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- Introduction
- The Challenge
- Chaos Theory and Health System Reform
- Opportunity For Leadership . A New Public Sector Paradigm
- Conclusions
- References
- Disclaimer
Introduction
This paper describes the challenge of health system reform and the situation facing governments in all OECD countries. The reform process is about aligning clinical decisions with resource allocation decisions. Governments are challenging the ability of the Hippocratic paradigm to deliver affordable publicly-funded health services. This poses a fundamental challenge to the way that health professionals will work in the future.
The escalating cost of health care is not sustainable. Considerable leadership is required from clinicians if there is to be a fair and affordable health system. Clinical leaders need to recognise an agenda that is likely to meet societal needs is driving the reform movement.
The Challenge
In every OECD country, someone in government will be aiming to make changes in the way health services are delivered. Governments have traditionally relied on health professionals to decide on how and what health services should be provided. Health professionals have in turn relied on the Hippocratic Code to guide their decision making. The Hippocratic Oath enshrines the relationship between patient and doctor: 1
"I will follow that system of regimen which according to my ability and judgement, I will consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous" (author’s emphasis).
There was a time when professional ethics alone gave health care moral commitment. However, that has irrevocably changed. Governments are facing increasing difficulty in paying the escalating costs of health care. The Hippocratic Code is silent on who pays and fails to address the issue of scarce resources as well as population needs. There will always be cases where medical interventions would be beneficial but cannot be funded. Choices have to be made and any choice results in an opportunity cost. Choices that maximise health from a given budget are most desirable.
However, individual people faced with illness expect to be treated. Any treatment defers illness until another occurs, before an inevitable death. Daniel Callahan referred to this as "twice cured, once dead". 2 Modern medicine is supplying individuals with high technology medicine that delays death. Nevertheless, this is valued by society because it allows individuals to be as healthy as possible into productive old age. The Hippocratic Code promotes competition in the development of medical technology that provides the greatest benefit irrespective of its high cost.
Governments are challenging the ability of the Hippocratic paradigm to deliver affordable health services and are attempting to align clinical decisions with resource allocation decisions. In New Zealand the Health and Disability Services Act 1993 was introduced to reform the public funding and provision of health and disability services in order to:
- Secure for the people of New Zealand.
- The best health
- The best care or support for those in need of those services
- The greatest independence for people with disabilities . that is reasonably achievable within the amount of funding provided (author emphasis).
- The best care or support for those in need of those services
The policy of integrated care also represents a move from a traditional medical focus on individual patients (Hippocratic Code) to a population-based medicine approach. 3 This approach balances individual with societal needs and aligns clinical with financial responsibility through population-based funding formulae.
These changes present a great challenge to health professionals as well as an opportunity for leadership.
Chaos Theory and Health System Reform
Chaos 4 is the natural selection pressure that forces organisations and policies to evolve. 5 The health care sector is not immune to this pressure.
Adam Smith argued that if individuals were allowed to pursue their own selfish interests a pattern of economic activity would emerge that would serve the greater good, "as if guided by an invisible hand". A century later Charles Darwin incorporated Adam Smith’s thinking into his theory of natural selection. The notion of competition was introduced into biology. Later, economists returned the compliment by introducing the Darwinian metaphor into the business environment. Biologists subsequently argued that competition was not necessarily the all-powerful force but merely one of the many factors that shape ecological communities. This, translated into the business environment, placed importance on creating opportunities to adapt in a complex network of companies that collaborate, compete or both. 5
All organisations are pulled in two directions . towards ossification and towards disorganisation (chaos). Success lies at the boundary of the two states. "Chaos" is a form of instability where the long-term future is "unknowable". Unpredictability is therefore a feature of "chaotic" systems. Survival in an unpredictable environment depends primarily on maximising adaptability. In order to survive health systems need policies that make them flexible, that buffer against the shock of sudden unforeseen change.
Complex systems encompass "chaos" and order, from a system that never settles, to being totally rigid and unable to adapt. Health care systems risk becoming rigid and are therefore unable to adapt to meet societal needs. The edge of "chaos" is where both stability and change operate.
Clinical leadership is leading change to meet the societal needs driving reform. The role of the clinical leader is to navigate at the edge of "chaos".
Opportunity for Leadership . A New Public Sector Paradigm
Health professionals should be playing a central role in making changes to the health system to:
allow the system to offer better outcomes, greater ease of use, and more social justice in heath status. Instead, most of the changes that are today called "healthcare reform" are actually changes in the surroundings of care rather than changes in care itself. Clinicians have an opportunity to exercise leadership for the improvement of care, but they must first agree to address the aims of the reform and to adopt an agenda of specific changes in their own work that are likely to meet the social needs driving the reform movement. 6
Clinicians in New Zealand, like many other countries, are struggling with the reform process and are reactive to changes. This struggle largely reflects a failure by clinicians to identify with the agenda of change as well as a lack of willingness to change. The notion of professional capture reflects frustration with a perceived narrow view of the issues that confront health systems.
There are clearly opportunities opening for clinicians to take a lead in health reform. The emergence of the "third way" in the United Kingdom heralds new approaches to policy making. Policy-making is the leadership of change 7 and clinicians should be a part of this.
The "new" public sector management is:
- the need to give space for politicians to lead
- fostering professional innovation
- ensuring effective outcomes
- an emergent theory of policy making.
The "tablet of stone" approach often applies in making policy, whereby a policy is developed and implemented and does not necessarily achieve its goals. An emergent theory of policy making is much more organic, based on trial and error, rewarding things that work (innovation) and learning which things do not work (refer figure below).
The leadership of change is also about working with communities. Different "communities of interest" desire different things from the health systems that serve them. Clinicians need to listen to these communities and discover what sort of health system and priorities are likely to meet community needs . not merely reflect the view of health professionals. Listening and communication are essential in order to move forward and to understand what society wants from its health system. Most people are realistic and understand the issue of scarce resources but also want fairness in resource distribution. Traditionally, the doctor has imposed his or her own Hippocratic view on society. A different approach is necessary, namely improving the health of an individual patient in the context of improving societal health.
Conclusions
Clinical leadership is the leadership of change. The role of the clinical leader is to navigate at the edge of "chaos" where change and stability operate. Clinical leaders should seize the opportunity to work with government and communities to adopt an agenda to improve societal health.
References
- Gillon R. Medical Ethics: Four principles plus attention to scope. Monash Bioethics Review 1995; 14:23. 30
- Callahan D. In: What kind of life: the limits of medical progress. New York: Simon and Schuster; 1990
- Feek C. Integrated care . the ethical debate: policy and ethics. Healthcare Review . OnlineTM. 2(7); May 1998. http://www.enigma.co.nz/hcro_articles/9805/vol2no7_001.htm
- Gleick J. In: Chaos. London: Cardinal Books, 1988
- Lewin R. It’s a jungle out there. New Scientist, 29 November 1997, 30. 34
- Berwick D. Eleven worthy aims for clinical leadership of health system reform. JAMA 1994; 272:797. 802
- Brazil R. Personal communication. Australian and New Zealand Health Leadership Programme, 1998
- Callahan D. In: What kind of life: the limits of medical progress. New York: Simon and Schuster; 1990
Disclaimer
The content of this paper represents the author. s personal view of some of the issues related to clinical leadership and does not necessarily represent the policy views of either the Minister of Health or the Ministry of Health.
