By Sohail Inayatullah
1. Background
Over 50 health care professionals met on April 17th at the Redcliffe Convention center to develop a shared vision of the future. The aim of this conference was underpinned by a need to create a single intent that ‘pulled’ multiple realities held by limited stakeholders into one vision that could:
1. Facilitate growth in community building.
2. Integrate and align effort towards a common purpose with a beginning towards an integrated planning approach.
3. Articulate an image of preferred Health Futures.
4. Create an opportunity to develop relationships and possible partnerships within a common cause.
The driving reason to conduct such a session was due to limited levels of integrated approaches to health planning by health professionals within the Redcliffe and Caboolture Regions but other regions throughout Australia. The intention was that this model of grassroots futures work could become portable, allowing real transformation in health delivery throughout the nation.
2. Conference Day
The conference day was divided into the following stages.
1. An opening presentation by Aboriginal Elder Peter Bird. Bird’s His main point was that to develop a shared vision of the future, we must acknowledge how settlement destroyed the health of aboriginal peoples. Creating a future must begin with redressing past grievances.
2. The first session focused on creating health pasts. The three main trends identified were: (1) less funds available and thus the move from abundance to tough choices; (2) the development of community health and (3) technological advances
3. A keynote address by Sohail Inayatullah. He made the following points. 1. Creating an integrated framework for health care is foundational necessity given the overwhelming changes to health. Whether it is genomics, cyberhealth, an aging population or the rise of complementary medicine, traditional delivery systems of health are being dramatically challenged. The economic reality of globalization – more porous nations, privatization – force agencies to do more with less. While daunting this is possible through integrative visions and strategies. Four solutions were provided: coordinate care; smart card; community care; and integrated system.
4. Sectorial presentations from Ralph Smallhorn (General Practice), John O’Brian (Queensland Health), Jeanette Evans (Blue Care); Darryl Baker (Redcliffe City Council) and, Chantal de Vere (Natural Healing). We briefly summarize their main points.
Ralph Smallhorn made the following points. 1. There are not enough gps (or nurses). 2. We will see an increased number of part time GPs. This is already evident in women GPs. 3. GPs should treat only what others groups cannot. 4. GPs must work with other groups as to create a multi-door integrated scenario of the future.
John O’Brian articulated Queensland Health’s vision for the future. This is:
Health is a lifetime investment, education as consciousness of health choices
both in terms of life style and smart consumer, and health as resource (a healthy population is cheaper to maintain). The main future issue is the transition from health for children to health for the aged.
Darryl Baker developed how the local council is working in the health area. His talk focused on community capacity building, as for example, the local library which has become a core areas of learning and community building.
Jeanette Evans saw health a pivotal investment to our future. While the demand for health for often insatiable and increased aging made health care delivery even more difficult, advances in technology (tele-health, for example) and the possibility of integration offered some hope for the future.
Chantel De Vere pointed out how complementary medicine was leading the way in many areas of health care, and, becoming increasingly respectable. The presented numerous case studies – for example, at Southern Cross University – to illustrate that the walls between traditional and complementary medicine were breaking.
Next were six break-out groups. They were charged with the task of developing a preferred vision. Points of agreement from the disparate groups where developed in a collective visioning session.
3. The Vision
VIRTUAL MULTIDOOR HEALTH/VIRTUAL MULTI PERSONAL LIFE HEALTH PLAN/HEALTH FOR LIFE
S Seamless Portals
M Multi-Tier
A Access
R Relations and Community Building
T Trust/Respect/Ethics
The following describes in more detail the vision:
· Virtual teams
· Person-based, holism
· Prevention, early intervention
· Unique ID number, card system, health points
· Co-ordinate life style interventions
· Community Care at the centre/core – person – trust
· Funding values shift towards wellness model
· Smart system – interactive – TV
· Seamless strategic alliances
· Volunteerism
· New measurements
· Smart astute use of current resources
· Shared doable vision
· Breaking down barriers
· Sustainablility
· Client focused
· Federal plus local
· All individuals accountable
· Multiple entry – suppliers
Some of the social factors necessary for this vision included.
