Interprofessional Collaborative Care Will Be Key to Meeting Tomorrow’s Health Care Needs

Maryjoan Ladden, Ph.D., R.N., F.A.A.N., Robert Wood Johnson Foundation Senior Program Officer

A little over a year ago, the Institute of Medicine’s landmark Future of Nursing: Leading Change, Advancing Health report put forward a series of recommendations for transforming the nation’s health care system. Among them was a call for a system in which “interprofessional collaboration and coordination are the norm.” That’s no simple assignment in a system that often operates in silos, from schooling through practice. But a number of innovators around the nation are already making headway.

Their work is the subject of a new policy brief from the Robert Wood Johnson Foundation, part of its Charting Nursing’s Future (CNF) series. The brief delves into what the IOM recommendation means for health care systems, offers case studies of several collaborative care models already in place, and examines the implications of the recommendation for how we train nurses and other health care professionals.

According to the brief, Implementing the IOM Future of Nursing Report–Part II: The Potential of Interprofessional Collaborative Care to Improve Safety and Quality, the “silo” approach must soon give way if we are to meet coming health care challenges. For example, chronic conditions are increasingly common—not surprising given an aging population. But the health care system is poorly structured to provide the sort of coordinated care and preventive services needed to give these patients quality care while reducing costs. Some health care institutions are gearing up for the challenge.

• In Boston, where Harvard Vanguard Medical Associates developed its Complex Chronic Care (CCC) program, primary care has become interprofessional, collaborative and noticeably more efficient. Each CCC patient is assigned a nurse practitioner (NP), a registered nurse with advanced education and clinical training. The NP consults with all the patient’s subspecialists and incorporates their guidance in a single plan of care. The NP then manages and coordinates that care, connecting patients to nutritionists, social workers, and other professionals as needed. The model is dynamic, allowing patients to meet more or less frequently with the NPs and their primary care physicians, who remain responsible for the patients’ overall care.
  

• In New Jersey, the Camden Coalition of Health Care Providers is “revolutionizing health care delivery for Camden’s costliest patients,” according to the brief. These individuals, sometimes called super utilizers, typically rely on hospital emergency rooms for care. Not surprisingly, such patients account for an outsized share of local hospital costs, often with diagnoses that would have been more properly handled in a primary care setting. The Coalition developed its Care Management Project to reduce these unnecessary emergency room visits by treating patients where they reside, even when that means treating them on the street. A social worker, NP and bilingual medical assistant work as a team to help patients apply for government assistance, find temporary shelter, enroll in medical day programs and coordinate their primary and specialty care.
  

Training the Next Generation to Collaborate

Of course, the silo effect usually begins in school. In May 2011, six national education associations representing various health care professions formed the Interprofessional Education Collaborative (IPEC) and released a set of core competencies to help professional schools in crafting curricula that will prepare future clinicians to provide more collaborative, team-based care. Such efforts are already under way at a number of institutions.

• Maine’s University of New England has developed a common undergraduate curriculum for its health professions programs in nursing, dental hygiene, athletic training, applied exercise and science, and health, wellness and occupational studies. The curriculum includes shared learning in basic science prerequisites and four new courses aimed specifically at teaching interprofessional competencies.
  

• In Nashville, Vanderbilt University is also pursuing an interprofessional education initiative that unites students from the medical and nursing schools with graduate students pursuing degrees in pharmacy and social work at nearby institutions. Students are assigned to interprofessional working-learning teams at ambulatory care facilities in the area.
  

• The Veterans Health Administration (VHA) is piloting an interprofessional initiative, as well, focused on preparing medical residents and nursing graduate students for collaborative practice. As part of the initiative, five VHA facilities have been designated Centers of Excellence and received five-year grants from the U.S. Department of Veterans Affairs. Each VHA Center of Excellence is developing its own approach to preparing health professionals for patient-centered, team-based primary care.
  

• In Aurora, Colorado, the University of Colorado built its new Anschutz Medical Campus with the explicit objective of creating an environment that promotes collaboration among its medical, nursing, pharmacy, dentistry and public health students. It features shared auditorium and simulation labs, as well as student lounges and other dedicated spaces in which students from different professions can pursue common interests such as geriatrics in a collaborative fashion.
  

Such initiatives are clearly the wave of the future, if only because the pressures of caring for a larger, older and sicker population of patients in the years to come will drive efforts to identify efficiencies. In the words of Mary Wakefield, PhD, RN, head of the Health Resources and Services Administration, “As the health care community is looking for new strategies and new ways of organizing to optimize our efforts—teamwork is fundamental to the conversation.”

...

