reductions and evidence of integrated health service delivery across the health system (both vertically and horizontally).
The mission to integrate health service delivery involves engagement of numerous health and non-health organisations and providers, across multiple levels (horizontal and vertical) involved in the delivery of health services.
In Australia the overlapping roles of the commonwealth and states for the delivery of health services makes identifying who is responsible and accountable difficult. The system is complex which influences its efficiency with regard to integrated service delivery.
Strategic and targeted financial incentives are required to deliver both long-term and short- term outcomes for integrated service delivery. Voluntary participation and goodwill facilitate health service integration.
Infrastructure is necessary to support coordination (e.g. shared records), needs assessments and longitudinal measurement of both population and individual health outcomes.
8 Conclusion
The difficulties inherent in major re-structures in the health system are well documented (e.g.
organisational culture and structural differences, lack of clarity in goals, competitive approaches, limited resources and complex funding arrangements, limited engagement of stakeholders and a poor understanding of relative roles and responsibilities, restrictions on sharing of information and resources, poor evaluation) and could easily overwhelm attempts at integration.
However, there is evidence emerging that initiatives which are realistic in their ambition (not over- reaching or imposing overly complex structural reforms) and that place much emphasis on
establishing and facilitating networks and partnerships are more likely to achieve integration and desired outcomes, albeit modestly at first and incrementally. The literature suggests that
establishing viable electronic communication is necessary when physical co-location is not possible so that diagnostic information can be shared and collaboration occurs, with client consent, on treatment plans; performance indicators to guide attempts at integration, and measures for evaluation, should be in place at the outset; and any major change attempt should not sacrifice any strengths of the existing system and should be flexible enough to give due weight to local contexts.
The national and international literature review yielded five recurring central themes to effective and efficient integration of organisations involved in health service delivery at the meso level. The five key components were: communication, organisational culture, structural system arrangements, information technology and resources and funding arrangements. The first two elements around enabling communication between individuals and organisations (within and across sectors) and the act of influencing workplace culture are arguably the toughest challenges for policy to influence. In contrast, the latter three elements (infrastructure, resources and funding) are common drivers or levers utilised by governments. However, recognising and investing support in the first two elements is required in order to meet local needs, align resources, and promote cohesiveness between and within sectors of the health system.
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