· Ten year funding cycle
· From greedy society to community
· 30 hour working week – improved connectedness/health
New indicators were measure movement toward this vision, among them were: no homeless and a comfortable death.
An essential value behind this vision was: trust and respect.
To move toward this vision, it was agreed that a pilot project was necessary.
Further next steps included:
Community Information
· Involvement
· Focus groups
· funding
· local members, political buy-in
· Media involvement
These communities needed to be: Physical and Virtual
Potential users/suppliers needed to be assessed as well.
4. Small Groups
What follows are the reports from the small groups. They are the data, information and values from which the group prepared a consensus vision.
1. Red Group: Facilitator Philip Daffara. Vision 2101
Ensure a wholistic continuous lifetime care plan is co-created for each individual, encompassing Prevention, Empowerment and Sustainable well-being
To achieve this Vision we the Redcliffe-Caboolture-Bribie community intend to:
· Develop a web portal of all health service providers in the District to integrate the sequential delivery of individual (care plan) based services;
· Build community leadership and Ethics;
· Promote and provide incentives for the development and maintenance of care plans using credits for preventative actions;
· Promote and facilitate the switch of restructuring of Federal and State funding and reporting arrangements so that it moves with the Care Plan outcomes.
· Develop a system and Strategic Plan to measure the “Health” of the community, the effectiveness of Strategic alliances and collaborative partnerships to achieve the vision;
· Facilitate the planning of future health service needs with Local Governments (Redcliffe, Caboolture and Kilcoy Councils) so that social infrastructure is provided for new developments in accordance with the integrated Planning Act.
· Habitat needs to sustain community health.
· Empower Minority and Mainstream communities and provide physical and cultural space and freedom to allow them to improve their own health. Eg Indigenous, Youth, Gay)
· Promote Life Education at schools and for the disadvantaged to increase the awareness of the benefits if a lifetime Health Care Plan, responsibility for their choices and the benefits of a holistic view.
· Promote the Investigation of the triple bottom line benefits of introducing a Health Tax or excise on unhealthy products, to increase alternative sources of funds; and investigate the impact of having Private Insurance premium reductions if preventive actions are implemented in an individual’s care plan.
Shared values were:
Innovative, tolerant, sensitive, compassionate, fulfilling, proactive, flexible, Ethical, confidential, equitable, socially just, sustainable, viable, responsive, mentors, sharing, honest, openly communicative, building relationships.
2. Green Group. Facilitator. Eric Dommers. Vision for Redcliffe Caboolture health system in 2012.
Structural
1. There is alignment of all district service providers (health, education, housing, employment, council etc), and all operate on a 10 year funding cycle. This enables budgets to be designed with a view to reaping savings/investments from prevention initiatives. This has enabled local service providers to invest in both inter-organisational integration initiatives, as well as primary prevention initiatives.
2. Inter-organisational arrangements include Memoranda of Understanding linking various service providers for both ‘population groups’, and whole of population initiatives. All service providers are fully accredited and are also academic institutions conducting professional/vocational preparation and training courses. The focus of these courses is on training service providers to be multi-disciplinary. Health service providers have agreed on the use of best practice protocols and guidelines for various disease entities.
3. Primary care is still provided and co-ordinated by GPs. GP businesses are operated within a range of quasi-corporate structures. The local community still regards GPs as a first point of access, and no-one in need is denied access (ie. some bulk billing arrangements are still in place). GPs work with a range of other primary care providers such as “St. Blues” to co-ordinate the care of patients with complex needs.
4. Structural efficiencies and a concomitant need for flexibility have resulted in a wide range of strategic alliances and amalgamations among health service providers. The preventive arena has become a market, with payments available for locals who are in danger of falling through the gaps in the safety net. A wide range of service packages is available for at risk/marginalised individuals.