My source: Matt Freeman (PRS)

End of Life Care: Gold Standards Framework (Heaven's door)

INTERPERSONAL : SCIENCES
humanistic ------------------------------------------- mechanistic
SOCIOLOGY : POLITICAL

individual

PRIMARY CARE	ACUTE CARE
CARE HOMES	DEMENTIA (CARE)

group - population

Looking at a table 'GOLD STANDARDS SET BY BENCHMARK PROGRAMME' (p.23) in Prof. Thomas's HSJ article, I could see an instant fit between the four listed care contexts and the domains of Hodges' model.

There are also many overlaps and of course Hodges' model is an idealised resource. For example,  governance applies across all the above and in that way all can be placed in the POLITICAL domain.

Further points explaining the above includes:

• The GP and primary care seeing the person first not the diagnosis. Again in this sense - respect and dignity we can place all these care specialisms in the INTERPERSONAL. You would hope that primary care 'know' the patient as a person, an individual; or at least through recourse to the primary care record.
• If a care home 'works' it will be able to deliver care almost transparently, it is not a process but a social gathering. It is not the person's home (their home is not something to be forgotten, replaced like their past), but it seeks to emulate this as far as possible. Care is a routine that is also personalised and even at the end of life there is peace, calm and dignity.
• Dementia care is a political challenge, a priority and challenge across all the domains. As in the previous post - what training is provided to Health Care Assistants and other staff? How is the strategy for dementia progressing across all these care environments?

The National Gold Standards Framework Centre in End of Life Care

Thomas, K. (2014) 'End of life care is a litmus test for the whole of the NHS'.  HSJ, 31 January, 124, 6384, 21-23.

Julian Tudor-Hart 'The Inverse Care Law' - c/o The Lancet

On the bottom of my notes re. Giarchi and 'distance decay' I'd written:

'Inverse Care law - p.60. - Giarchi. "those who suffer more ill health are less likely to be assisted."

It made me wonder about the origin of this law having posted about it in 2020.

The Lancet has an editorial and an associated podcast:

50 years of the inverse care law. The Lancet, Volume 397, Issue 10276, 767. February 27, 2021.

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)00505-5/fulltext

'“The availability of good medical care tends to vary with the need for it in the population served. This inverse care law operates more completely where medical care is most exposed to market forces, and less so where such exposure is reduced.”

These understated opening lines of Julian Tudor Hart's paper, The Inverse Care Law, are as relevant now (50 years to the day since publication) as in 1971. The paper is one of the landmark publications in The Lancet's near 200-year history, and the resonance of Tudor Hart's definition of the inverse care law has global and timeless importance. Simply expressed, Tudor Hart observed that disadvantaged populations need more health care than advantaged populations, but receive less.

Tudor Hart's life and career took him from highly privileged beginnings in London and Cambridge to decades spent in the deprived and deeply socialist Welsh valleys. His experience and work has inspired a generation of influential health-care leaders including Andrew Haines, Allyson Pollock, Cesar Victora, and Graham Watt. Today's anniversary issue of The Lancet explores both the global reach of the inverse care law and primary care initiatives in deprived areas around the UK.

Although inequality in health and its many causes are widely understood, inequity in health-care service provision is enduring and fundamental: an intractable concept that lies at the heart of the inverse care law. The inverse care law is primarily about inequity (injustice) in health care that results in unfair social inequalities (imbalances) in health. Since the inverse care law was published, the UK's National Health Service (NHS) has strived to reduce inequity with mixed success. Notably, long-lasting progress was achieved through the 1970s resource allocation formula, which reduced geographical inequality in hospital and institutional expenditure. In the early 2000s, the NHS strengthened primary care provision in disadvantaged areas, leading to a temporary reduction in social inequality, although this progress has reversed following shifts in funding, a slowing of spending, and years of living with austerity.'

See also: 

