Internal Medicine Journal 45 (2015)
E D I TO R I A L
On the barriers to signiﬁcant innovation in and reform of healthcare This is the first in a series of editorials that will address the reasons why healthcare remains largely refractory to the innovation and reform required for ongoing system sustainability, affordability and fitness for purpose. The series is based on the following observations: 1 There is a growing mismatch in regard to demand, supply and affordability in all Organisation for Economic Co-operation and Development countries’ healthcare systems.1–4 Innovation is required,5 but healthcare is ‘paradoxical’ in this context. 2 Healthcare systems are vulnerable to ‘micro-change’. These changes make healthcare planning and investment difficult;6 in some cases, the ‘micro-change’ has mitigated the demand, supply, affordability mismatch, whereas many others have aggravated it. 3 By contrast, healthcare systems are essentially resistant to ‘macro-change’. The core operating model, which is hospital based and doctor led, has not really changed over the last 150 years, despite a profound change in disease burden.7 Given the natural history of almost any industry studied of ongoing disruptive change,8 healthcare and education are exceptions. There are many commonalities for the latter two, one of which is that they are both dominated by professional power elites. The barriers to ‘macro-change’ in healthcare consequently need to be identified and addressed for necessary and overdue innovation to take place. For this series, eight core barriers to innovation have been identified, each of which will be the subject of individual editorials. These are introduced briefly here. 1 Provider-centric models of healthcare in which many consumers of that care are passive. The hypothesis is that real innovation will only occur when healthcare becomes ‘patient-owned’. An example of this is underway in New Zealand where disabled people are literally given the budget to purchase their own support services. Other local small steps towards patient-owned care include self-ownership of health records and advanced care plans, but how can this be accelerated? To put this in marketing terms, what is needed for citizens to get some ‘skin in the game’ of health and healthcare – bearing in mind the extant cohort of anxious well-worried sick ‘over-consumers’? A major shift in the orientation of private insurance schemes is also necessary to alter the current proconsumption bias.
2 Shortfalls in clinician and health system leadership. Leadership has been a popular subject,9 but, with few exceptions,10 the address has been too strategic. In particular, the problem definition has been poor, which does not inherently lead to tactical solutions. If the answer to the ‘question’ is better health system leadership, then the question itself will determine what should be done. For example, if the question is where is the next generation of health system governors and managers going to come from – the answer will be talent spotting and mentoring. By contrast, if the question is what is needed for a sustainable and fit-for-purpose health system,11 then the solution will have to address behaviour at the patient–provider interface. The solution will be based on contextual and values-based leadership training as a fundamental domain of professionalism for all health professionals. 3 Inadequate health system intelligence. Intelligence is another subject that has received attention,6 which has not made an appreciable difference to the status quo of healthcare. A distinction is made between data (e.g. the number of pharmacists who engage in clinical practice beyond dispensing) and intelligence (e.g. what would need to be done to encourage other pharmacists to take up such extended practice). The pharmacist example is cited because the absence of such a key piece of intelligence led to a very unsuccessful innovation development and legislative change in New Zealand. The time of annual practising certificate renewal is an obvious point of ‘capture’ for both qualitative and quantitative intelligence gathering for the regulated healthcare workforce. However, how is similar intelligence obtained for the very large unregulated workforce? 4 Restrictive business models and (often perverse) funding and remuneration systems. There are numerous examples of ‘failed’ business models, and funding and remuneration systems, in healthcare – varying from poorly constructed pay-forperformance schemes, to activity-based transactional funding, and to essentially incentive-free capitation/ population-based funding.12–18 These models and systems have generally inhibited innovation, and or caused a loss of productivity, and have usually not resulted in improved quality of individual healthcare or better population health – and most have not reduced the cost of healthcare. Indeed, many have added cost and not value.