5. Service information is accessible through various home and community media, and a key social education tool is ‘service literacy’, and ‘health literacy’.
6. All salaried employees work a maximum 30 hour week. This enables people to have mote quality time with their families, and in supporting their local community. Volunteering is a strong community theme. The 30 hr working week has also increased the levels of employment, and improved local health, and social connectedness.
Scenario
Mrs. Jones wakes in the morning, and tunes into her health information channel. The monitor bids her good morning, bio-senses her health status, makes a health service appointment with a local GP, and advises her of the time of the appointment with the Mayne-Blue-QUT-Salvos Health Service and tune up centre.
Mrs. Jones’ estranged younger cousin Mary, is homeless, unemployed, and physically and emotionally depressed. She is identified as ‘at risk’ by the ‘Blue Salvos’ bounty group. Mary is offered a holistic and co-ordinated package of services including temporary shelter, a shower, aromatherapy, ‘quality listening’, a health check, and employment counselling. The package is paid for by the ‘Upstream Health Investment Fund’, which pays for the services from a ten year ‘prevention contributions levy’ contributed by relevant local service providers on the assumption that there will be a return on their investment through a reduction in Mary’s estimated future use of acute and emergency services. Mary’s QoL improves dramatically, and she is now working as a volunteer for the local council.
3. Blue Group Facilitator., Steve Gould
Stated Vision: ‘Relational Health’
To break down the barriers through community/service provision, education, and sharing by empowering that which leads to seamless care in sustainable health environments.
This vision was based upon descriptive statements of what measures could be observed by participants within their respective health care fields of work and is based upon preliminary descriptors of meaningful outcomes/visions previously mentioned.
Themes
No paper.
High levels of customer satisfaction (both internally and externally).
Acceptance of “stay ins” as a right of choice to remove oneself from the community.
Expedient access and processing of health clients through the medical system by multi team approaches.
Layered assessment of health clients to target interventions based upon primary vs acute care.
Empowered and informed communities to facilitate targeted interventions based upon primary vs acute care.
Provision of alternative options to ‘first choice’ medical interventions other than the GP as the first point of contact.
Removal of barriers to local GPs which prevent locals accessing their preferred GPs.
(This situation was due to long waiting lists.)
Increased access points to multiple health providers within the existing health system by community.
Increased usage of virtual technologies to alleviate demands on health system.
Functional integrated planning for local health community.
Developed partnerships and relationships within the local health community.
Sharing of health clients and information to facilitate expedient service to clients.
Partnered ‘funding generation’ activities.
Care providers as a vehicle of change via communication and braking down the barriers.
Increased opportunities to be involved in future visioning.
Shared values were:
· Direction or told what to do.
· Learning
· Sharing
· Relationships
· Purpose
· Results
· Influence
4. Facilitator: Ivana Milojević. Preferred Vision for the Future of Redcliffe-Caboolture Health.
Collaborative Care 2020
· Only two levels of government in Australia: e.g. national (federal) and regional
· Movement from the greedy society towards giving one. Cultural values are changed: promotion of ‘old-fashion’ values of caring, tolerance, compromise. Sense of community also back.
· Health system more integrated: ‘share-care’, collaborative approach, collaborative action research planning, teamwork – ‘mobile working teams’ (not necessarily in the same building). Mutual respect and recognition crucial (instead of saying nurses or doctors or allied health practitioners ‘are only good for …’). Everyone’s skills are respected and valued. Also important to accept the limitations of what service providers can offer.
· Collaboration between ‘mobile working teams’ through improved communication and connection. There is enhanced communication and referral linkages facilitated by unique ID number, client data record (similar to smart cart), owned by client.
· Client and community are put in the middle – services are planned around them and their needs.