https://en.wikipedia.org/wiki/Julian_Tudor-Hart

https://www.chpi.org.uk/blog/julian-tudor-hart-and-the-essence-of-primary-care/

Person-centred care [PCC]: is it really happening? c/o National Voices

individual

|

INTERPERSONAL : SCIENCES

humanistic --------------------------------------- mechanistic

SOCIOLOGY : POLITICAL

|

group

PCC = what’s important to the individual, is co-ordinated around their needs and involves them in decisions. "To be person-centred, that care needs to work together to wrap around all the needs of the individual in a holistic way. Sadly, our report found that neither the NHS nor adult social care can demonstrate co-ordination of care, despite ‘integrated care’ being a key goal of all national and local leaders over the past five to 10 years. The way health and care services work must change to reflect the needs of the population. It would be a start to recognise that co-ordination of care is an important factor, and that we need to be measuring whether it is happening."	(many) Definitions = 5 key indicators of pcc:  good information, good communication, involvement in decisions,  care co-ordination  and care planning. Service user reported data from 19 nat. surveys NHS:  in primary care, only 39% of patients said their GP was ‘very good’ at involving them in decisions. What’s more, personalised care planning doesn’t really happen. Only 3% of GP patients with one or more long-term conditions reported having a written care plan, suggesting that opportunities to deliver personalised care in the NHS are being missed.
"Personalisation of care is more advanced in adult social care than in the NHS, with 89% of adult social care users reporting that the care and support they received helped them to have control over their daily life. Similarly, 63% of people using a social care personal budget said that this had improved their ability to make everyday decisions. Participation and control of decisions is well-established in adult social care, with just over 90% of those using community adult social care saying they were involved in decisions about their care and support needs." (See original post - report for important additions)	20+ years policy  England Care Act 2014 National Voices coalition of health and care charities  report ‘Person-centred care in 2017' No National data on this... "It is clear from our report that a strategic overhaul of how care is measured is needed. Rather than single-service, single-setting, activity measures, more credence needs to be given to the experiences of the people who rely on services. Only then can we help local systems succeed in offering personalised, integrated and holistic care. Whilst there have been some advances in the delivery of person-centred care, there is still a long way to go before the policy rhetoric matches the reality experienced by people."

Evidence for simplicity, genericity, openness and holistic competence

N-th mover to Integrated, Person-Centered and Holistic Care

walk the talk, sour grapes, or holistic humbug?

Although, sadly (and all down to me) I stepped off the PhD programme with an MRes, the intention was not to bring my journey with Hodges' model to a close. The joke of course with this model is that you are always presented with a crossroads. As I've written previously (even in draft!) this model is a baton to pass on to others. If the workforce of the 1970s to date evaluates its contribution to health care change and progress, then while the achievements speak for themselves, the challenges^* that remain still shout out:

1. parity of esteem 
2. integrated - co-ordinated and collaborative care

This week I received an email, purely as a list member I must add:

NHS Innovation Accelerator 

Applications for the 2017 NHS Innovation Accelerator (NIA) are now open. For 2017, the NIA is seeking local, national and international innovations that address the following NHS priorities:

·         Mental Health
·         Urgent and Emergency Care
·         Primary Care

The above is now closed but I immediately thought about Hodges' model, given that from the information provided mental health is a priority and a top priority for citizens. Plus, the things that can make a difference to problems:

• Suicide and relapse prevention
• Access and availability with a focus on perinatal, children and young people, dementia and psychological therapies
• Early identification and intervention to minimise the impact on a person’s life, the likelihood of escalation and, in some cases, the chances of survival
• Care closer to home including self-care and access to services at home, in a primary or community setting
• Holistic care of both mental and physical health needs including prevention, screening and treatment for those at greatest risk of poor physical health   

"There are many innovations available to improve mental health services, however they are not always used..."

There are however a series of requirements, which present a stumbling block as high impact evidence is lacking.

The purpose of NHS Innovation Accelerator lies in the name. The target is established initiatives and projects that would benefit the NHS and others from a boost of further momentum and leadership support including funding and mentoring. Hodges' model is far from this, but the call is interesting nonetheless.

Reading the details I can argue, for example, that Hodges' model is immediately applicable across the life-span. The model is already designed, but in use the model could be said to meet the requirement of being co-designed with people (including carers, where appropriate). I have used the model with patients and carers (young and adult) who have lived experience of mental illness. With some consideration of the patient, carer, as I have stressed here before on W2tQ the model is accessible to a diverse population. Critically, the delivery of the most significant benefit in terms of outcomes and cost savings needs proof.

It seems that many of the world's problems could be ameliorated through education. This has been evidenced for decades and yet globally there are those who politicise their respective educational system, or even worse deny sections of a society access to education.

In healthcare how can we demonstrate the effectiveness of what is basically a back-of-an-envelope tool? While not a solution Hodges' model helps us to resolve the constituents of healthcare demand and supply, to critically analyse and synthesize - what is going on? I'm sure Hodges' model is just one of many local 'innovations' (in this case created in NW England) that are not evidenced and are therefore missed. Why is this? It may be that the model needs to be re-discovered since being invented somewhere else, by somebody else makes it a non-starter. Similarly, reading the information 'model of care' always grabs my attention:

Your innovation can be a device, digital app or platform, 

a service, process, pathway or model of care. 

But as is often the case, this is framed in service commissioning, funding, delivery and yes patient outcomes terms. Devices, apps, platforms and services can be specified to a high degree. This is essential to success in research (as is dissemination). Aims and objectives can then be clearly defined, outcomes can be recognised and measured. Processes and pathways are perhaps more fuzzy? These are all important tools, aspects and contexts in health care.

