Serving an Ageing Population Well implications for health management. Expert Roundtable, 15 December 2010 Meeting Report

Serving an Ageing Population Well –

implications for health management

Expert Roundtable, 15 December 2010

Meeting Report

Introduction

By 2050 it is predicted that 32% of the EU’s population will be 65 and over, compared to 20% now. It is increasingly accepted that this will lead to fundamental reshaping of health and healthcare: in the types of services that are delivered, funding, relationships between health and other sectors and in patient empowerment, to name but a few. Delivering a reshaping of health services takes us beyond the efficiency paradigm into important system change– and skilled management and leadership will be central to this.

The purpose of the roundtable was to explore these issues with a relatively open agenda, giving experts a forum in which to reflect and exchange learning across national and sectoral boundaries. The meeting is the first of a series to be developed in 2011, and a core purpose of this first workshop was to identify priority themes to be discussed next year.

The roundtable also comes in the context of the launch of the Active and Healthy Ageing Innovation Partnership, a new European Commission initiative in the field aiming to help support EU citizens to live longer independently in good health, in particular by increasing the average number of healthy life years.

The participants at the roundtable came from a broad range of backgrounds, including postgraduate education of senior managers, clinical work with older people, professional groups at EU level, and the European Commission. The meeting was held under Chatham House rules, so that the discussion is reported in full, but comments are not attributed to individuals.

Mapping the Issues

The first section of the meeting focused on mapping the issues of an ageing population, and in particular issues in relation to health management and leadership. A few parameters were set early on to frame the problem:

• Focus on implementation: understanding implementation in practice is crucial to

informing policy frameworks. Connecting the policy and practice discussion was a key aim for this roundtable.

• Definitions of management: the one used in this roundtable was the broadest

possible, encompassing not only those with “manager” in their job description of title, but all those who are involved in the organisation of services.

• Definitions of health: the scope of the roundtable was similarly broad, encompassing

not only healthcare services (such as hospitals, family doctors etc) but also home care and other services that impact on health (housing, transport). One participant suggested that serving older people well is about quality of life and includes the following domains:

1. Physical 2. Mental

3. Social well being 4. Environment

Issue Mapping

Serving an Ageing Population Well – implications for

management Collaboration/ Competition Integrated care Self Management Technology/ICT (i) task shifts

(ii) equality of access (iii) training

(iv) financing Workforce

New competences, skills, knowledge, values for managers

Quality of Care Responsibility of system

and family – where is the boundary? Prevention Policy contradictions? How to incentivise collab? Integr. DRG? challenges efficiency paradigm?

How to move money around the system?

Informal care and role of carers

Networks, working across boundaries, working with informal carers... Harnessing energy of

younger older people

tool for change or a good in its self?

How to shift managerial behav / attitudes? Distinction between

complex patients and single morbidities What will the

health(care) setting be?

Public/private financing

Reshaping workforce around needs; needs vs shortages

Dilemmas for managers: comp/ collab; decentr/ centr; transp/ privacy; independ/ regulation Shrinking pool of workers Changing mindsets (prof) to wellness not illness How to implement change of mindset and shift funding?

2

˚

Perception of older people: how to shift away from seeing older people as a burden?

Generational shift in pt expectations? Importance of educ. within orgs What is preven-tion? What kind of care model do we want and how do we produce change?

Identifying priority issues for discussion

Having mapped the issues, participants put them in priority order. The following were the top five themes. The discussion and debate following picked up on the top three.

Competition and Collaboration Workforce

Integration of care Prevention

Technology

It was suggested that the group adopt a model used in geriatric care to distinguish between different groups of older citizens: fit older people (usually 60s), a transition period (usually 70s) where the older person has multiple health needs, and frail older people (usually 80+), where the need for rehabilitation services increases significantly in dealing with health conditions.

Discussion and Debate

In a context where many health systems encourage competition as a stimulus to efficiency, how does this affect the collaboration needed to deliver the best possible services for older people?

The top issue highlighted by participants for further discussion was the question of whether the emphasis on markets within healthcare creates a policy contradiction with the collaboration needed to deliver a continuum of care to an ageing population, and how managers can respond to these system drivers. There was a broad consensus that different parts of the health system need to link together and link with other sectors to provide high quality care for older people. An example was described of a multidisciplinary team working in Scotland (including doctors, nurses, dieticians and others) to provide holistic care for frail older people. Access routes into the programme include referrals from acute presentation in secondary care, through the family doctor or through social care.

On the question of competition, a distinction was made between competition encouraged in some health systems between similar institutions (for example hospitals) and what one participant termed ‘antagonism’, which sometimes exists between different parts of the health system and/or between health and other sectors. An example was given of the transfer of patients between secondary care and rehabilitative services. Both are challenges to delivering the best possible care for older people but the roundtable participants particularly emphasised the challenge of interservice/intersectoral conflict.

The group questioned the proposition made in some health systems that competition between institutions furthers quality, concluding that for older people the key is good quality care that provides an aligned or integrated experience rather than specifically choice of service provider. On the question of the relationship between different parts of the

health system, or between health and other sectors the group discussed the lack of relationship sometimes between institutions treating the same patient, and the ‘blame culture’ that can hamper collaboration.

By way of response to these challenges, the importance of financing for the continuum of care was underlined by several participants. An example of an integrated DRG (diagnosis related group) across a number of different parts of the health system was given as a pointer to one possible way of integrating financial responsibility. The need for further work on options to incentivise collaboration was underlined.

Integration of care

What do we mean by integration and do we know what benefits it provides?

The discussion focused initially on what is meant by integration, particularly on whether the continuum of care is best served by aligning services and organisations or by formal mergers of organisations.

A number of the participants had experience of systems with different approaches to integration, ranging from loose alignments to formally merged organisations. There was substantial debate and some disagreement, with some participants arguing for more formal integration, and others for a looser ‘coalescing’ of services. Of the difficulties in aligning or merging organisations discussed, the need to deal with cultural differences between organisations and sectors was particularly noted. The challenges of aligning professionals with different terms and conditions, processes and working practices all contribute to a major challenge in delivering high quality services for older people.

The evidence on the benefits of formal organisational mergers was questioned by a number within the group. An example was given of a cross-sectoral merger where two professional groups did not share offices many years afterwards because of lack of working relationships and differences in professional culture. Although there were different views among the group, the discussion concluded on the importance of skilled change management and leadership in either aligning or integrating services as a focus rather than the exact organisational form that the collaboration takes. The implications for health managers and health management education were also discussed, in particular the anticipated need for changing skills for managers. These include being able to manage in a network environment, being able to adopt collaborative language that does not antagonise other services or sectors, and being skilled negotiators in order to successfully manage the interfaces between institutions and sectors.

The group also discussed the dynamic of personal budgets held by patients, a policy in some of the countries represented, in the context of a continuum of care for patients. One participant described shifts to personal budgets as “very challenging” to some health systems. There was significant debate on the role of clinical advice in the context of patients managing their own care. Participants also discussed the likely generational shifts in patient expectations and its impact on self-management.

Workforce

Who will we need to care for Europe’s ageing population, and how do we develop the workforce we need?

The discussion on the workforce needed to serve an ageing population started with a call to stimulate a debate at EU level on the kind of health workforce that is needed for the future and the impact on professional roles, flexibility in skill mix and opportunities to work with informal carers. A particular point was made on the possibilities of younger-older people caring for old-older people.

There was also significant discussion of the potential issues of workforce shrinkage, shortages and skill gaps. In particular, the issue of attrition of the health workforce was focused on, and the importance of working conditions, flexibility and new ways of working in retaining the health workforce. As several participants observed, the loss from health professions of people moving away from the health sector is far greater than professional mobility between EU countries, and poses a major challenge for managers across the EU in the coming decades.

Conclusions and gaps

Two particularly important issues were not discussed at length in the second session of the roundtable.

Prevention: it was agreed that a further roundtable will be held to explore the issue of prevention of ill health in an ageing population. As participants at the roundtable commented, the messages on the importance of prevention and the need to move funding away from treating illness to keeping older people well have been known for many years. Even so, as the recent Health at a Glance report from the OECD and the European Commission has shown, only a tiny percentage of health budgets is spent on prevention. It was therefore agreed that EHMA’s work in this area would focus on strategies for implementing change in shifting from illness to wellness.

Technology: although technology was highlighted as an important area by all participants, with significant benefit for older people, it was less discussed. The particular points highlighted on technology and health ICT include the issues of equity of access, the opportunities for task shifting, the importance of training and of shifting managerial attitudes towards new technologies. There was debate on the role of new technology, however, with some participants arguing that technological advances are not a good in themselves, but only useful as a tool for clear policy priorities. Discussions on the potential of technology as a potential tool to serve quality care for older people will be picked up in the two further roundtables in 2011.

Next steps and key dates

9 February 2011, Serving an Ageing Population Well – integration and collaboration EHMA office, Brussels

Based on Wednesday’s discussions, the follow up meeting to the roundtable will be focused specifically on collaboration and integration of care: particularly how to incentivise collaboration and looking at the evidence on the impact of formal mergers of organisations vs other models. Please hold the date in your diary if you would like to attend. We also intend to schedule a further roundtable in April to work on the issues related to prevention and strategies for implementing change in shifting from an illness to a ‘wellness’ model.

2-4 March 2011 EHMA/MCI Winterschool on Health Leadership: Integration and collaboration in healthcare – towards truly patient-centred care?

An event focused on the practical implementation of integration and collaboration, with opportunities to work on solutions and questions of change management as a group www.healthleadership.eu

22-24 June 2011, Integration in Health and Healthcare Porto, Portugal

The call for abstracts (research and practice papers) for EHMA’s Annual Conference is open until 17 January 2011. Registration opens on in late January 2011. For more information please see www.ehma.org

About EHMA

The European Health Management Association (EHMA) is a not-for-profit membership association with over 150 member institutions across 30 countries working in the health field. EHMA’s aim is to improve the quality and build the capacity of health management in the European region. For more information on EHMA, please visit www.ehma.org

EHMA has a long track record of active engagement in issues on active and healthy ageing. EHMA was the lead partner for the Carmen project (dates) which focused on integration of care, and also co-ordinated the HealthQuest study, which looked at access to healthcare for vulnerable groups including older people with functional limitations. For more information on joining EHMA, please contact Elisabeth Jelfs ([email protected]).

This meeting has received funding in the form of an Operating Grant EHMA-FY-2010 from the European Union, in the framework of the Health Programme (2008-2013). Sole responsibility lies with EHMA and the Executive Agency for Health and Consumers is not responsible for any use that may be made of the information contained therein