Part 3 tackles the structure and dynamics of health system organisations. The introduction begins with how we perceive whole and part and teases out levels once again. These have their own concepts and language as we move through layers. This transition between layers means we also have to dispense with, or suspend the detail that a layer gives us - the 'cellular level' for example. Sturmberg describes the properties of layered systems that include, concepts, discovery, interaction and constraints. As is often the case through the book, table 1 (chapter 9) captures a great deal with figure 3 - health system phenomena and different levels of organisation. The final addendum of part 2 posed the questions: what to change?; what to change to?; and, how to cause the change (p.158)? This introduction reminds us of the constant need to consider parts (data) anbd the joining of wholes (wisdom).
Chapter 9 is about modelling, potentially a dense and jargon-ridden subject, but the treatment here retains the book's accessibility, clarity and interest. This chapter is like an answer to a soapbox of mine as it highlights the role and use of spatial modelling and geographic information tools. Admittedly, as clinicians (all disciplines) we cannot be service planners and public (mental) health specialists, but services should have access to such tools. (Teams could have a running list of 3 research questions that can be taken up, revised by students and team members, perhaps allied to CPD and other training/education commitments). Sturmberg gives us: mental health services in Helsinki; childhood obesity in Berlin; Life expectancy in a city and infection risk in Democratic Republic of Congo.
On first picking up the book, the arrangement of the parts with an introduction and the chapter introductions can be a little confusing. But the disorientation is brief. The book has some typos: 'intense' for 'intents' p.171; 'locking' for 'looking' p.179; 'build' for 'built' p.225; 'pleural' for 'plural' p.234; outlined, p.251. (I used to read papers for data definition standards.)
This does not detract from something special in 9.3 modelling system problems. The question is "What ... if..? and a series of scenarios in aged community care: What if -
- We double the number of nursing home beds?
- We double the social care workforce?
- We combine a 50% increase in both the above?
The addenda for chapter 9 are system diagrams and link to chapter 10 very nicely returning to micro, meso and macro levels. I could sketch out the multiple cause and sign graph diagram fig 10.1 for a patient and how deteriorating health results as much from the interdependent variables of his social context as basic physiology (p.197 - another case study).
With a book that can serve as a key reference for Hodges' model - it had to happen (sorry!). Here I have mapped some of the content of Table 10.1 (p.209) to h2cm:
individual
|
INTERPERSONAL : SCIENCES
humanistic ----------------------------------------------- mechanistic
SOCIOLOGY : POLITICAL
|
group
|
| Hip replacement surgery
Flu vaccination
Multimorbidity management of polypharmacy
Intensive Care Unit
Managing a second degree burn
Protocols - handwashing - |
Community care for frail elderly
Managing a natural disaster (social impact) | - policy
Health financing
Nurse unit manager ensuring staff record every patient incident regardless how trivial
Surgeon managing theatre team
Acute psychiatric Unit
Bed management of a hospital
(*see below) |
This week driving between my community visits, a radio public health notice asked listeners: what is the 2nd most significant cause of cancer after smoking? It begins with 'O' and ends with 'Y'. Chapter 11 concerns obesity at the personal, personal-community, and community-whole society levels. This chapter relies on diagrams-figures, some are difficult to read and with no web reference to go to the detail is lost (figure 11.10). The message is not lost, however; a magnifying glass might help (figure 11.8). 'Obesity' must include the industrial and political dimensions.* 'Food sovereignty' is an important point (p.223). If blockchain technology does prove itself beyond cryptocurrencies could it find an governing application in food system regulation?
Sturmberg anticipates there is/will be resistance and refers to the need:
"to overcome some of the false and unhelpful conceptual dichotomies in the debate about the obesity epidemic"p.227.
What follows then is a need for informed debate and argumentation?
Part IV brings to life the book's subtitle and achieving this goal: Chapter 12 how things ought to be. The introduction here is rich - 6 pages, 16 references mainly tables but informative.
Personomics p.246 is a gift to me and unsurprisingly it is allied with person-centredness. Sturmberg rightly stresses how we need to put the person at the centre of the system. Although referred to constantly - to the point of rhetoric? in the literature, politicval media. In Hodges' model I have stressed how 'work' is involved in achieving person-centredness and being person-centred. In the model the individual needs to 'moved' conceptually, in the first instance to the centre of the model.
With figure 12.2 I'm still sore from the back-flip. I've possibly seen this before, but the version on p.249 is again very meaningful and vital to holistic and integrated care.
I would switch this slightly for h2cm, thus:
EQUITY :: EQUALITY
REALITY :: LIBERATION
The book ends on design and design thinking. H2cm leads inevitably to structure and content and as such care architecture and so design. Here the book is talking 'problem solving strategies' and hence Health System Redesign. Such ambition needs to attend to barriers and once again in 13.4 we consider "what might stand in the way". Even at the end Sturmberg is clarifying and extending definitions: Adam Smith - the Public Good AND the free market; 'social' and 'socialised'. This is not an oversight but helps close a fascinating circle and excellent book.
The 'blurb' as they say refers to the book as a "forward-looking volume" - together with the knowledge here - and crucially the combined wisdom that results - we can make it
here-and-now.
I would like to express my many thanks to Prof. Sturmberg and Springer for the review copy.
Sturmberg JP. Health System Redesign. How to Make Health Care
Person-Centered, Equitable, and Sustainable. Cham, Switzerland:
Springer; 2018.
See also:
Book Review: [i]
Book Review: [ii]
Book Review: [iii]
orcid.org/0000-0002-0192-8965