My frustration is that this and similar research formulations seem to exclude tools and resources that are by their nature intentionally simple, holistic, generic and cognitive-reflective. The "model of care" is broken. A whole systems approach^# is needed that incorporates education and with it prevention and staying well; plus caring for those affected by illness and disease. We have to honour the legacy problems that the political, education and health systems have 'delivered'. Even if not broken the model of care is missing its twin, the model of life-style choices'.

I still believe there is a model - a conceptual framework - that must precede the (politicised?) model of care, if health and social care are to be truly transformed. Without this, well yes the NHS can accelerate, staff have demonstrated this repeatedly while negotiating all sorts of obstacles. The line of travel will however be circular; circular, but without the discoveries and change gifted to the particle physicists.

individual

|

INTERPERSONAL : SCIENCES

humanistic ----------------------------------------- mechanistic

SOCIOLOGY : POLITICAL

|

group - population

education mental health cognitive access benefits - outcomes subjective	Evidence process primary care, accident and emergency physical access objective
qualitative home social care co-design public engagement	quantitative strategy 'model of care' education system citizens cost savings

My source: 
Irina Johnston
CHAIN Administrative Assistant

If you wish to publicise information on the CHAIN Network please email your request to: enquiries AT chain-network.org.uk

CHAIN - Contact, Help, Advice and Information Network – is an online international network for people working in health and social care. For more information on CHAIN and joining the network please visit website: www.chain-network.org.uk

^*

1. parity of esteem (a very broad interpretation - the comparison and contrasts between mental health and physical care on several levels - demand, supply, funding, research, integration, staffing, policy, outcomes, evidence-base, social determinants...)
2. integrated - co-ordinated and collaborative care (this is not one thing, but several. These terms are sometimes used interchangeably. Care that is truly integrated will also be co-ordinated and collaborative.

^# This is not recourse to jargon, Hodges' model implies several systems from the outset.

Southern Sudan Medical Journal: May 2019 issue on Primary Health Care

Dear SSMJ Reader,

 

The special May 2019 issue on Primary Health Care is now online here and includes items on support for PHC in refugee camps, approaches and strategies for PHC, charging for health care, literacy and health, community screening for diabetic retinopathy, vaccination coverage and CHWs treating malnutrition.  See details below.

Send us your feedback, your manuscripts (which we can help you prepare), encourage colleagues to join the mailing list here, follow us on twitter: @SSMedJournal and our Facebook Group, and find previous SSMJ articles at African Journals Online (AJOL) and the Directory of Open Access Journals (DOAJ).

 

The SSMJ Editorial team

admin AT southernsudanmedicaljournal.com.

In the May 2019 issue:

EDITORIAL

• Forty years of primary health care programming and its future in South Sudan Dr Ayat Jervase 

ORIGINAL RESEARCH

• Using livelihoods to support primary health care for South Sudanese refugees in Kiryandongo, Uganda Dominic Odwa Atari and Kevin McKague 

MAIN ARTICLES

• Integrated Primary Health Care (iPHC) for developing countries: a practical approach in South Sudan Victor Vuni Joseph and Eluzai Hakim 
• Addressing high vaccination coverage in primary health care setting: challenges and best practices Bobby Paul and Indranil Saha 
• Preventing blindness from diabetic retinopathy through community screening Wani G Mena 
• UK-South Sudan Alliance: a strategy for increasing capacity and access to primary care and public health Rich Bregazzi 
• What is the best way for healthcare systems to charge sick patients? Alfred Lumala, Lucien Wasingya-Kasereka, Martin Opio, Jenard Ntacyo, Samuel Mugisha, John Kellett 
• How can we bridge the gap between literacy and health in South Sudan? China Mayol Kuot 

SHORT ITEMS

• The Evidence for Contraceptive Options and HIV Outcomes (ECHO)
• Performance of low-literate community health workers treating severe acute malnutrition in South Sudan Elburg Van Boetzelaer, Annie Zhou, Casie Tesfai, and Naoko Kozuki 
• Martha Primary Health Care Centre: how resilience and international collaboration is transforming a community Poppy Spens 
• Point Of Care Ultrasound (POCUS) is saving lives Achai Bulabek 
• Juba College of Nursing and Midwifery milestones in 2018 Anna Modong Alex 
• Obituary: Dr Joy Theophilus and Dr Emmanuel Kenyi

LETTER TO THE EDITOR

• What South Sudan must do to reduce high maternal and infant deaths? Janet Mugo and Munawwar Said 

BACK COVER

• The Ten Steps to Successful Breastfeeding WHO

We thank all the authors, reviewers and editors who helped to produce this special issue.

