The Influences of Ethics and Policy on the Development of an Integrated Care System - An Overview

1. purchase of services on an outcome basis rather than as many separate components;
2. increase in provider responsiveness to consumers, eg by providing consumers with the ability to exercise choice.

The HFA Board also wishes to ensure that any policies adopted ensure that the risks of increased demand and the possible benefits from reduced utilisation or changes in service mix are managed appropriately.

Such lofty announcements are commonplace in policy documents world-wide. They imply an ethical content. An ethical framework may not necessarily be based on traditional medical professional ethics. Many critics of the health professionals perceive the traditional codes to be little more than codified systems for maintaining professional status and power. Conversely, business ethics, as understood vaguely within the community generally, matches badly with such principles as those which underlie the patient’s bill of rights, or which are based on the needs of the patient or client being paramount.  ²  

Given then, that perceptions of ethical standards vary widely within the groupings which must contribute to the current debates on rationing and integrated care, it is not surprising that there is little agreement concerning key definitions in other areas of debate. There is no commonly agreed definition for the term “integrated care”, and certainly widely different views about its meaning are held within New Zealand.  ³  

The Philosophy of Integrated Care

For the purposes of this article the definition used is one which is likely to be adopted by the Executive of the New Zealand Medical Association:

“Integrated care is an approach whereby health services for a defined population are financed and delivered through an integrated system to ensure access, equity and quality of care in a cost effective way, which is modified by patients, professional and community values, including acceptance by all parties of limited resources.”

That definition incorporates most generally accepted features of integrated care and can be interpreted as complying with the considerations of the HFA Board. Like the HFA Board statements, the above definition does not define (nor can it) what quantum of resources is being inferred, or what system of allocation. Undoubtedly, those charged with the task of developing the integrated care concept will seek guidance, but they are likely to face a daunting situation. It is to be hoped that they will not become cynical and seek the fundamentalist escape from the difficulties through blind adherence to a particular economic–political ideology. The history of the 1991-93 health reforms in New Zealand, of the Core Health Services Committee, and of the Public Health Commission, provide clear sign posts concerning both the hazards and at least some of the patterns of solution which are fallacious. The current restructuring of New Zealand society is based on a particular political–economic hypothesis, and not upon an historically proven formula of achievement for solving various sets of social problems.

Essentially, the concept of integrated care, as expressed in all the somewhat vague definitions produced to date, needs to address a resource allocation problem which is perceived as becoming progressively more acute and politically destabilising. Put another way, the belief is widespread that health care spending is rising too rapidly for the private and public resource to meet demand and more particularly to ensure equity of access. The changing structure of the population, the potential introduction of new and expensive technologies, the expectations of what universal health insurance can offer, and the relative slowing of economic growth are perceived to be the culprits. Cabinets have been slow to accept, let alone acknowledge, that they cannot meet the growing expectations of individual citizens through taxation,  ⁴   but individual citizens have had their expectations heightened through the ineptitude of the politicians, and through the self-promotional exercises of the medical-technology industry and the health professions generally. Within New Zealand that issue is further complicated by debates concerning the extent to which the individual citizens should contribute, as opposed to the general resource allocation through taxation. Obviously, ethical considerations must influence the outcome of the various sub-debates. Integrated care involves the concept of a shared responsibility between private and public resources. In ethical terms, however the nature of the relationship between patient and health professional differs between these two health sectors.

Within the private system, both traditionally and today, the contract is directly between the patient and family and the health provider. The third-party influence in the private sector is becoming more intrusive but remains less so than within the public system. In the public system, the relationship between the receiver and the provider is blurred in an individual sense. A patient undergoing surgery in a public hospital does not have direct choice of the surgeon and anaesthetist. The ethical considerations are not quite the same. In the public system, the requirements of the individual must be fitted into the total operation in a manner which, even now, does not dominate the private sector. However, particularly for older people, that distinction between private and public is becoming steadily more hazy as third-party influences become dominant. The concept of integrated care will blur that ethical distinction even more.

The problems and readjustments will not be limited primarily to the patient and family. Health professionals generally are being confronted at an increasingly alarming rate with situations that have a series of implications all of which have major ethical aspects. Private practice is becoming less private. Traditional concepts of professional freedom are becoming increasingly illusory within the public system. Perspectives on information, its collection, collation, analysis and the validity of consequential actions, vary across the professions and amongst the players in our health services.  ⁵  

Before proceeding to analyse these changes further, some further general points must be outlined.

