The Health and Care Revolution - Kevin Dean and Muttukrishnan Rajarajan - ebook

The healthcare sector is facing a series of challenges that could seem insurmountable - an increase in demand caused by the ageing population in western, developed countries; the corresponding reduction in the numbers of young people to pay for and resource care; and simultaneous squeezing of funding, eternal issues with the quality of care, and patients' rising expectations. All of this is compounded by advances in medical technology that offer longer, healthier, happy lives while simultaneously increasing the cost burden to the healthcare system. This book collects together the experiences of practitioners, technologists, clinicians, managers and economists in helping to deal with these challenges. The Health and Care Revolution describes through the eyes of real experience the current transformation of healthcare to support healthy living - preventing, detect and managing disease early, and expanding its horizons from essentially acute clinical interventions into a care continuum throughout people's lives. The examples discussed put the individual in the driving seat of their lives, rather than the professionals surrounded by organisation, geography and working practice boundaries. Here you will find, from around the world, experts talking about the ways personal responsibility, access to information, working practices, access to care, and the underlying motivations to change, have been transformed. The eminent authors are often working at the forefront of change in processes, governance, capabilities and technology - and share their pains and gains clearly. With a preface from one of the World Health Organisation's thought leaders, and featuring a wide variety of topics from Information Therapy to changing clinical working practice, via telemedicine to the innovative design of new facilities, The Health and Care Revolution captures essential knowledge for those wishing to drive progress in one of the world's most important industries. The royalties for this book are being donated to charity at the Editors' request.

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The Health and Care Revolution

Kevin Dean and Muttukrishnan Rajarajan (Eds.)

Copyright © 2011 by EAI Publishing. All rights reserved.

Preface © 2011 World Health Organization

Introduction © 2011 Cisco Systems, Inc

Published by EAI Publishing, 100 Wells Avenue, Newton, Massachussetts.

No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, or otherwise, except as permitted under Section 107 or 108 of the 1976 United States Copyright Act, without the prior written permission of the publisher.

Edizione digitale: luglio 2012

ISBN: 9781936968503

Edizione digitale realizzata da Simplicissimus Book Farm srl


Joan Dzenowagis, Ph.D.

World Health Organization

As the contributions to this timely book attest, the case for adoption of eHealth has been made for at least a decade. Yet it has taken a crisis in the health sector in many countries to move eHealth from the periphery to the centre of health care planning and delivery. Crisis is a powerful stimulus for change but as the world becomes increasingly digital, other new forces are further accelerating the uptake of eHealth. The emergence of these forces has been fuelled in part by technological advances, economic investment, and social and cultural changes which have facilitated the integration of information and communication technologies (ICT) into everyday life.

The first major force for change is the realization that data is a new source of value and a central asset to improving processes and systems in any business, in the health sector as in any other. From the home to the hospital, health authorities are aiming to bring down costs and improve the quality, safety and efficiency of care, and are realizing that the data generated and available through ICT is critical to achieving these goals. Managed well, health data from many sources can be pulled together to provide fresh insights for public health, health policy, the social sciences, clinical care and research.

The second major force for change is the fact that across all sectors and all geographies, the general public – consumers – are expecting and demanding better products, services and value for money. The Internet and the World Wide Web have changed the means and ease of sharing knowledge and information, transforming the world in ways never imagined a decade ago. Technology is more user-friendly and readily available, access to information is more reliable and affordable, and today’s consumers are embracing mobile phones, social networks and tools of the information society to become more informed and more active in their own health. In doing so, their expectations and behaviour are re-shaping the health sector, changing the rules and relationships between consumers, professionals, industry and government.

Fortunately these forces are emerging not only in high-income countries, but all around the world, including in developing countries. The focus of this book, The Health and Care Revolution, primarily reflects the challenges and solutions of established market economies, while still based on the values and the tenants of primary care. These tenants include the obligation to reach all people, enabling care for everyone regardless of where they live and how much they earn. Further, they include the reform of health services towards citizen-centred care, involving people in their health. They stress the engagement of all sectors, recognizing the role of others in supporting health. Fulfilling these requires committed leadership and effective, responsive government. So in this sense, The Health and Care Revolution has lessons for all countries.