Two workshops on Infrastructures in Health Care

'Infrastructure' is a word of our time with both reductionist and wholist connotations. The 4P's of PROCESS, POLICY, PURPOSE and PRACTICE can be found here together with at least several C's: COMMUNICATION, CO-ORDINATION, COLLABORATION and COMPLEXITY. So, here for 2009 is an infusion of the socio-technical at two health infrastructure events:

Call for Papers: 2nd International Workshop

Infrastructures for Health Care: Connecting practices across institutional and professional boundaries

June 18-19, 2009, University of Copenhagen, Denmark

Scope
The 1st international workshop: Infrastructures for Health Care was held at the Technical University of Denmark in June 2006. It attracted researchers, health care professionals, IT professionals, administrators, and others engaged in the development of infrastructures and new, integrated applications and services for improving the quality of health care services. The purpose of this 2nd international workshop is to continue this forum for discussing current issues and trends related to the integration and coordination of health care practices across institutional, organizational, and professional boundaries.

The health care sector is characterized by a worsening shortage of personnel and endlessly growing costs caused by the development of new treatments in combination with rising demands for treatment, which are associated with an aging population and an increase in chronic diseases. Against this backdrop, policy makers, health care professionals and researchers show an increased interest in innovative systems of care, which improve communication, coordination and collaboration among patients/citizens, care providers in primary care and specialty services (clinics, hospitals, emergency departments, old people's homes etc.). Concepts like shared care, integrated care and continuity of care are indicative of ambitions of creating coherent and effective health care services for patients that require complex - and often long-term - care. Although these concepts are often used in relation to projects that seek to enhance communication, coordination, and collaboration around particular patient groups, they also have bearing on more general visions of reorganizing health care.

Infrastructural arrangements - such as electronic patient records, classification schemes, accounting systems, communication standards, and quality systems - play a crucial role in these new models of care, and it is increasingly hard to imagine integrative initiatives that do not have a strong IT component. This raises a multitude of questions about the - actual and imagined - role and impact of IT and other infrastructure components in the development of patient-oriented, integrated healthcare services.

We wish to highlight how new infrastructures - socio-technical assemblages - simultaneously connect existing practices, influence and change these practices, and create entirely new practices in health care work (e.g. related to the maintenance of the infrastructure itself). What characterizes infrastructures in health care? What role do they play in transforming and reorganizing health care and in creating new actors in health care? How are infrastructures established and maintained? What is the impact on work practices, organizational structures, cost effectiveness, quality of care, etc.?

Topics of Interest
Our aim is to bring together researchers, health care professionals, IT professionals, administrators and others involved in establishing infrastructures and/or developing new, integrated models of healthcare. We seek practical case studies as well as empirical and theoretical research contributions. Topics of particular interest include, but are not limited to the following:

* Infrastructures as socio-technical achievement in health care
* Health care organizations and infrastructures
* Infrastructures and new patient practices
* Designing infrastructures for health care
* Economic aspects of infrastructures for health care
* Myths of infrastructures
* Infrastructures and politics
* Managing infrastructures

We encourage potential participants to submit an abstract (3-500 words) describing the contribution before March 1, 2009. Abstracts must be submitted by email to
infrastructures2009 AT sundhedsITnet.dk

After the conference, a selection of the contributors will be invited to submit a full paper to an edited - and fully reviewed - book or special issue (to be decided).

List of important date
Submission of abstracts 2nd of March 2009
Notification of acceptance 1st of April 2009
Deadline for registration 15th of May 2009
Conference 18th - 19th of June 2009

Workshop Co-Chairs
Finn Kensing, University of Copenhagen, Denmark
Jørgen P. Bansler, Technical University of Denmark
For abstract submission and further information, contact
infrastructures2009 AT sundhedsITnet.dk
We are looking forward to an exciting workshop!
==================================

The other event is in April (and has already closed in terms of submissions):

Health and Care Infrastructure Research and Innovation Centre

HaCIRIC International Conference 2009 -
Improving healthcare infrastructures through innovation

2-3 April 2009, Hilton Metropole, Brighton

The conference will bring together researchers and practitioners from across disciplines and countries with different healthcare systems to focus on how to use innovation to improve the delivery and operation of healthcare infrastructure. Areas of particular interest include:

Integrating infrastructure and service planning
Can we translate service planning into infrastructure asset planning more effectively? Are moves towards greater contestability and a local devolution of responsibilities making this harder? What lessons are there from different national health systems? What tools, models and performance metrics are appropriate?

Stimulating innovation in infrastructure provision
How can procurement and incentivisation models be designed to deliver innovation? Can policy targets be used more effectively? How do we ensure that innovation is embedded on a sustainable basis? How can the design process be more effectively used to generate innovation? How do we capture and diffuse knowledge of innovative solutions?