© 2015 Royal Australasian College of Physicians
A key issue that will be covered in the subsequent editorial is what is the difference between loose-loose-loose, loose-tight-loose and tight-loose-tight funding of healthcare and what is required for the latter – which is the most desirable – to be successfully implemented. Additionally, the balance of publically and privately funded healthcare is generally not sustainable and the private spend is often not synergistic – it encourages consumption, which can detract resources from the public system, and create excessive consumer and provider expectations. Affordable insurance schemas that promote compliance in people with chronic disease and reduce the consumption of healthcare are needed. 5 Restrictive regulatory practice. Regulation is a frequent barrier to innovative healthcare reform – ideally, the regulatory definition should be of competence and not professional group. There is also considerable debate about the net impact of some continuing education requirements and re-accreditation processes on the quality and diversity of healthcare.19,20 6 The threat of litigation. The threat of litigation is cited as a barrier to innovation and a reason for consequent uptake of provider – protective but low utility (and often costly) healthcare. However, the importance of this factor is challenged by the observation that the New Zealand health system is probably as counter-innovative as that in tort-liable countries such as Australia, England and the United States, despite New Zealand’s no-fault treatment injury compensation system.21 7 Territorial behaviour by potentially disrupted craft groups and professions. The behaviour of health professionals is well described by way of the anthropology of guilds – this is not to say that such guilds have not made a positive contribution to the quality of healthcare, but is to argue that territorial behaviour by potentially disrupted craft groups and professions is often a barrier to innovation.22 These behaviours are frequently exaggerated by the business models and
References 1 Lewis S. A system in name only– access, variation, and reform in Canada’s provinces. N Engl J Med 2015; 372: 497–500. 2 Iacobucci G. Financial crisis is inevitable in the NHS by 2015–16, King’s Fund says. BMJ 2014; 348: g3048. 3 The NZ Institute of Economic Research. Ageing New Zealand and Health and Disability Services: Demand Projections and Workforce Implications, 2001–21. A
funding schema in place. There is an obvious requirement for inter-professional training, attention to contextual leadership and ‘follower-ship’ in professionalism curricula and the avoidance of competitive funding models. Outcome-based and alliance contracting is preferable. 8 Intrinsically flawed health systems by design. The argument is that ministries and departments of health are generally role conflicted and tactically weak. Given the different customers and practitioners involved, the role conflict is such that regulatory and policy functions probably need to be separated from system administration. Many countries also have a distributed governance system for public health services, and the problems are, again, common and commonplace. The department or ministry involved is usually not a sophisticated purchaser and particularly in the context of actuarially based longterm funding of chronic disease – the end result is that innovative care is generally not incentivised. For most, there is no real ‘structure’ for purchasing at a regional level and the system then is essentially one of autonomous district health providers. The autonomy is generally substantive and uniform, regardless of competence and ongoing performance. Autonomy has not had to be earned and is difficult to lose. Central oversight is weak and intervention is usually late – a suitable accountability framework is needed to underpin and reward progressive practice. Given that the status quo is not a tenable response to future health needs, the barriers to innovative reform of healthcare must be both systematically identified and overcome. Hopefully, this editorial and the subsequent series will be a useful stimulant. Received 29 March 2015; accepted 29 March 2015. doi:10.1111/imj.12775
D. Gorman Occupational & Environmental Medicine, University of Auckland, Auckland, New Zealand
Discussion Document. Wellington, New Zealand: New Zealand Ministry of Health; 2004 [cited 2014 Nov 24]. Available from URL: http://nzaca.org.nz/ publication/documents/nzierreport -ageingnzandhealthanddisabilityservices .pdf 4 The New Zealand Treasury. Health Projections and Policy Options for the 2013 Long-Term Fiscal Statement. Draft Paper for the Long-Term Fiscal External Panel. Wellington: New Zealand Treasury; 2012.
5 Corrigan P, Exeter C, Smith R. Innovate or die. BMJ 2013; 346: f1699. 6 Gorman DF. Planning healthcare workforces for uncertain futures. Acad Med 2015; 90: 400–3. 7 Australian Institute of Health and Welfare. Burden from chronic disease. 2015 [cited 2015 Feb 12]. Available from URL: http://www.aihw.gov .au/burden-from-chronic-disease/ 8 Christensen CM, Bohmer R, Kenagy J. Will disruptive innovations cure health care? Harv Bus Rev 2000; 78: 102–11.
