The urgencies and the elderly

Reflections (and proposal) in the face of the impending winter emergency crisis

@varelalaf

If nothing is done, vulnerable people will increasingly go to the emergency room because of their multi-pathology, the presence of certain symptoms that are difficult to manage from home or the problems of their environment, they call 061 increasingly often. And that is how hospital emergency services become refugee camps within health systems. A clinical trial conducted in 24 French hospitals, which included more than three thousand people over 75 years of age in a clinically critical situation, showed that the centres most likely to enter older people in critical units, in addition to not reducing their long-term mortality term, neither improved their functional capacity or their quality of life.

Chronic Complex Patients and the Blue Ocean Strategy

The book "Blue Ocean Strategy" by W. Chan Kim and Renée Mauborgne has been celebrating 10 years, having sold more than three and a half million copies, and now, to celebrate, a revised edition has just been published. The central thesis of the book is that today's markets are characterized by oversupply and therefore, companies must compete fiercely between them and the oceans (It’s a metaphor) are stained red with the blood of the fight. For this reason, the authors propose to companies to go on the search for blue oceans, like Cirque du Soleil or Ikea, where their products or services will be incontestable because people will see them as novel and useful. The strategy of these companies is clear: their contribution must be perceived as a value innovation, and as a consequence would able to open new unexplored markets like oceans that will not go red.

Leaving aside the commercial aspects of the theory, the book left me with the (attractive) vision of a blue ocean that, inevitably, I have contrasted with the difficulties that all health systems have when it comes to implementing convincing programs of patients’ care and I thought that perhaps at this point a blue ocean strategy would be beneficial when aiming to implement new projects that would arise from overcoming current difficulties. I have to admit that applying Chan and Mauborgne's theories to complex chronic patients is a bit far fetched, but I am convinced that there are some strategic methodology proposals that could be of some use.

Strategies for the integration of services

King's Fund has published a timely and in depth document "Acute Hospitals and Integrated Care" where they question what role should hospitals play in the integration of services. Given the approach, one could ask: What role should primary care play? How about community services? And the social health services? However it may be best, King's Fund has focused on it in this way and I believe it has its reasons for doing so because, right now, the organizational model that everyone tends to is that of territorial management or that of integrated health organizations, all of which are intended to integrate services from a hospital-centred position.

Who should lead the integration of services?

According to the document, it’s fundamental to generate the network of services on a territorial basis and the question of leadership should depend on the nature of each clinical process. Let's take a few examples: a) A remote dermatology project should be led by specialized care, b) An infarct ought to be led by cardiologists, intensive carers and emergency specialists, c) Care for type 2 diabetes mellitus, should be led by the primary care, d) Individualized therapeutic plans of complex chronic patients, should be led by primary care with the community nurse and the social worker taking a high profile role, e) Complex end-of-life processes should be led by community-based multidisciplinary palliative teams.

Integration of social and health services: 3 issues and 3 solutions

Aging population has many interpretations, some of them very positive such as the fact that more and more people are fortunate that they live for longer with a fairly healthy life. The other side of the coin is that there are also problems such as increased multiple combined chronic diseases, social deprivation and the fact that many people reach an advanced stage of geriatric frailty. And this is where service delivery models that have been consolidated in recent decades are still struggling to give satisfactory answers. Governments know it and, for this reason, are launching initiatives to address chronic disease and frailty in a more effective manner but these programs often face political difficulties, resistance to change and difficult to overcome bureaucracies.

From everything I've seen in this issue, I think the British are the most daring, so I chose the report of the "Commission on the future of health and social care in England" published by King's Fund, because it synthesizes very well what the problems of current models are and what are the solutions to be put on the table.

First problem: the current model is unfair. The health system is universal and free, while access to social services is restricted. Let's say two examples: people affected by cancer enjoy global coverage, regardless of process costs and economic level of the patient, while Alzheimer's patients suffer from limited access to services, especially in more advanced stages when their needs are more social than medical.

Second problem: funding sources are different. The health system feeds directly from the public budget, while social funding source is hybrid, with participation of different administrations, including the local, and with a variety of complex management copayments.

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: