Elements of chronic disease control in a provincial health service.

1. Elements of chronic disease control in a provincial health service. Assoc Prof Paul Dugdale Director, ANU Centre for Health Stewardship

2. Elements of chronic disease control in a provincial health service • The growth in chronic disease burden • Elements of a policy response • Toward lucid health care • E Health • Multidisciplinary practice • Patient empowerment

3. Elements of chronic disease control in a provincial health service • Demographic and epidemiological analysis predicts a large increase in chronic disease burden in many areas of Australia. • Increasing longevity • Increasing migration • Fertility no longer falling • The “Urban Penalty” (McMichael): prolonged sitting, processed food, • Higher diabetes rates

4. Responding to the chronic disease challenge • governmental policy support at national and regional level; • a sound business case and appropriate financing; • reorientation of health service culture from episodic to continuing care; and • community development for people with chronic disease to self manage effectively.

5. Health system reform for better chronic disease management • Detailed planning is required as part of this response. • Multiple institutions and governments need to be involved • a systems engineering approach may look good on paper but will fail to make headway in the real world. • Multilevel government arenas shift responsibility across jurisdictional boundaries • And generate continual negotiation.

7. Forms of knowledge in health system research • Normative • Therapeutic • Technical • Interpretive

9. Between the forms of knowledge • The forms of knowledge are radically disconnected • Some forms of knowledge are necessary – but not sufficient – for the generation of others • Work that traverses the forms, and shows their connections and disconnects, has the potential to generate real insight.

11. The production, dissemination and use of knowledge in the health system • The health system produces information and knowledge with volcanic intensity • Management and the research community have powerful access to this information • This knowledge underpins the power struggles between management and doctors • Everyone else – patients, front-line health workers, administrative support staff – operate in a dark fog.

13. Toward lucid health care • Some developments suggest this is changing: • The E-health revolution • Multidisciplinary practice • Patient empowerment and deliberative democracy

14. Toward lucid health care • Each of these developments centres on the accessibility of useful, comprehensible information. • self –interested comprehension of the situation you find yourself in so as to know what to do is part of what Bourdieu identified as the ‘social conditions of lucidity’. • The view that various aspects of health service don’t make sense arises from a perception that there is information missing, • with better knowledge of what is going on, things could be done better.

15. E-Health & Information Liquidity • Information is abundant and its transport is cheap. • Information overload is unhelpful • Information interpretation must be widely distributed • Intelligent distribution of information is an important governance strategy • the use of information flows can produce a culture change toward health as a knowledge industry

16. Interprofessional learning and the learning institution • Encourage quality improvement, prototyping, and interprofessional learning to improve chronic disease management practice. • “The fundamental notion of the learning healthcare system—continuous improvement in effectiveness, efficiency, safety, and quality—is rooted in principles that medicine shares with engineering. • “In particular, the fields of systems engineering, industrial engineering, and operations research have long experience in the systematic design, analysis, and improvement of complex systems, notably in such large sectors as the airline and automobile industries.” • Institute of Medicine “The learning health system” http://www.nap.edu/catalog.php?record_id=12213

17. Features of a learning health system • The system’s processes must be centered on the right target—the patient. • System excellence is created by the reliable delivery of established best practice. • Complexity compels reasoned allowance for tailored adjustments. • Learning is a non-linear process. • Emphasize interdependence and tend to the process interfaces. • Teamwork and cross-checks trump command and control. • Performance, transparency, and feedback serve as the engine for improvement. • Expect errors in the performance of individuals but perfection in the performance of systems. • Align rewards on key elements of continuous improvement. • Education and research can facilitate understanding and partnerships between engineering and the health professions. • Foster a leadership culture, language, and style that reinforce teamwork and results.

18. Patient empowerment • Encourage the enactment of deliberative democracy through citizen engagement in policy making and the creation of arenas for continual negotiation. • Consumer representation in governance, use of Social media, representative surveying, and responsive complaint handling are all useful strategies. • http://www.iom.edu/Reports/2011/Patients-Charting-the-Course-Citizen-Engagement-in-the-Learning-Health-System-Workshop-Summary.aspx

19. Community development • Reinvention of post retirement community structures • Work the baby boomers’ education, service culture and sense of entitlement • From trad jazz to dinosaur rock; cycling is the new golf; • Take control of your health care and get out more. • “Training group leaders how to include people with chronic disease in community activities” http://eview.anu.edu.au/chronic/toolkit/index.php