Examples of infrastructure innovation targeted at key problems
Healthcare acquired infection is an example of an area where a multi-disciplinary approach embracing service delivery, behavioural and infrastructure change is needed. We are interested in case studies and research reporting on how this has been tackled, as well as the methodological challenges in conducting such research.

c/o HIFA - Publications re. primary health care & community health

Dear [HIFA] friends and colleagues with an interest in primary health care and community health:

Since my last communication with you more than 6 months ago, the entire field of global health has continued to be upended by our US government, with unconscionable effects on millions of people around the world, on advancements in global health research and its ethical foundations, and on the careers of thousands and thousands of people working around the world in the field of global health. As I said before, and I repeat now the obvious, it will take decades to build back what has been destroyed and to regain respect from the rest of the world for the United States and the values that most of us hold dear.

William Foege, eminent global health leader and former Director of the Centers for Disease Control and Prevention wrote this biting editorial <https://www.statnews.com/2025/08/18/rfk-jr-public-health-threats-william-foege-smallpox/> in which he said, among other things, 

"We will live through this drought of values, principles and facts and again apply our talents to improving global health and happiness. Do not back down.”

Atul Gwande, now one of the foremost champions of primary health care and community health of our time (even though he is, like me, an erstwhile surgeon!) and former Director of the USAID Bureau of Global Health during the Biden administration, gave an eloquent presentation of his perspective on the aftermath of the destruction of USAID on 28 April 2025 at the Harvard School of Public Health.

You can watch this here:
<https://www.bing.com/videos/riverview/relatedvideo?q=Atul+Gwande+presentation+at+Harvard+School+of+Public+Health+April+28%2c+2025&mid=26DA144398CF1F613D0A26DA144398CF1F613D0A&FORM=VIRE>.

Here are a few items of possible interest:

The Fourth International Symposium on CHWs will be held virtually next week.

I was most fortunate to be able to attend the second International Conference on Primary Health Care was held in Addis Ababa, Ethiopia, from October 6-10. It was a glorious event, with 750 attendees, mostly from Africa but with strong representation from UNICEF, WHO, Africa CDC, and other international organizations. 

The conference was sponsored by the International Institute for Primary Health Care – Ethiopia. <https://iphce.org/> Directors of PHC from 45 different African countries were present along with at least 50 community health workers from across Africa. There was palpable enthusiasm for the growing momentum for PHC across Africa.

Abhay and Rani Bang are world-renowned champions of community-based primary health care through their work with SEARCH <https://www.searchforhealth.ngo/> (Society for Education, Action, and Research) in Gadchiroli, India, with tribal people. Their seminal publications on the effectiveness of community-based primary health care and community health workers as well as their contributions to India’s national program for reducing neonatal mortality through home-based neonatal care, among others, have gained for them global recognition. Attached is an English translation of an article about their life’s work that was published in April Der Spiegel in the leading German magazine, Der Spiegel.

Nicholas Kristof has continued to share with the world some of the heart wrenching effects of the collapse of the United States Agency for International Development. The New York Times opinion columnist wrote <https://www.nytimes.com/2025/09/20/opinion/trump-usaid-cuts.html> on 20 September 2025 on the human dimension of the shutdown of USAID, citing estimates that 690,000 will die in 2025 and 829,00 will die in 2026 as a result of cutbacks in USAID funding, and 3.1 million children will die during Trump’s second term from these cuts (a PDF is attached if the link doesn’t work for you [mod: HIFA does not carry attachments]).

Two recent publications on novel approaches to reducing child mortality have gained widespread attention.

One study <https://www.nber.org/system/files/working_papers/w34152/w34152.pdf> in Kenya provided a one-time transfer of $1,000 to poor families and observed a decline of nearly half in under-5 mortality as well as in infant mortality. Another study reported that wrapping

A recently reported study <https://pmc.ncbi.nlm.nih.gov/articles/PMC12462887/> from Uganda found that giving mothers fabric treated with permethrin, a long-acting insecticide to protect against mosquito-born illnesses, as a baby wrap dramatically reduced malaria infections in the infants carried in them. There were 66 percent fewer cases among those children compared with babies in the untreated wraps. By the end of the six-month study, only 16 percent of children in the treated wrap group had been sick with malaria, compared with 34 percent in the untreated wrap group, many of whom had multiple malaria episodes.

Now available for purchase on Amazon.com are several important publications related to community-based primary health care and community workers.

Feel free to share this email and these resources with anyone else or with any relevant listserve you may have access to.

You are receiving this email because of your interest in primary health care and community health.

If you know of anyone that you think would like to be included in the listserv, just send me the person’s name and email address.

Warm regards, Henry

Henry B. Perry, MD, PhD, MPH Senior Associate, Health Systems Program Department of International Health Johns Hopkins Bloomberg School of Public Health Baltimore, MD, USA 21205 Hperry2 AT jhu.edu

HIFA profile: Henry Perry is a Senior Scientist at the Johns Hopkins Bloomberg School of Public Health, USA. Professional interests: Community health and primary health care. hperry2 AT jhu.edu

True (group) therapy for the masses ...

