Patient perspective in an integrated people-centred health services (IPCHS) context
Every aspect of our lives has been changed by the digital revolution. Digital disruption has changed how we live, relate and trade with each other. The Intelligent Digital Mesh now weaves our devices, homes, cars and social and workplaces into one portal, giving us choice, options and access that is tailor-made for us. When you add artificial intelligence and machine learning to the mix, you then discover that your apps and devices know you much better and signpost you to the right service at the right time that fits like a glove to your life.
Sadly, healthcare has to catch up with the rest of the digital and artificial revolution. Fragmented, one size fits all and found at the end of a complicated care pathway maze, patients may end up receiving unsafe and poor quality healthcare that is not acceptable, accessible, appropriate and affordable, and worst, that is discriminatory.
For patients advocates, the WHO Framework on integrated people-centred health services is the first comprehensive policy instrument that deals with the whole institutional, legislative, policy, practice and standards framework to bring about a patient-centred universal health coverage for all.
To see the best in something, you must first see it at its worst. I have a fascination with clinical negligence litigation and Coroners’ Court hearings; they show health systems at their worst. Having attended a number of court hearings on a clinical negligence injury that took place within integrated and fragmented healthcare systems within common law jurisdiction countries, I saw how good an integrated healthcare system was even when it was at its worst.
In common law, in order to prove negligence, a civil law tort, you have five stages to prove:
- The defendant who treated you owed you a legal duty of care
- The defendant breached this legal duty in an act of commission or omission
- The act fell far below the national healthcare standards or recognised good practice prevailing
- But for the defendant’s acts, this patient harm could not have happened. The defendant’s acts directly caused the harm or injury (prove causation)
- The patient had given their full consent and understood all that was to happen to them.
In integrated healthcare systems, I saw that the patient had to deal with just one or two overarching bodies (the department of health or a national health service), who took on the responsibility for the entire healthcare value chain. The duty of care was assumed directly or vicariously by a single entity. It was very easy to prove that the standard of care fell far below that expected as in an integrated healthcare system we had, the whole system cognisant of the national healthcare plans and the various healthcare policies and protocols. Often, this system also has a health technology assessment body that frequently produces latest evidence-based guidelines that are assimilated into best practice and improved standards. The coroner or judge then feeds back the findings to the health system in order that this does not happen again. An integrated health system is a learning system.
In fragmented healthcare systems, firstly there is no one in the healthcare value chain accepting the legal duty. The fragmented services shift the blame and legal duty up or downstream on the value chain. The patient has to sue all of them.
Then a fragmented healthcare system operates using various healthcare guidelines and the standard of care is so variable that proving one or all of them fell far below the standards is difficult. One part the health system may be working to 2000 guidelines, the other to 2020 guidelines. The judiciary too sometimes is caught in a time warp.
The next challenge is the: ‘the but for test’. You must prove causation and directly link it to the defendants’’ clinical negligent act of commission or omission. It is near impossible to do so in a fragment institutional and care regime that has no common records and notes. Each part of the value chain has poor records or conceals them and will be blaming the other.
Lastly, the worst part: you will find that the patient in many cases did not give a legal consent. The patient was moved about the healthcare value chain along different care pathways with no preparation or advices.
If the patients have not already been bankrupted by the healthcare services within the fragmented healthcare system, then they will most definitely when they seek redress and compensation after a clinical injury.
The final take home message is that patients have a far better outcome even when there is a clinical negligent act within an integrated healthcare system than within a fragmented healthcare system. An integrated healthcare system is still at its best in the worst-case scenario situation.
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