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9 Gorman DF. Citizenship, health and the challenge of clinical leadership. Intern Med J 2010; 40: 739–41. 10 Gorman DF, Horn M. Productivity gain a triumph for clinician leadership. Intern Med J 2012; 42: 605–6. 11 Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff 2008; 27: 3759–69. 12 Campbell SM. Effects of pay for performance on the quality of primary care in England. N Engl J Med 2009; 361: 368–78. 13 Gillam S. Should the quality and outcomes framework be abolished? Yes. BMJ 2010; 340: c2710. 14 Gorman DF, Thompson M. Encouraging and rewarding the good behaviour of
healthcare providers. Intern Med J 2011; 41: 585–7. McRae IS, Paolucci F. The global financial crisis and Australian general practice. Aust Health Rev 2011; 35: 32–5. Mehrotra A, Melony ES, Sorbero MS, Damberg CL. Using the lessons of behavioral economics to design more effective pay-for-performance programs. Am J Manag Care 2010; 16: 497–503. The New Zealand Medical Council. The New Zealand medical workforce in 2013. [cited 2015 Feb 12]. Available from URL: www.mcnz.org.nz Siriwardena AN. Should the quality and outcomes framework be abolished? No. BMJ 2010; 340: c2794.
19 Irons MB, Nora LM. Maintenance of certification 2.0 – strong start, continued evolution. N Engl J Med 2015; 372: 104–6. 20 Teirstein PS. Boarded to death– why maintenance of certification is bad for doctors and patients. N Engl J Med 2015; 372: 106–9. 21 The New Zealand Accident Compensation and Rehabilitation Corporation. (ACC). Annual Report 2014. [cited 2015 Feb 12]. Available from URL: http://www.acc.co.nz/ 22 Gorman DF, Brooks PM. On solutions to doctor shortages in Australia and New Zealand. Med J Aust 2009; 190: 152–6.
Reversible cerebral vasoconstriction syndrome Z. Calic,1,2 C. Cappelen-Smith3,4 and A. S. Zagami1,2 1
Institute of Neurological Sciences, Prince of Wales Hospital, 2Prince of Wales Clinical School, 4South Western Clinical School, University of New South
Wales, Sydney and 3Department of Neurology and Neurophysiology, Liverpool Hospital, Sydney, New South Wales, Australia
Key words reversible cerebral vasoconstriction syndrome, thunderclap headache, posterior reversible encephalopathy syndrome, primary angiitis of the central nervous system. Correspondence Cecilia Cappelen-Smith, Department of Neurophysiology, Liverpool Hospital, Locked bag 7103, Liverpool BC, NSW 1871, Australia. Email: [email protected]
Received 6 September 2014; accepted 6 December 2014. doi:10.1111/imj.12669
Abstract Reversible cerebral vasoconstriction syndrome (RCVS) is a clinical-radiological syndrome characterised by severe thunderclap headaches with or without other neurological symptoms and multifocal constriction of cerebral arteries that usually resolves spontaneously within 3 months. Most patients recover completely, but up to 10% have a permanent neurological disability and some even die. Previously RCVS has been described in many clinical contexts and under different names with the term RCVS first being suggested in 2007 to unify the group. The condition may be spontaneous, but in up to 60% of cases it is secondary to another cause, including vasoactive substances (medications and illicit drugs), blood products and the post-partum state. It is believed to have a similar pathophysiological mechanism to the posterior reversible encephalopathy syndrome (PRES), and both can occur in similar clinical contexts and are frequently associated. Treatment options include calcium channel antagonists. RCVS occurs in a broad range of clinical situations making it an increasingly recognised condition about which doctors in various specialties need to be aware.
Introduction The reversible cerebral vasoconstriction syndrome (RCVS) is characterised by severe recurrent thunderclap headaches (TCH) with or without other neurological
Funding: None. Conflict of interest: None.
symptoms and signs and diffuse segmental narrowing of cerebral arteries on imaging that is fully reversible by 3 months. TCH, an acute severe headache with pain reaching maximum intensity in less than 1 min, is usually the presenting symptom and recurs for 1–2 weeks.1–3 Seizures, subarachnoid haemorrhage (SAH), posterior reversible encephalopathy syndrome (PRES), intracerebral haemorrhage and ischaemic stroke are recognised
© 2014 Royal Australasian College of Physicians