Draft thoughts ...

 INDIVIDUAL
|

   INTERPERSONAL    :     SCIENCES               

HUMANISTIC --------------------------------------  MECHANISTIC      

SOCIOLOGY  :   POLITICAL 

|

GROUP

 

 SPIRITUAL

MENTAL MAPS PSYCHO-THERAPIES	MAPS PHYSICAL-THERAPIES
SOCIAL THERAPY?	POLITICAL THERAPY?

SITUATED - META-COGNITION

'Social therapy' is very much a thing - an invaluable therapy and intervention for patients / clients and  option for the multidisciplinary team. In form it may differ from the social therapy, industrial therapy encountered in 1977, with occupational therapy. Today, can I suggest that it has been diminished? Even as (in the UK) we have social prescribing, and very welcome it is too.

I still wonder if social therapy has been tainted politically, by its proximity to community?

Back in the 80s ... 90s ... I remember the mini-bus arriving with day care patients, people who had attended for years. Dependency was often a fact of life, for them, their family, or the choices were stark. and I've seen hints of dependency again. Psychological therapies were not offered as readily back then, and lack of engagement would have been the gate-keeper then and for many patients now. Day care is much diminished now, if provided at all. As a response to dependency, stasis this may not be a 'bad' thing, but what replaced it? How and where did people move on to?

Community, the original home and origin of the forum, the market place, and town crier has been left by successive governments to market forces. Now the High Street footfall is a sepia-coloured snapshot. Passers-by now, can read 'for sale' signs, 'units to let', see shutters, litter, pigeons on their break from 'being' online. The Ubers and e-food delivery enterprises now clog the roads, previously trodden by the clogs themselves (I've been told you could here them outside).

I realise there is a continuum at work here (and as 'group' in h2cm suggests - it does its work). A crossroads, hamlet, village, town, community, neighbourhood - with the exact position of some terms - 'community'  (on the IND-GRP axis) for example, subject to debate. 

The post back in May, concerning an individual therapy - New book: "Talking with a Map"

- has me thinking about the GROUP related domains of SOCIOLOGY and POLITICAL. 

About therapy not individually, but a need to address the idea of therapy at the community level. You might call this a 'root and branch' review, and yes, this is the sentiment. 

It is clearly more than 'levelling up'.

Stepping outside of the boxes (outside of #h2cm - the clinical context ...); this isn't a person with an illness. Neither is it an effort to instantaneously medicalise society (that's another post). The community (UK*) is also not best placed to self-care, to prosper - which would be quite a feat if it were possible.

Back in June, I saw tweet about WHO and the need to strengthen primary care; and the global role for primary care was highlighted in the previous post. I can't find the tweet now, but I think it was a global health call, as so many nations are still developing, even creating primary care.

Here in the UK (USA?) - like the longevity stats - we appear to be going backwards. Therapy here is not going to improve access to primary care, or correct the dental desertification the UK NHS is experiencing.

If I am true to the model - #h2cm - here as displayed above, then there must be group therapy equivalents. Not group therapy in the usual - psychological / psychotherapy - sense, but a real transition from the individual to the group as found in social and political terms. Perhaps, this can be summed up as the need to revisit and re-negotiate the social contract - if it were ever agreed? This is were healthcare and time must coalesce: the past, present and future. Our health systems need to change.

I need to work on this muddle!

*If I may be so bold.

The model is encompassed within situated cognition - meta-cognition and the spiritual.

Dementia, Drugs, Nursing by Degr[EE]s and Care Transitions

Of all the policy issues that government faces the care of an ageing population is irresistible in demanding attention. This one will keep tapping MPs, policy makers and families ... on the shoulder. It will constantly cycle through the government's gamut of official papers. In the UK this past week people suffering with dementia and the prescribing of anti-psychotic medication and deaths arising from the same has been highlighted and not for the first time.

Whilst my spare time web attention is also given to nursing IT and socio-technical matters, as an NHS community mental health nurse these vulnerable individuals are the primary focus of my work and that of my colleagues. There are three strands to the current role - in brief:

• Nursing home liaison - dedicated to specific homes;
• assessment, intervention and subsequent review;
• working with social services integration project duty desk.

Drugs are of course a day-to-night constant for all nurses, with the addition of debate across all the knowledge domains of Hodges' model - that is interpersonal, sciences, sociology and political domains of knowledge. We have witnessed this in the scientific evidence of substance misuse and the government misuse of drugs advisory group 'difficulties' and now this issue which is professionally closer to home: right on the doorstep in fact.