· Responsibility goes back to people themselves who are in charge of their own health. People are more responsible and accountable for their health. Affordable and timely access to healthy lifestyle is improved. Focus on lifestyle change and promotion of wellness. Focus on education (of children, parents, health workers, community, society).
· There is an increased focus on prevention across community service providers. Resources are re-distributed – there is a balanced placement of funds on ‘prevention-early intervention-illness-palliative care’ continuum.
· There is life course approach to health – intervention at transitional milestones (e.g. birth, starting school, adolescence, etc.). Services working together around schools.
Recommendations
· More funding into community. Community based system.
· More aged care facility. More appropriate staff, nurses, allied health practitioners, teachers-educators.
· $ freed by money moving from (1) rearrangement in governance, (2) illness end – prevention saving money in the long term
· Land development taking into account broader set of issues – e.g. public spaces.
· Development of healthy food chain stores.
· High employment rate, reduced gap between rich and poor.
· Euthanasia debate over – replaced by palliative care [not generally agreed upon]
· Emergence of a ‘major computer virus’ – re-introduction of traditional games among children, as subjects at school, etc.
5. Faciltator. Marcus Bussey.
The vision had two dimensions – a wellness building and wellness hug.
The Wellness Building
This definition of wellness as an essential social capital builds a 4 tiered health system that is rooted in consciousness: education for Living. It progresses through a Community health network of positive relationships; moves to the physical centres of health and healing and has at its summit the Spiritual “I”, that acknowledges that the role of meditation and personal reflection is central to a well being.
This was represented as a pyramid.
The “Wellness Hub”
Represented as a wheel with relationship at the centre.
This idea places relationships at the centre of health, both personal and professional.
A sick person enters the health system through their own chosen modality. This trusted professional acts as a guide. She or he may or may not be a GP but they will be able to provide clear pathways through an integrated system that includes home care, library access, meals on wheels, mental health, specialist treatments, etc…
Values Shift
· Sickness to Health
· Specialist to Holistic
· Isolation to Integration
Key Ideas
· Needs Management for client based on personal relationship
· Relationships between client and workers
· Information Management Infrastructure (Computers)
· Clear Marketing of integrated services
· Opportunities for self referral
Outcomes
· Relationships leading to responsiveness to individual needs
· Wellness Vs Sickness resolved in favour of former
· Value structures for funding to change
· Information management – techno + humane
6. Facilitator: Patricia Kelly
Vision: Client Focused Future
Features
· One prime level of government
· Tiered roles addressed staff shortages as professionals are supervising and engaged in educating families.
· Community and residential services integrated including transport services – to support well aged
· A comfortable death -pain free, intervention if required, euthanasia not illegal
· Health maintenance and prevention of illness means that everyone experiences wellness in all aspects, physical, mental, spiritual, cultural.
· It is a concerned community, with everyone accountable and responsible
· No homeless, no pollution
· Nuclear and extended families
· Ethical decision making
· Consensus based on trust. Competition has gone with changed funding
· Competency testing for over 65s
· More accountable – accurate, informed choice
o May not get the choice you want eg if you are a smoker or a drinker you may not get access to heart transplant
· Better focussed
· Discourse – turn problems into challenges
- At a personal level only one person stated his preferred life in 2012 but others agreed. The elements were 3 days work, from 10- 4, twice the salary, a healthy person, valued, resourced to meet individual and community needs
Drivers for change:
· Funding – limited supply
· Yearning for quality of life
· Explosion of technology
· Expansion of knowledge
The Client focussed future was presented as a diagram with a virtual centre at the core.