The World Health Report 20081 called for a revitalized approach to primary care. At its core, primary care is a commitment to equitable and affordable care for all people, ensuring the delivery of citizen-centred services enabling people to live a healthy and productive life. The World Health Organization considers primary care as an approach to organizing health services and systems. And it is clear that the technologies of the information age have become essential to organizing health systems and supporting health and care in every country.

Improving access to care – reaching all people – is a fundamental tenant of primary care. Yet some countries, chronically burdened across a range of government obligations, have difficulty sustaining even basic health services. In these countries, ICT facilitates planning, managing and deploying services and supplies so that more people may benefit. In countries in conflict or those affected by disasters which require special assistance, strategic use of ICT can help governments and agencies coordinate aid and put in place measures to help displaced persons. Recent natural disasters in China and Haiti have demonstrated that ICT delivers critical support for reaching those in need with the basics of care.

Improving health care delivery and citizen-centred care depend on a spectrum of applications, some of which link patients with each other, and others which link patients and professionals where distances are great and local expertise limited. Every person involved in health care, whether as patient, informal care-giver or health professional, needs information to act and to communicate effectively. A revitalized approach to primary care recognizes the greater role that patients, families and communities play, and uses ICT to enhance this role by providing for two-way communication as well as information and guidance, treating the patient as a full partner in their own care.

ICT is also changing primary care through its impact on professional and research communities. Facility-based tools such as e-prescribing improve accountability and enable more responsive, integrated and safer care. Resources such as decision support systems, electronic health records, journals and databases, and professional networks enhance the delivery of care at all levels. Large-scale computing initiatives are solving long-standing challenges in diagnostics and targeting therapies, ultimately leading to more personalized care and more effective management of primary care services.

Countries all around the world are faced with prioritizing health investments, providing safe, cost-effective care and ensuring the education, deployment and management of personnel. As national e-government initiatives have already shown, ICT supports transformation and revitalization. Where the strategic objective is that governments are well managed, accountable, and resources are allocated to achieve results, different functions are aligned towards ensuring that government acts as one. Information, data, practices and tools are shared, with greater accountability and relevance to meeting people’s needs. This type of transformation – the first force for change – is clearly needed in health care today. As they strive to take advantage of ICT in health, governments can build on the lessons from other sectors as well as those from other countries.

Yet this will not be enough. Looking to the future requires an openness to leveraging the potential of the second force for change – the power of technology to connect and engage individuals and communities in their own health. The Health and Care Revolution shows us the way, and in doing so advances the principles and practices that will make this phenomenon one of the new, true opportunities for health in the information age.

Joan Dzenowagis is an international health policy specialist with experience at the country, regional and international level in information and communication technology (ICT) and public health, policy and strategy development. During the past 14 years at the World Health Organization she has held posts in disease surveillance, information technology strategy and research, as well as managing an international public-private partnership in ICT and health. Currently she is responsible for eHealth governance and Internet affairs. Her research covers global and regional developments in new technologies in the health sector, ranging from eHealth policy and ethics to health information on the Internet.


Introduction – The Health and Care Revolution

Kevin Dean

Part I

New Priorities - Health, Care and Patient Empowerment

1. The Third Healthcare Revolution

J. A. Muir Gray

1.1. The 21st century Healthcare Crisis

1.2. Out of the Crisis

1.2.1. Transformation of Culture

1.2.2. Transformation of focus from structure to system

1.2.3. Empirical evidence

1.2.4. Hard and Soft System Methodology

1.3. The Third Healthcare Revolution

1.3.1. Knowledge

1.3.2. Information Technology

1.3.3. Telephone reminders

1.3.4. Transforming the consultation

1.3.5. The Patient as Transformer

1.4. Disruptive Technology and Disruptive Patients - The Mental Health

1.4.1. The model of a mental health service

1.5. Conclusion

2. Patient Empowerment in the World of Web 2.0

James Munro

2.1. Patient voices on the web

2.2. Reviewing and rating health care

2.3. Sharing stories of health care

2.4. From feedback to conversation

2.5. Increasing the value of the donation

2.6. Seldom heard, often ignored

2.7. A new kind of patient

3. Continuous Healing Relationships in Health 2.0

Joshua J. Seidman, PhD

3.1. Defining Information Therapy

3.2. The Need for Ix

3.3. Information Triggers and Leveraging New Science

3.4. Who Can Be an Information Therapist?

3.5. Putting It All Together: Ix as a Means to Continuous Healing Relationships in a Health 2.0 World

Part IILeading the Revolution - exemplars using innovative communications technology to support “system” change

