Trust, an ingredient needed to innovate

Mònica Almiñana

"One, the citizenry will not forgive the president for hiding health information that can help save their lives. Two, in a crisis, people must feel like a soldier, not a victim. Three, telling the truth generates trust, silence generates fear. "

CJ Creck, The West Wing. Season 3, Episode 9 (2001-2002)

When Aaron Sorking wrote these sentences for his character, the White House press chief in the series The West Wing, in a chapter where a health problem was addressed, came up with some of the keys needed to manage the communication of this type of crisis. In a recent article in BMJ Leader, "Leadership during the COVID-19 pandemic: building and sustaining trust in times of uncertainty," Susannah Ahern and Erwin Loh also outline some of the keys to leadership in times of uncertainty. And one of those keys is trust. The authors themselves define it as "The expectation or belief of an individual, often in vulnerable circumstances, that another person's actions or motives will be honest, fair, and based on integrity (following sound ethical principles)." (1)

10 priorities for integrating physical and mental health, according to The King's Fund

Andrés Fontalba

The current health care model that classifies patients by system or medical specialty categorises care to for any health problem. The causal attribution to diseases according to the psychic vs. organic dichotomy inhibits seeing the process of the pathologies in their totality and contributes to the problem of patients taking their illness from one service to another, with the risk of overacting in some cases or of non-holistic intervention method of integrated solutions in other complex cases.

Beyond the reforms (on the subject of Franco Basaglia)

What can we do when reforms are in short supply? This is a question that many of us ask ourselves when rigidities and bureaucracies show us their sordid face. Without going any further, the integration of services and community work is the only way (I think there are no dissenters in this) to adequately care for complex chronic patients, but when it comes to the truth, it turns out that the levels of care, professionals’ abilities and the fragmentation of medical specialties are a drag on the progress of the necessary reforms.

I’ve pondered on this when I read that The Guardian had just published a book by John Foot, "The man who closed the asylum" that tells the life of Franco Basaglia, a psychiatrist with an exceptional entrepreneurial force. During the war, according to the author, Basaglia was imprisoned as an antifascist and this experience was key to the fact that when he was appointed director of an asylum in the early 1960s, he realized that the psychiatry practiced in that establishment was inspired by and took the shape of prisons.

Hospital general vs factory hospital

In the post October 5, I explained how, according to the report "Future Hospital Commission" (Royal College of Physicians 2013), it would be ideal that, as soon as possible, the organizational models of the hospitals would be able to evolve in two directions: a) about one third of the health care activities should apply techniques of industrial quality, and b) the other two thirds of patients admitted (complex case-mix) should be treated radically differently from how it is done now, given the shortcomings of the work organization in the hospital wards.

In the current model, each admitted patient has a medical service and a medical specialist assigned. The clinical activity of this medic develops primarily through the clinical course of medical orders (including requests for evidence and pharmaceutical prescriptions) and through interdepartmental advice from colleagues from other specialties. As for the nursing work , there are several intensity models ranging from a major involvement in the clinical process to a trivial change of shifts.

Summary of the limitations of the current model of care for inpatients and the arising risk situations:

1. The allocation of a medical specialist doesn’t guarantee at all the care continuity because many of these specialists also have their other technical functions, specific to their speciality that are often more attractive that visiting the wards.
2. The guards’ medical model does not guarantee the maintenance of a homogenous quality of care, nor at night, nor on holidays.
3. The interdepartmental work, generally means little involvement. Specialists try to fulfil the commitment with an opinion and, rarely, joint clinical work derives from this activity.
4. In many hospitals, nurses have a working commitment to the continuity of care quality for admitted patients but this is not universal, and great variations between centres are detected.
5. Inpatients often undergo changes of bed, or even ward changes for reasons of centre’s logistics organization, and this fact is known to subject the patient to avoidable risks.
6. The quality of transfers of complex patients from the hospital to their homes is not guaranteed in all places and at all times.

Coordination, integration (in Spanish Health Care System)

Each of the care system levels has become strong in a particular feature in Spain: in primary care, it has been the role of the gatekeeper; in hospitals, the hierarchization of medical services and in the socio-sanitary area, the offer of post-acute beds. And if we look at what these strengths have been translated into, we will rapidly agree that the primary care has achieved a performance of proximity and effectiveness in prevention, the hospitals have obtained very satisfactory levels of resolution in acute diseases and the socio-sanitary has contributed the essential decompression to the system.

These same strengths, which are certainly well recognized, become rigidities when new requirements that somehow question the status quo, emerge. However, I will demonstrate in 4 examples how the health system has been able to offer imaginative responses, without any hassle:

Readmissions (2). What are the experiences that are yielding results?

The Congress Investigation Services of the US (CRS) published in September 2010, in support of the Obamacare, a report on charges for Medicare of hospital readmissions. The very well documented report assumes that 17.6% of discharge bills issued by hospitals to Medicare are due to the readmissions occurred within 30 days of discharge. Therefore, the two economists who signed the report assumed that they found in the readmissions a source for collecting Medicare savings, moreover taking into account that the variations between areas were making it possible to foresee that an adjustment in the contracting model could be fruitful.

From this document I liked the classification of the actions aimed at reducing readmissions, actions that as it will be seen to be effective, must be tailored to the complexity of the elected patients.

Model 1: very complex patient, intensive action

Readmissions (1): what are the best policies to reduce them?

To create this readmissions post, I have chosen three publications, the first of which provides a critical review of how the American public insurers address the issue, the second publication gives the point of view, also critical, of two hospital doctors, whilst the third is a review promoted by "The Commonwealth Fund" on the policies of US hospitals that are having the lowest rates of readmissions nationwide.

First publication

According to this article, CMS (the public body that manages the Medicare and Medicaid contracts in the US) estimates the average for the 30-day readmissions rates for patients who have been hospitalized for myocardial infarction, pneumonia and heart failure. If a hospital’s rates go above the average, CMS penalizes it with a reduction in the fees of all income in the following year, in proportion to the deviation of readmissions of the three monitored conditions. It’s estimated that in 2013, in a particular centre, the punishment can reach up to 3% of the turnover. Ah! And there will be no prize for hospitals with rates lower than the average.

Heart failure: what works?

Heart failure is the end result of most heart diseases, especially ischemic coronary disease. This is a highly prevalent chronic condition among older people (6-10% in those over 65 years), which provides a great disease burden to the healthcare system.

Both for its origin, which is none other than the long-term failure of acute cardiac pathology, as well as for its diagnosis, the cardiologists, and not the family physicians are the ones leading the management of some clinical processes that are almost always torpid and uncertain and which require a lot of action in the community and a lot of coordination between the hospital and primary care; as you can see, it’s not an easy business.

Heart failure, unlike diabetes, is a chronic process that, as I have already mentioned, slips away from the hands of the family doctor. To begin with at the time of diagnosing, because the clinical diagnosis is only presumptive and sending the patient to the hospital for an echocardiogram confirmation is required. It now appears, however, that it has been shown that the "NT-proBNP*" test (Verdú 2012), detectable in both blood and urine testing is sufficiently cost-effective to be able to expect that primary care units could begin to autonomously solve the diagnosis.

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(*NT-proBNP. Natriuretic peptides are hormones with diuretic and vasodilator effects, segregated mainly in the left ventricle as a compensatory mechanism for a pressure overload).