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Redesign of healthcare needs a commons perspective

on Sun, 09/09/2012 - 19:50

Having just returned from the US where I heard numerous horror stories about the difficult to navigate and inadequate healthcare system I was truly surprised when a friend drew my attention to the very comprehensive and radical 'Crossing the Quality Chasm' report published by the Institute of Medicine in America in 2001. 

The outlined principles and practices are tremendously inspiring and extremely useful for re-designing healthcare in the UK to make it fit for the 21st century.               

The report provides overarching principles for specific direction for policymakers, health care leaders, clinicians, regulators, purchasers and others.

What the report explicitly does not do is to look at organizational approaches to achieve the aims set forth. And it is here where communities and the Commons framework need to fill the gap to put the redesign into practice.

Redesign in the report refers to a new perspective on the purpose and aims of the health care system, how patients and their clinicians should relate and how care processes can be designed to optimize responsiveness to patients needs. 

In chapter 3 on page 61 it offers a set of 10 new rules to guide the transition to a health system that better meets patients needs and nurtures innovation and excellence. (Copyright © National Academy of Sciences. All rights reserved. Crossing the Quality Chasm: A New Health System for the 21st Century)

1. Care based on continuous healing relationships. Patients should receive care whenever they need it and in many forms, not just face-to-face visits. This rule implies that the health care system should be responsive at all times (24 hours a day, every day) and that access to care should be provided over the Internet, by telephone, and by other means in addition to face-to-face visits.

2. Customization based on patient needs and values. The system of care should be designed to meet the most common types of needs, but have the capability to respond to individual patient choices and preferences.

3. The patient as the source of control. Patients should be given the necessary information and the opportunity to exercise the degree of control they choose over health care decisions that affect them. The health system should be able to accommodate differences in patient preferences and encourage shared decision making.

4. Shared knowledge and the free flow of information. Patients should have unfettered access to their own medical information and to clinical knowledge. Clinicians and patients should communicate effectively and share information.

5. Evidence-based decision making. Patients should receive care based on the best available scientific knowledge. Care should not vary illogically from clinician to clinician or from place to place.

6. Safety as a system property. Patients should be safe from injury caused by the care system. Reducing risk and ensuring safety require greater attention to systems that help prevent and mitigate errors.

7. The need for transparency. The health care system should make information available to patients and their families that allows them to make informed decisions when selecting a health plan, hospital, or clinical practice, or choosing among alternative treatments. This should include information describing the system’s per-formance on safety, evidence-based practice, and patient satisfaction.

8. Anticipation of needs. The health system should anticipate patient needs, rather than simply reacting to events.

9. Continuous decrease in waste. The health system should not waste resources or patient time.

10. Cooperation among clinicians. Clinicians and institutions should actively collaborate and communicate to ensure an appropriate exchange of information and coordination of care.

With the health commons event on 23rd October in mind, I asked James Quilligan to make a comment on these ten principles and how they reflect the emerging commons perspectives.


His cogent reply nails the point:

" In Westerns societies, government provisioning of public services for people under the 20th century social welfare model has broken down.

The emerging commons society points the way toward new political accountability structures which reflect less command-and-control delivery of public services and more subsidiarity, pluralism and polycentricity in the provisioning of people's needs.

Not only are people demanding greater choice and quality in public services, they are seeking to provide the services themselves where possible.

The commons movement is demonstrating how technology, culture and evolutionary forces are driving resources users to become the producers of their own resources. In health care, where people cannot always provide their own technical, specialized services, the ideal is to close the gap between resource users and resource providers.

It seems to me that the ten points outlined in this report, Crossing the Quality Chasm, clearly reflect this trend; but they do not describe how to make this work at the community level. Here is where I think the commons has something to say.

New accountability structures must emerge within communities, rather than outsourcing responsibility for public services to government or to corporations, which creates a top-down service delivery structure. Communities need to form their own trusts, with legal and financial responsibilities, to guarantee and manage health care for their members. This means that communities are going to have to organize in new ways to make this happen. 

People should not be forced to be consumers of health care, but partners in health care. Creating new political accountability structures through social charters and health trusts would enable communities to obtain quality health care services on their own terms.  Community trusts would ensure that resource users are driving this process, not resource providers or managers.”

If you are interested to find out what it takes to redesign the healthcare system to be fit for the future and if you want to be part of the process to make it happen, you are warmly invited to our forthcoming whole day event on the 23rd October in London: ‘Co-creating the Commons of Health and how together we will make it work’. If you join our 'Commons of Health & Wellbeing' group on CommonsRising you can follow or join the  conversations leading up to the event. We look forward to co-create the future of healthcare with you.