4. Next Generation Telecare

Tim Craig

4.1. Recognising the need for a new approach

4.2. The role of Telecare/Telehealth

4.3. Organisational issues

4.4. Conclusion

5. Implementing Telehealth – a Clinician’s View

James Ferguson

5.1. “How” healthcare is delivered is as important as “what” is delivered

5.2. “Insanity: doing the same thing over and over again and expecting different results” Albert Einstein

5.3. TeleHealth Application

5.4. Conclusion

6. Telemonitoring – the Intelligent Solution for Cardiac Patients

Harald Korb, Carolin Baumann, Michael Hübschen, Axel Müller

6.1. Introduction

6.2. Methodological approach and care program

6.3. Telemonitoring of chronic heart insufficiency

6.4. Perspectives

7. Transforming the Economics of Care - Telemedicine

Marcel Garnier, Corinne Marsolier

7.1. Telemedicine in France: A slow evolution during the 20th century

7.2. 2007-2010: A new era for Telemedicine

7.3. Telemedicine technologies ready to transform healthcare

7.4. Making the economic model work

7.5. The key players – new ecosystem and how to make it work

7.6. Conclusion

8. Opportunities and Challenges – International Telemedicine

Christina E. Wanscher, Janne Rasmussen

8.1. Introduction

8.2. eHealth infrastructure

8.2.1. National health networks – the Danish example

8.2.2. Joining networks for international collaboration

8.3. Medicine crossing distances

8.3.1. Transmission of images -- teleradiology

8.3.2. Non-technology factors in telemedicine

8.4. Innovative business models in health care

8.4.1. The e-Marketplace for teleradiology

8.4.2. A new business model for health service provision

8.4.3. Trends in health care – professionals’ and patients’ role

8.5. Conclusion

Part III

Lessons Learned and Planning for the Future - What next?

9. Establishing Ecosystems to Catalyse and Meet Consumer Market Demand for Health and Wellbeing

Justin Whatling, Loy Lobo

9.1. Disrupting healthcare through mass market wellbeing ecosystems

9.2. The challenge

9.3. A different approach

9.4. Key principles and features

10. The Value of Healthcare IT in a Collaborative World

Ian Smith

10.1. Background to Nottingham University Hospitals Trust, UK

10.2. The case for change

10.3. From driver to enabler

10.4. Why a pull is stronger than a push

10.5. Adoption of technology becomes organic

10.6. Organic growth can be managed

10.7. The search continues

11. Envisioning the Hospital of the Future

Orlando Portale

11.1. What is Second Life?

11.2. Palomar West, Hospital of the Future

11.3. Cutting-Edge Hospital Design Concepts

11.4. The Virtual Palomar West Experience

11.5. Distributed Nursing Care Model

11.6. Multi-Procedure Interventional Platform

11.7. Conclusion

12. Driving Change in Healthcare – an Alignment Model

Gordon Peterkin

12.1. Building the Alignment Model

12.2. Encouraging change – understanding how to drive alignment

12.3. How to bring in more congruence?

12.4. Summary

Interview with Professor Muttukrishnan Rajarajan, Assistant Dean, eLearning, City University London

The Health and Care Revolution

Introduction – The Health and Care Revolution

Kevin Dean FBCS, MRI

Managing Director, Connected Health, Europe

Cisco Internet Business Solutions Group

A challenging situation

As we enter the second decade of the 21st Century, the world is facing an unprecedented series of challenges to our healthcare systems. Those challenges that will increase demand for treatments, add to already rising costs, or constrain the supply of welltrained, experienced clinicians are well documented – not just in the specialist journals of medicine, but increasingly in the popular press.

The need to drive significant changes in the way we provide healthcare (to use the current terminology) features high in political agendas across the world. Scarcely a day goes by without commentary in newspapers and business journals, online and on television. Top of the agendas virtually everywhere in the developed world is the Ageing Population, and its consequences of higher and higher levels of chronic disease as medicine becomes ever better at prolonging life. Simultaneously, we are assaulted daily by innovations in treatments, diagnostic tests, and complex interventions – all of which must be assimilated by the healthcare systems and professionals, and paid for by either the taxpayer, insurance companies or individuals. The newsworthiness of medical innovations – who isn’t interested in things that will make life longer and more comfortable? – works also to raise patients’ and their families’ expectations of treatments and cures.

Even in healthy financial times, these pressures on healthcare would be dramatic; in the mid- to post-recessionary period the world is experiencing, the financial squeeze exacerbates the situation, and looks likely to do so for the next 5-10 years – by which time the demand problem will have increased dramatically. In the same period, further pressures – carbon taxes, shortages of mineral resources, energy crises – look set to impact healthcare organisations’ budgets and resources, along with patients’ pockets as taxpayers or individual consumers of healthcare.

These huge pressures are causing all political administrations and healthcare organisations to focus hard on the three critical elements of the industry – productivity, access and quality. These have always been top of mind for managers of healthcare systems. However, the need to change, to drive higher levels of productivity while maintaining or improving levels of quality, and providing access to new treatments, is intense. In particular, improvements in productivity have reached the top of the agenda.

Most people involved in healthcare realise that there has to be fundamental change, fast – incremental improvements to the healthcare processes of the 1990s are just not sufficient. Many are reworking the basic models of healthcare to focus on Health – prevention of disease and disease crises through promotion of healthy living, personal responsibility, exercise, diet – and integrated Care that brings together healthcare and social care to support the very different needs of an ageing population beset with long-term conditions.

This is what I term “The Health and Care Revolution” – because the change is so profound. Every part of the Health and Care system of the future will need to change, as citizens are incentivised to stay healthy, professionals are pressured to catch diseases earlier, treatments move from operating theatre and hospital ward to living room and workplace, and social care blends with healthcare to avoid hospitalisation of the elderly, or to return them quickly to their homes after treatment.

Making IT relevant again

For those planning for this seismic change, however, there is a critical dilemma. Over the last 10 years, huge amounts of time and money have been spent on healthcare information technology – with many countries and organisations still investing to reach something like critical mass of IT systems across their operations. And yet there is very little evidence that the major investments have made any impact on the productivity of the current healthcare systems. So what role should IT play in the Health and Care Revolution?

To establish an answer to this critical question, we need to dig beneath the headlines on IT projects that are late, over budget, risking patient confidentiality, and worse.

Firstly, to quote Paul Coby, former Chief Information Officer for British Airways, “There are no IT projects – only business projects.” This short statement is profound – failed IT projects are rarely so because of technology failure, but because the business did not specify well, plan thoroughly, train users, undertake process redesign to capitalise on the technology, adopt ubiquitously, and so forth. The lesson here is that if IT is to support the massive changes in Health and Care, then the organisations involved have to understand their challenges, requirements and the capabilities that they need IT to provide; and they need to treat IT as a component of changing processes, governance, competencies – not as a stand-alone initiative that business leaders observe from the sidelines.

Secondly, we must realise that as recently as 2000, IT in healthcare was years behind that of other industries in its development. Importantly, this is not the IT used at the point of care, to capture and create, say, an MRI scan. The IT to which I refer is that used to manage the organisation, to manage patient journeys, to communicate among professionals and with patients, and the standards for interoperability on which such systems depend in all other industries. Much of the investment in the last 10 years has been in basic systems, standards and databases – the electronic patient record (EPR), electronic picture archiving and communication systems (PACS), and patient administration systems (PAS). These systems are important to quality and reliability of care, but cannot and do not change the efficiency of the processes that make up most of healthcare – the human-to-human processes that move a patient from the reception area of the Emergency Department, through pathology and radiology, to treatment and discharge, for instance.

Thirdly, a whole new era of communications and collaboration IT is required to support vastly different patient pathways – pathways that begin with prevention activities in the home and workplace, for instance, moving through self-treatment and condition management, to medical interventions across professional boundaries and organisational boundaries in non-acute hospital settings of the GP Practice, surgery, or even retail pharmacies.

