6.5. Mechanisms to facilitate integration
6.5.1. Stewardship
At the meso level, stewardship relates to vertical integration where higher level policies are implemented by organisations to promote shared visions and establish an optimal, sustainable health system. This is coordinated through mechanisms such as governance and regulation, as described below.
Governance
As discussed in Report 1 (Integrated care: What policies support and influence integration in health care in Australia?), governance is a key responsibility of governments at the macro level; however, it is also important for policies and leadership to be translated vertically to meso level organisations.
This mechanism is included in the current report as integrated structures can exist both horizontally between government and/or non-government agencies, and vertically across levels of government and/or non-government sectors. At the broadest/primary level, governance can be analysed in terms of those involved in collaborating to establish society’s public policies; and at a secondary level, in terms of the forms of specific public policies, such as the resulting rules, institutions, laws and enforcement mechanisms. In addition, governance can be analysed at the level of particular organisations, as in the governance of a district health system or a hospital.For example, health care governance considers whether improvements in the way services are governed affects service delivery. Further, the notion of integrated governance refers to the formal relationships between organisations that allow them to manage deliverables, risks and processes through collaborative business approaches (IPAA, 2002). Emerging partnerships require management of interactions between differing modes of governance, which in some instances promote collaboration and in others, competition. This can lead to difficulties sustaining successful relationships among diverse partners - a possible challenge for MLs as they work to coordinate GP, allied health and community health professionals in the PHC sector (IPAA, 2002).
Several challenges in the current PHC system, such as power-sharing, funding, care models and the absence of effective relationships between organisations, can be addressed through appropriate
Stewardship (oversight)
Creating resources (investment and training)
Delivering services (provision)
Financing (collecting, pooling and
purchasing)
Responsiveness (to people's non-medical
expectations)
Fair (financial) contribution
Health
Functions the system performs Objectives of the system
governance. As integrated delivery systems/networks are formed, governance structures must be responsive to both internal and external stakeholders. Both internal efficiencies and socially
responsible actions are required of these relatively new organisational forms. One systematic review (Jackson et al., 2008) described three potential methods for integrated health care governance (Figure 8):
separate organisations merging
developing a separate incorporated structure for areas of common business overlap
coming to a common collaborative arrangement while maintaining separate independent governance and funding.
Figure 8 Methods for integrated health care governance
The authors also described the need for a clear separation between governance and operational management, and the value of local communities with the vision, leadership and commitment to extend health service integration (Jackson et al., 2008). It is important to recognise the distinction between governance performance (e.g. Are organisational rules followed?) and organisational performance (e.g. Does the hospital have low infection rates?). This latter distinction is important because many measures of governance performance are closely related to organisational
performance and yet different factors intervene at each stage. For example, absenteeism is a good Separate organisations
merge into one single incorporated body which
delivers all services on behalf of the original
organisations
Where organisations have a common business overlap, funds and control
in that specific area move to a separate incorporated
structure which delivers services to the specified
population
Organisations formally commit to a common governance arrangement in which there is business
overlap across a geographical area, but
otherwise maintain separate and independent
governance and funding Governance option 1 Governance option 2 Governance option 3
Collaboration & funding 3 Models of integrated health care governance
Collaboration, not funding
Source: (Jackson et al., 2008)
measure of governance performance – it measures the degree to which governance arrangements promote managerial actions to recruit, motivate, supervise, and discipline staff to comply with their formal work obligations (Jackson et al., 2008).
Common concerns relating to governance have been identified such as board structure and function, size, membership, continuing education, affiliations and alliances (Savage et al., 1997). The
effectiveness of the LHIN model of PHCOs in Ontario (Canada) identifies the importance of increasing the clarity of decision-making processes, reviewing and aligning resources, enhancing collaboration processes and partnerships, refining accountabilities and processes and governance (KPMG, 2008). Successful integrated governance requires strong leadership, which is promoted by clear delineation of roles and responsibilities across and within organisations. This may exist in the form of clinical leadership, such as the role played by the newly established National Lead Clinician Group (LCG), or it may refer to GP leadership as was the case with the DGP. Barriers and facilitators to governance in integrating care are like those of any large-scale organisational change – i.e.
leadership, organisational culture, information technology, physician involvement and availability of resources (Ling et al., 2012).
Regulation
As described above (see page 29), arms-length bodies are regulatory bodies which work closely with meso level organisations to provide stewardship through regulation and performance monitoring.
They are separate entities that promote independence, transparency and objectivity. These bodies are an important part of integration as they ensure that practice and frameworks are consistent across organisations and agencies. In addition, some peak bodies may play a regulatory role such as the AML Alliance and the former AGPN, which coordinate the function and outcomes of their respective organisations.
Sustainability
Sustainable healthcare is defined as - "a complex system of interacting approaches to the restoration, management and optimisation of human health that has an ecological base, that is economically, environmentally, and socially viable indefinitely, that functions harmoniously both with the human body and the non-human environment, and which does not result in unfair or disproportionate impacts on any significant contributory element of the healthcare system” (Open sustainability). It also refers to the long-term ‘staying power’ of a model or system (Scheirer et al., 2008). A recent report from the World Economic Forum (World Economic Forum, 2013) noted the need to expand the traditional boundaries of healthcare to consider a broader health system that integrates a range of non-health agencies and experts in the development of sustainable health systems. The report notes that, with the current global economic challenges, it is important to consider the long-term effect of current plans and perhaps shift the way of thinking about reform to ensure that new developments in health systems promote sustainability. One example of this can be seen in the ongoing changes in England’s health system structure, which have led to disruption, confusion and change fatigue related to the formation and termination of CCGs and PCTs, respectively (Boyle, 2011). Further to this, the research literature commonly identifies the importance of allowing sufficient time to enable cooperation and collaboration to develop; and cautions that sustainability will occur only if new models are given the opportunity to embed themselves within systems.
In Australia, sustainability can be achieved by learning from the activities of international health systems. For example, a lack of resources and opposition from both competitors and the medical establishment contributed to the demise of the IPAs in NZ. Therefore, Australia can learn from this
experience and ensure that there are sufficient resources and clearly delineated and advertised roles and responsibilities to facilitate a smooth path for new organisations created in the PHC sector.
A further challenge to sustainability is the changing demand for services. For example, while health promotion and prevention strategies and effective chronic disease management may enable healthier populations, the resulting increase in life expectancy creates a different set of demands.
Sustainability in this sense needs to include flexibility and the ability for governance to allow
organisations to act according to local needs; and for training and education opportunities to enable development of the workforce to keep in step with the changing composition of the patient
population (Gruen et al., 2008).
Gruen et al (Gruen et al., 2008) describe how developing a comprehensive approach to sustainability based on the type of evidence/data discussed in sections below could be of benefit to a range of stakeholders including policy makers, funders, and managers.