As indicated in the preamble to this paper, the problems concerning integrated care are being defined by people who cannot be expected to share common perspectives. In a thoughtful chapter entitled, “How much should we spend on health services?”, Professor Jeffrey Richardson from the Department of Economics, Monash University quotes the results of an Australian study surveying population perspectives contrasting maximum of quality life years versus equity of access to health care.  ⁶   “The 551 survey respondents rejected the principle that, all else being equal, the least costly option should be adopted because this would permit more patients to be treated.” The same study also revealed that “a smaller number of health years may be preferred when they are shared amongst a larger number of recipients”. The important point made by Richardson is that “it is not known exactly what ethical principles people wish to incorporate in the overall health sector and what price they are prepared to pay for these principles.”

Studies such as those quoted by Richardson draw attention to the gross lack of information concerning individual versus collective attitudes as to what should be the ethical drivers determining health service structure and financing. Methodology in this area remains primitive, thus allowing wild statements to be made by people supporting particular ideologies or economic theories, whose views cannot be substantiated or rejected in the absence of sound evidence. We continue to have major problems defining the value of health services and the value of health outcomes in terms of individual viewpoints on the one hand and across society perspectives on the other. The sets of values do not appear to mesh. In this sense the lack of congruence in outlook mirrors that of the health professional, in terms of responsibility to the individual patient versus responsibility to the insurance company or State. Changes in outlook must occur across the health professions and the whole community coincidentally with any new pattern of rationing – reform and rationing are inseparable.  ⁷  

The notion of integrated care is, thus, being introduced at a time when essential information is lacking and when methods available to explore the consequences of particular sets of action are inadequate. This does not bode well when it comes to making key decisions. If the benefits are unknown or it is unclear how to measure them, or how they are valued by individual people, what basis is there for proceeding with the development of integrated care?

In keeping with Richardson, the way ahead must lie in addressing the power imbalance in the system. The traditional system in New Zealand has involved a medical profession which requested and received resources from the community, essentially via the taxation system. Under that system, the primary duty of a medical practitioner was to the individual patient. In addition, and to varying degrees, some practitioners accepted that they had the added responsibility of considering opportunity costs. The very nature of the consumer society, the not-so-hidden power of media persuasion, and of the media-feeding industrial process, must somehow be circumvented in terms of the decision making processes.

The Inherent Conflicts of Social Reconstruction

It is obvious that the ethical considerations of these groupings, from their perspectives, must conflict with those which determine overall resource allocation to health services. The HFA and PHARMAC, despite strident statements to the contrary, represent New Zealand’s current, and initial attempts to establish agency arrangements which can moderate the effects of power imbalance. Genuine market conditions have never applied, and never will to the health sector, and the current ideology underlying much of social reconstruction within New Zealand is inappropriate. In this situation, New Zealand has gone down the pathway of the purchaser–provider split, and the HFA envisages a fair, transparent and uniform contracting system as the appropriate pathway to follow. This obviously has implications for the pattern of integrated care development. The alternative pathway of so-called managed competition would satisfy one arm of the current ideology but conflict with the other, ie the call for deregulation.

In a managed competition environment, equity is achieved through regulation of the risk-related subsidies, an inevitable accompaniment. However, as Richardson points out, managed care of the type originally proposed in North America might be the most effective system for achieving the desired allocation efficiency. “With either option the era of professional dominance and passive government/private insurance would come to an end.”

All that discussion, begs the question concerning the quantum of resource. Once again, core values of beliefs of individuals, versus citizenry generally, should determine the setting of balances via the ballot-box. Recent history suggests that this does not happen. Cabinet certainly considers, and takes risks concerning, opportunity costs before it allocates the budget. Recent history suggests that the Government perspective on opportunity costs does not tally with that of the electorate generally. The Government obviously has reservations concerning the overall benefits which accrue from increasing health expenditure. The citizens of the smaller rural towns of New Zealand do not see things that way.

Thus, it is again the issue of which individual’s or groups’ sets of values should determine which decisions are taken. The people taking those decisions do not necessarily do so on the basis of the ethical principles to which other sections of the community claim allegiance. It is not difficult to make the case that an Old Testament-type fundamentalist attitude has driven some of the key people behind the health reforms in New Zealand. “He who is not for us is against us.” Because the health professions could not be trusted to align enthusiastically behind the reforms, they were not to be trusted. The ultimate consequences of this fundamentalist approach taken, in an absence of any overt covering ethical “social” umbrella, reached their peak in the circumstances leading to the investigation of Canterbury Health in 1998.

Thus, it is in some ways an absence of ethical considerations that may yet determine at least the initial framework of integrated care. Evidence in favour of that viewpoint comes from the manner in which the odometer-fraud situation has been handled by Government. In that situation, what most health professionals would regard as fairly loose ethical guidelines have been turned on their head to produce a pragmatic solution for a fiscally daunting problem.