Delivering real productivity, quality & access improvements

This is the real challenge for IT in the next 10 years – layering on top of the basic essentials of EPR, PAS, and PACS the ability to find knowledge, people, and things (such as medical devices) on demand, and have them collaborate on complex processes that are personalised to the patient over a long period of time – not stand-alone episodes. The measure of success will also be much harder for the next generation of Health and Care IT – productivity and cost containment, with hard benefits that allow more demand to be met from the same – or reduced – resources.

To rise to this challenge, activities on many fronts are required, ranging from better and more rapid adoption of standards, to radical changes to the way patients (and their families and carers), professionals and organisations take responsibility for their health and care – and in so doing, dramatically change the support they demand from IT.

Undoubtedly the greatest requirement is that health & care IT changes from being a niche specialty – an afterthought when designing policies, processes and services – to being an asset at the centre of planning services, led by those who will use the IT (patients, professionals). This change in emphasis is vital to successful adoption and delivery of the very real benefits that are available. A recent report from the ACCA, “Collaboration and Communication Technology at the Heart of Hospital Transformation” [1], demonstrates not only the tangible benefits available, but also that leadership by clinicians is vital to success.

Beyond this fundamental change, other opportunities await. One is the use of IT to power more integrated communications and collaboration throughout patients’ journeys, eliminating wasted time and resources, and improving quality. “Traditional” health IT, focused on records, administration, and imaging, rarely addresses the crucial, yet mostly informal, area of the integration of processes that link a patient’s journey from healthy living through diagnosis into care. Many of these processes are quite informal – often “agreements” between people to complete tasks (a patient agreeing to take regular blood sugar readings; a porter agreeing to take and retrieve a patient from the radiology department) that fail through a lack of appropriate governance, fail-safes and reporting.

Modern communications and collaboration technology can dramatically improve the patient’s experience and the productivity of the expensive resources applied to their care. But similar technological advances can offer an even more exciting prospect – borderless operation of health advice and care services, across clinical specialities, organisations and even geographic borders, to deliver seamless care.

Cloud Health & Care

At the extreme, new concepts may be required that test the acceptance and interests of all current stakeholders – “cloud”-based health services, with services and advice delivered on demand from remote resources directly to patients, or to potential patients trying to avoid disease.

Cloud computing is being discussed with increasing frequency, but the advent of Cloud Health & Care Services could be very disruptive to current models of delivery – and highly significant in meeting the future needs of many countries with growing demand and falling numbers of traditional expert resources due to demographic changes or funding constraints.

Cloud Health & Care could provide on-demand clinical advice and services delivered from specialist centres globally, using the latest video and telemedicine techniques. Cloud Health & Care would understand and interpret demand (language, clinical speciality, location, urgency, context of the patient’s record), match suitable “present” resources (i.e., available to provide assistance in the required timeframe), then connect the points of care and resources (whether human resources like nurses or doctors, or video-based knowledge sources) at a quality comparable to, or better than, traditional face-to-face consultations. Although this concept may appear farfetched, several chapters in this book point in the direction of such a radical new model of advice and care being delivered already, although not quite yet in its entirety.

Insights on the Revolution

In this book, we have brought together, in three themed sections, some of the most prominent examples of this new layer of IT supporting the Health & Care Revolution.

In the first section, “New Priorities”, we showcase examples where patients are being empowered through the technology of Web 2.0 to take responsibility for their health and care.

In the second section, “Leading the Revolution”, we highlight leading examples of using new communications technologies to support “health system”-level changes, considering not just technology for telemedicine and personal health management, but also the economics of such changes.

In the final section, “Lessons Learned and Planning for the Future”, we look to the future, providing innovative examples of how new models of care can be envisaged, and also how practical steps to engage professionals must be improved to deliver widely adopted technology supporting dramatic levels of process change.

All of the contributors to this book have worked hard to give you, the reader, honest and open insights into their innovations and experiences. The chapter authors are all practitioners in their field, with a vast range of skills and knowledge. Many thanks to all for their efforts to capture the essence of their acquired knowledge so that we can all learn for them – and use IT to support the Health & Care Revolution.

About the Cisco Internet Business Solutions Group

Cisco Internet Business Solutions Group (IBSG), the company’s global consultancy, helps CXOs from the world’s largest public and private organizations solve critical business challenges. By connecting strategy, process, and technology, Cisco IBSG industry experts enable customers to turn visionary ideas into value.


