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This month’s edition of Healthcare Review – OnlineTM is the second in a series focussing on integrated care.
This follows the first edition in this series which provided an introduction to integrated care from Professor John Ovretveit, whose paper provides a valuable overview of integrated care and outlines five models around which integrated care systems can be based.
This edition considers ethics in integrated care, both the influence of ethics on the development of integrated care and the ethical issues around the delivery of integrated health care.
Traditionally, ethics has been concerned primarily with clinical practice. With the emergence of new approaches to health delivery through integrated care or managed care systems, there is a now a much broader ethical focus that includes societal, policy and corporate ethics.
Professor Grant Gillett, from the Otago Bioethics Centre, University of Otago, considers the ethical constraints that an integrated care system needs to recognise in order to conform with good standards of professional practice. He writes on ethics in integrated care from a perspective that reflects his grounding in philosophy and his practical experience in bioethics.
The paper outlines the various systems of health care delivery that are entitled integrated care. Professor Gillett details issues that arise within these different arrangements and cause tension or compromise good practice. Each of the systems and their degree of vulnerability to the issues discussed is evaluated.
He concludes with a reminder that the ethical guidelines appropriate to good health care delivery do not change with health care delivery systems. But he notes that integrated care can be vulnerable to distorted management incentives and ideologically-driven planning which is not necessarily backed by an understanding of the reality of clinical care.
In his view, there is a need to ensure that the guardianship of the health care delivery system remains answerable to health needs and not to externally driven agendas which fail to account for the community’s wider health needs. To achieve this, systems need to be controlled by health care professionals and consumers working together with competent advisors who are free of ideological bias.
Professor George Salmond, Director of the Health Services Research Centre at Victoria University of Wellington, has addressed issues associated with the development of integrated care more broadly. He discusses such subjects as the need for a balance between the influence of market forces, bureaucratic regulation and professional expectation in health care development, while considering the ways in which moves to integrate health systems are likely to impact on the practice of health professionals and the governance of health care organisations. He identifies the need for a spirit of openness in health practice in order for professionalism to flourish in the new environment.
The paper outlines suggested principles to guide integration and system improvement, and recognises that for integrated care to meet its aims for improved care, services, outcomes and costs, there needs to be an investment in improving interdependency among individuals, professionals and organisations.
Sir John Scott, Professor Emeritus of Medicine, University of Auckland, highlights the different perspectives on ethical standards in medicine within society and within professions, and notes the impact of these varying perceptions on the debates surrounding integrated care. He writes from a perspective that reflects his extensive clinical experience.
In his paper, Sir John highlights the gross lack of information regarding individual versus collective attitudes as to what should be the ethical drivers determining health service structure and financing, and the lack of congruence between individual and societal perspectives in defining the value of health services and health outcomes. He draws the parallel between this inconsistency and the conflict facing the health professional in terms of responsibility to the individual patient versus responsibility to the insurance company or State.
He expresses concern over the impact of social reconstruction in New Zealand on the manner in which decisions are taken. Inherent conflicts between the values of altruism and commercialism are identified as reasons why these processes are not necessarily based on sound principles. Sir John advocates an explicit ethical framework against which government decision making should take place.
He outlines the role that a better definition of ethical principles could play in addressing the challenges faced, and sees that the way forward is in building better doctor-patient relationships, involving bilateral concessions, and the re-establishment of trust between the two parties.
A contribution from Dr Colin Feek, Ministry of Health, addresses ethics issues from a perspective based on his clinical and policy experience. Dr Feek considers the range of service delivery systems which fall under the title of integrated care and discusses the different ethical implications of those various structures, from the simpler co-ordinated care models through to the more complex population-based models of delivery of care where the benefits to the population versus the benefits to individuals become important considerations.
The next edition in the integrated care series in Healthcare Review – OnlineTM will overview the roles of policy in the development of integrated care and will bring you viewpoints from some of those people who are most influential in the development of integrated care in New Zealand.
