Improving access needs a whole systems approach
BMJ 1999; 319 doi: https://doi.org/10.1136/bmj.319.7214.866 (Published 02 October 1999) Cite this as: BMJ 1999;319:866All rapid responses
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I read with pleasure the article titled "Improving access needs a
whole systems approach". The three main perspectives for such improvement
outlined are all equally important and highly relevant to improving access
to healthcare in the NHS. However, with the steady amount of healthcare
information provided by the internet, and the ease of access by the
general public (55% of access to the internet is health related in the
US), the second perspective around the public managing and improving its
own health in the whole system is a vital component that I believe we in
the NHS are yet to fully realise.
The article allowed me to relate the concept of access and systems to
some of the work currently been done within the Institute for Healthcare
Improvement, Boston, USA, around the Idealized Design of Clinical Office
Practice (ID-COP). One of many important components of ID-COP is the
steady development of GP registers to monitor and contain patients on
lists that suffer from conditions such as diabetes with high levels of
Haemoglobin AYC or Cornary heart disease or other long term, often
manageable conditions (asthma etc.).
The registers allow GP's to access patients with mild problems and
control such problems in partnership with the patient, rather then
seriously ill patients accessing the health service system later with a
deteriorated condition. The system has met with good results in the US and
has ensured that many GP's, using information technology or the telephone,
can discuss and update long term sufferers to ensure they are managing to
maintain their conditions insted of ignoring such suffers until conditions
get worse or their brief period of access to the system is allowed.
This type of approach to access of health care helps the system at
community level become proactive; it seeks to control and influnece rather
than be controlled. It allows the systems facilitators (clinicans,
patients, etc.) to control the system before it controls them and
therefore enables a new, healthier dimension of access based around
information sharing and partnership. I would also argue this approach
allows for a more carefully crafted medium of patient focused care that
facilitates joint working across many disciplines; this is because it is
proactive and both long and short term.
The question of access has also, as we are keenly aware, a political
dimension, and it is important that this should not blind our desire to
improve and control access into the whole system. 'Walk in clinics' for
example may merely shift the access problem from one part of the system to
another. For example, a Doctor in a 'walk in clinic' is highly likely to
finish their time with a patient by requesting the patient follows up with
their General Practioner. The question of long term access is not solved
or controlled in this system, it has merely been handed off in the short
term to another part of the system.
I am in clear agreement with the article written around viewing the
system as a whole to improve access; but maintain that the role of the
patients, and to a degree clinicians, in the system is changing. This,
coupled with the advent of technology, means that we must all along with
the patients in the NHS make sure we manage and control the access to the
system proactively. We must also harness mediums and concepts such as
information technology and partnership, or the system will continue to
control us.
Competing interests: No competing interests
If the marketing and thus access to NHS Direct is anything to go by
the message of this paper may be a very long way from being achieved and
may be unachievable; perhaps this is because the problems of complex
systems are all too familiar to policy makers and politicians who cannot
be seen to have a plan for fear of the consequences if or when it goes
wrong.
Complex systems like the NHS have problems because such systems:
- often produce unexpected and counter intuitive results
- the links between cause and effect are often distant in time and space
-are highly sensitive to some changes but remarkably insensitive to many
others (1).
Systems theory which looks at organisations as either machines or
biological organisms has many attractions but is often criticized for
presenting too tidy and rational a view of the world which may suite
policy making in theory but can present problems in practice where
conflict meaning and emotion come into play(2).
1.Stacey R (1996) Strategic Management & Organisational Dynamics.
Pitman: London
2.Sims D Fineman S Gabriel Y (1993)Organizing & Organizations an
introduction. Sage: London
Competing interests: No competing interests
The editorial 'Improving access needs a whole systems approach'
raises several issues which I think need further consideration.
'Access' is a term often used but rarely well defined, although there
is a growing body of literature on the concept (1). It seems to be
somewhere between the potential for the identification of a need, and the
actual delivery of an appropriate and effective intervention. It may not
therefore be a particularly useful term to use. Instead it may be better
to consider, intially, the identification of need, which could be
classified as passive (in which the onus is on the individual to
'present') and active (in which there is action to identify an unmet need,
e.g. screening, community development, social marketing). Appropriate use
of active identification of need, and the delivery of the intervention
effectively and appropriately will address 'access'.
The term 'whole systems approach' is showing increasing useage, which
implies a common understanding of its meaning; although whether this is
the case is not certain. 'Whole systems thinking' can be considered a 'New
Age style application of systems thinking' (2). The main disadvantage of
the concept is that everything in the universe has influence on everything
else. Given this, no activity aimed at improving the health of the
population could be justified for fear of its having an unrecognised
detrimental effect. It may be more appropriate to consider purposeful
systems which may influence health, and consider them in terms of their
viability (3).
I think the underlying message of the editorial seems to be that
there needs to be a better understanding of the systems involved and the
relationships between them. This is important; and not just for the year
2000. A pardigm shift towards inter-disciplinary, trans-disciplinary (4)
or even 'preter-disciplinary' working will be important for the new
millenium. And with the current emphasis on partnership working it is
already beginning to happen.
(1)Beyond coverage and supply: measuring access to healthcare in
today's market. Gold M, Health Serv Res 1998 Aug;33(3 Pt 2):625-52;
discussion 681-4
(2)Principa Cybernetica http://pespmc1.vub.ac.be/CYBSYSLI.html
(3)Diagnosing the System for Organizations
Stafford Beer S, John Wiley and Sons June 1994
(4)Complexity and Human Health: The case for a transdisciplinary
paradigm, Albrecht G,Freeman S, Higginbotham N. Culture, Medicine and
Psychiatry 22: 55-92, 1998
Competing interests: No competing interests
Re: Survival for over five years after diagnosis does not mean cure
To The Editor,
As a physician and as a Thyroid Cancer Survivor
(Papillary-Follicular-Neck Dissections 1985 when I was age 45), I
appreciate the letter of the Radiation Oncology TEAM (Professor Alan
Rodger and Karen Taylor Fellow) at the William Buckland Radiotherapy
Centre, The Alfred, Melbourne, Austrailia published in BMJ Volume 319
page
1573 on 11 DECEMBER 1999 "Survival for over five years after
diagnosis
does not mean cure."
Might I inquire, in what period of years, the survival curves of
individuals with Papillary-Follicular Carcinoma of the Thyroid
parallel
those of individuals of the same age without carcinoma of the
thyroid?
Might I further inquire, if there is an reasonably
anticipated and expected increased incidence of Papillary-Follicular
Carcinoma of the Thyroid in individuals who wre exposed to x-
irradation as
I was in a Cardiac Catheterization Laboratory in the decade of the
sixties
prior to the development and use of the lead-lined "Thyro-Shields?"
Joshua Grossman, M.D., F.A.C.P.
Clinical Assistant Professor
The James H. Quillen College of Medicine,
1005 Melrose, Johnson City, TN 37601
Competing interests: No competing interests