1.  Association of Chartered Certified Accountants (ACCA) Report 2010 “Collaboration and Communication Technology at the Heart of Hospital Transformation” in collaboration with the European Commission


Kevin Dean

As the Managing Director of Cisco’s Internet Business Solutions Group (IBSG) European Connected Health Practice, Kevin Dean, with his team, works with health & social care organisations, public sector leaders and major life sciences corporations to help them use technology to accelerate transformation of the health and care sector. Kevin has detailed experience in numerous aspects of health IT strategy and execution, especially in large scale programmes at the leading edge of health knowledge and information use by patients, clinicians and administrators. The common theme of these engagements is the use of leadingedge technology support the transformation of processes and services, to improve the affordability, access, safety, quality and sustainability of health and care in the 21st century.

Kevin also has extensive experience working outside the United Kingdom, working with his team supporting projects all over the European Union and beyond, and with the European Commission & World Health Organisation (WHO). Published in 2004 and with over 35,000 copies printed, Kevin edited the book “Connected Health”, collecting the experiences of pioneers and thought-leaders from around Europe.

Kevin has a BSc (Hons) in Engineering Science & Management from Durham University in England, is an Honorary Research Fellow in Biomedical Engineering at City University, London, a Member of the Royal Commonwealth Society, a Member of the Royal Institution and a Fellow of the BCS, The Chartered Institute for IT.

Part I

New Priorities - Health, Care and Patient Empowerment

1. The Third Healthcare Revolution

J A Muir Gray, Kt, CBE, DSc, MD, FRCPSGlas, FCLIP

Director – Knowledge into Action

The third healthcare revolution is upon us, and is critical if healthcare is to meet the challenges of the 21st Century.

The first revolution was a public health revolution in the 19th century when advances in water, housing and nutrition led to the prevention of the infectious disease epidemics that followed urbanisation. In the 20th century the second healthcare revolution saw the development of the doctor as the charismatic and influential professional, replacing the priest in many societies, and, particularly in the second half of the 20th century, the rise of the healthcare bureaucracy. The development of the medical profession and the growth of bureaucracies were the inevitable consequences of the scientific revolution which has had an impact on longevity as great as the impact of the first healthcare revolution by the development of astonishing technologies, some of which are listed in Figure 1.1.

Figure 1.1.

1.1. The 21stCentury Healthcare Crisis

This second revolution, driven by scientists working with clinicians has led to further dramatic increases in life expectancy and freedom from disability. However, at the end of the 20th century, it was clear that there were still a number of outstanding problems in every health service:

•  Safety - clinicians, and the systems they work with, make or allow too many errors and mistakes

•  Quality - sub standard clinical practice and poor patient experience is far too prevalent

•  Failure to maximise value – in particular there is too much waste of time and resources, combined with a tendency to adopt overenthusiastically adopt interventions of low value. Finally, there are unacceptable delays to get new evidence into practice

•  Inequalities – the same standards and access to care is not available to every patient regardless of location or their healthcare provider

•  Failure to prevent the preventable – healthcare has not adopted the systems used in many other industries to analyse and foolproof processes, equipment designs etc.

Nor is there evidence that these problems will be solved in time to deal with the additional challenges facing healthcare funders and providers in the early 21st Century (Figure 1.2):

•  Increasing demand due to rising expectations

•  Increasing need due to population aging obesity due to too much food and too little exercise

•  Climate change which will create health problems and health emergencies

•  Financial constraints

•  Carbon constraints

•  Increasing complexity, primarily as a result of more partime staff working shorter hours

Figure 1.2.

1.2. Out of The Crisis

However, these problems can be solved neither by further scientific advances nor by reorganising the bureaucracy and financing of healthcare; whether tax-based or insurance-based, co-payment or no co-payment, run by counties or run by a national board, the problems are ubiquitous. They are too complex for structural solutions. What is required is a third healthcare revolution and this is currently taking place, driven by three inter-related forces – knowledge, information technology (particularly the Internet) and citizens themselves. Some professionals are at the forefront of this revolution but the professions, those organisations, which Paul Starr called the “sovereign professions” are often out of step with, and behind, the Zeitgeist [1].