Coming off this were these elements
1. client focussed – in all dimensions
2. trust
a. professional respect
b. re-evaluated roles – chosen core business, specialty areas
3. one bucket of money
a. shared accountability
b. local government to take responsibility for health services through negotiating and accountability
4. community services
a. minimal duplication
5. consumer choice
a. “health points” linked to…
b. smart card,
c. better marketed to population … linked to…
6. information integration and transfer
a. data bases all linked electronically so no need for reassessment, hard to lie to system
7. health maintenance and illness prevention
8. All These Changes Began With A Pilot Program In 2002/3with the suggestion this might be North Lakes.
Additional information
Trust. Service providers need to be non-territorial and recognise the professionalism of others. This requires trust that has to be built through discussion hence the pilot project. All agreed that competition for limited funds creates much of the current tension between groups.
Integration, Including transport services
An Alternative Scenario to the preferred vision was:
2012 Breakdown Scenario
· No integration
· Duplication of infrastructure leading to wastage and inefficiency
· Under-resourcing
· Low socio-economic groups leading to third-world conditions and disasters in multiple areas, including raised suicide rates.
· Unrepresentative demographics with majority aged
· Budget cuts leading to equity issues – not enough people to provide services leading to
· Burn-out
There was consensus that we are currently on this track
Facilitator Comments
1. Ivana Milojević
Comment
General agreement on the first part. ‘Other ideas’ show some contradictions with the general vision or haven’t been more thoroughly explored, or there was some disagreement among participants. E.g. there was a contradiction between ‘more aged care facility’ (promoted by palliative care nurse) and ‘no need for increased funding, instead, redistribution of resources’ as well as ‘more balanced placement of funds’ meaning more resources into prevention and less into ‘end-stage of illness’. Similarly, emergence of a ‘major computer virus’ inconsistent with the development of electronic ID card. Also, some ideas too broad, e.g. high employment rate or reduced gap between rich and poor.
2. Steve Gould
Reflections
Upon assessment of events from Wednesday 17th April 2002, the following questions remain unanswered:
· Q: How will GPs release themselves from traditions knowledge based hierarchies?
· Q: How will future policy making impact upon how decisions are made?
· Q: How will future funding be dispersed and under what criteria?
· Q: What are the implications for future technologies upon industries that are dependent upon existing health service provisions.
· Q: How will the shift towards self-diagnosing and self-dispensing technologies impact upon current service deliveries?
· Q: Who are the future stakeholders?
· Q: What is the future role of Government entities? Regulation or Socialistic Service provision?
· Q: Where is the ‘way forward’ manual?
Conflicts to the Vision
Possible barriers to ennobling the preferred Vision are:
· Loss of power bases.
· Hoarding of patient knowledge.
· Impotence of action.
· Translation into pragmatic languages.
· Adherence to existing health practices.
· Espoused rhetoric without behavioral transformation.
· Limited stakeholder ownership.
Future Implications
Possible implications are:
· Diffusion of traditional power bases, from GP to allied health practitioners.
· Equity and access to medical information.
· Development of ‘redundancy mentality’ within practitioners.
· De-mystifying the diagnostic processes through knowledge empowerment.
· Developing the evolution of alternative health intervention choices as acceptable and valid.
· Growth in litigation behaviours within the community.
Future Actions
To continue with the momentum generated on the vision workshop, it is crucial to follow up quickly with a series of activities to evolve the endorsement of the vision by all stakeholders. This can be achieved by:
1. Plan a series of workshops to develop ‘ownership’ of the vision. This can be achieved through stakeholder assessment workshops.
2. Develop a ‘Values Statement’ for the Region to dovetail into the Vision.
3. Explore preferred scenarios for the Region
4. Develop a Strategic and Operational plans to enable the ‘operationalisation’ of goals and strategies from the preferred vision.
5. Develop ‘meaningful measures’ that PULL the desired future and act as feedback loops into future reflection workshops.
3. Patricia Kelly
Comments:
. The preferred scenario depends on an assumed computer literacy, which seems unlikely for the majority of this ageing population.
. Any futures work with any of the groups or in the suggested pilot project would benefit from time to air and discuss concerns and current problems, possibly in separate groups and then coming together with a summary of issues.
. To do quality futures work the participants may need more work with Futures ideas and concepts.