The need for urgent action is compounded by the fact that not only do health services face major challenges in tackling the problems listed in Table 2 above but also they have to face new 21st Century problems - notably AIDS, obesity, population aging and the effects of culture change. What is needed is fundamental transformation. However organisational and financing re-structuring only achieve change without transformation – at the cost of money, time and resources. To transform a service requires interventions which change the way people behave and organisations behave, and the two are related (see Figure 1.3 below). Transforming organisations requires a focus not on structural reorganisation but on the two other components of an organisation - its culture and systems.

Figure 1.3.

1.2.1. Transformation of culture

A new culture is needed – the differences are listed in Figure 1.4.

Figure 1.4.

The transformation of care requires the transformation of culture and is a challenge for leadership. There are, however, some things that can be done to help the leader, taking into account the common definition of leadership as distinct from management in which the leader is responsible for the change of culture and with managers being responsible for implementation within that culture. Obviously all people who manage contribute to culture change. The guru of management culture, Edgar Schein, emphasises that a common set of concepts and a common language are essential elements of a corporate culture [2].

Even when people work together face-to-face and use the same terms, it cannot be assumed that they are using the terms with identical meanings, and steps need to be taken to develop a common language, a common set of concepts, and a common evidence base. For example, do people working in mental health, both patients and clinicians, have a common language, a common sharing of the word “recovery” or “effectiveness” or “quality”, for example? Do they all have a common conceptual framework, for example a common understanding of the concept of stigma and a knowledge of the writing of Erving Goffman? Do they all have a common evidence base to back their initiatives?

How people feel about their job is difficult to influence directly but it is possible to influence how people think. The Oxford Healthcare Culture Programme, an initiative I have created with colleagues, focuses on three different aspects which influence how people think:

a common language – ensuring that the frequently used terms are used with a common meaning;

•  a common knowledge base – ensuring that the individuals within an organisation have access to the same evidence base and that they are presented monthly with

•  a key document or research report, with the focus of this service being on the evidence base for service management;

•  common concepts– drawing on influential books, both books directly focused on healthcare and books which, although not on the subject of healthcare, are of direct relevance to people who work in a health service.

The approach delivers key books, key words and key papers using different media, including five minute podcasts and a web site where the recipient can store their reflections on what they have heard or read to their personal development folder. This approach make it possible to embedd the change in culture in the daily tasks and processes that clinicians, and patients follow – rather than as a grand, one-off exercise quickly forgotten.

1.2.2. Transformation of focus from structure to system

Healthcare in every country is organised horizontally into primary, secondary and tertiary care. In the 20th century both primary and tertiary care evolved with a clear distinction between academic health centres offering tertiary care and general hospitals offering secondary care. The growth of primary care in the 20th century, particularly in the latter half, led to the pattern of care that we recognise in virtually every developed country today. This pattern of care is supported by different funding systems but in general it is possible to define clear funding streams for primary care, for secondary care, and for certain aspects of tertiary care, notably research, education, and, in some countries, highly specialised care. However, when addressing the challenges for the 21st Century, there are two weaknesses that must be addressed.

Firstly, this silo’d, horizontal organisation approach completely ignores the fact that self-care and informal care are of vital importance, particularly in chronic disease, and self-care, with the informal care provided by friends and family, is a type of care as important as any of the other levels of care.

Secondly, the diagram shown as Figure 1.5 shows that patients are assumed to be distributed among these levels of care appropriately – whereas in reality at every level there are some patients who should have been referred to a higher level of care and others who could have been kept at a less specialised level.

Figure 1.5.

Furthermore, work done to clarify the relationship between the levels of care does not take into account the fact that the appropriate distribution of care is dramatically different for different types of healthcare problems, and for this reason it is clear that programmes of care need to be focused on presentations and conditions. The key components of the Oxford Healthcare System’s alternative approach are shown in Figure 1.6, while a worked example of this approach is shown in Figure 1.7. The system is also characterised by feedback loops as shown in the Figure 1.8.

Figure 1.6.

Figure 1.7.

Figure 1.8.


The benefits of the programme approach are many, but notably include:

•  allocation of resources to be based on programme budgeting with marginal analysis, for example comparing the benefits of investing in rheumatoid arthritis as opposed to osteoarthritis, or vice versa;