'Home' is the operative word as many of the people concerned reside in residential care and nursing home facilities. Let's scratch the surface of what we already know:

• These people can be very confused, vulnerable, they may be agitated and not easily reassured and placated without repeated skilled intervention.
• Facilities are subject to inspection and care standards.
• Many do not have an advocate in the sense of a family member who visits at least weekly and will challenge and question care and prescribing.
• Older people may already be on several drugs (polypharmacology) due to other chronic health problems.
• There is still a disconnect (holistic gap!) between the interdependence between mental - physical health problems.
• These facilities are that individual's home - they continue to live and hence age there.
• Homes get attached to their residents; in the best homes they (and their relatives and friends) become part of a greatly extended family.
• For confused people there is a potential community (albeit a closed one) that people can participate in or choose to stay in their room. This space, the freedom of movement it affords - toing-and-froing - should itself be subject to history taking and ongoing assessment.
• The quality of this community depends on the core staff and additional skills seen as essential by the organisation and care standards, e.g. activities coordinators, residents committees that also engage family, friends.
• NVQs and mandatory training in the sector is making a positive difference.
• There remains a high level of staff turnover.
• Some homes are dual-registered catering for nursing care with another floor for dementia care (does a 1st or 2nd floor provide secure access to a garden in the summer?).
• Homes rely greatly on the specialist services of local community mental health service, also given the placement of people in homes 'out of area' this involvement may be more remote and subject to varying degrees of engagement and hence quality.
• Homes are businesses and the movement of clients incurs changes in income.
• The quality and standards of architecture and design for residential accommodation has seen great strides in the past decade.

The bottom line (no pun intended) is the need for macro-management in terms of multidisciplinary team input; that is, primary care, modern matron, mental health and micro-management in terms of personalised care with regular review of physical and mental well-being and medication.

As government's of all persuasion utter the mantra of education! education! education! - this must be heard in the residential and nursing home care sector. The good news is that standards, competencies and the quality of care in the sector are improving; but to education we must add environment! environment! environment! As someone who appreciates aesthetics in design we should all be aware of the seductive properties of newly designed and furnished nursing homes (new carpets plus brand new flat screen LCD TVs does not automatically mean multi-dimensional care).

The counterpoint to this are the long stay, geriatric wards of old (c. 1977-1984) and the reaction of family friends when they first walked through the (three) doors.

They were distraught.

In time they came to appreciate the efforts of the staff and the importance of the knowledge, skills and attitude of the ward team. They could understand and see what staff were trying to achieve regards individualised care. Many responded to the open invitation to be part of the team, to get involved. Yes, the environment was far from 'right' (it was terrible), but it's the people on all sides of the care equation that count. It is the same today, but if the care environment is no longer appropriate then people should be moved to a place were their care needs can be met without recourse to anti-psychotic medication. That is why initial and ongoing person-centred assessment is very important.

It is very difficult to predict future needs and yet trying to anticipate them is the primary nursing challenge. If life is a book, then the turning of the page that ends one chapter and starts a-new is a non-trivial transition. That said and make no mistake, it is not for dramatic effect that we describe the behaviour of some individuals as challenging. Drugs are a tool and like all tools it is how they are used in assuring the highest standards of care, retaining personal dignity and maximising whatever quality of life an individual can achieve. Accounting for care interventions including medication is critical. If due diligence cannot be effectively applied in the financial sector then perhaps there is scope for due diligence in the care of older adults*?

*Some clients are under 65 years of age.

The number of pages count (in a medical MOT)

Received in the post: an invitation.

For a medical MOT that would cost me £129 - which is a saving of £141.

I am informed that a competitor charges £564 for a "360" Health Assessment and £424 for an "Essential" Health Assessment.

Recently I spoke to someone who had major surgery and they remarked on the lack of assessment not on the medical side, but the social, especially in relation to discharge and the circumstances they would be returning to.

This example of apparent disinterest in a social assessment contrasts with practice in the past - several decades ago.

Apart from an awareness of  'silver clouds' and rose-tinted glasses what struck me was securing a sale by a manifest of paper:

The various blood tests that would be completed are detailed using medical terminology across four A4 pages. Depending on age there is a free respiratory screening too.

The following quotations (Alber, et al., 2017) state clearly the risks:

"There is a growing awareness among clinicians and health care scientists, that medical overuse comprises unnecessary health care lacking benefit for patients [3] or putting them at risk of harm outweighing a potential benefit [4]. Moreover, unnecessary medicine adds to rising health care expenditures [5] and a misallocation of scarce resources [6]. Asymptomatic individuals are at risk of being labelled as patients, causing anxiety and affecting their quality of life [7]." ...

"Moreover, in secondary prevention, risk factors are increasingly treated as diseases [8]. There is a tendency to screen asymptomatic populations at low risk and to label pre-diseases as manifest diseases [1]. Serum cholesterol levels are a good example of threshold lowering by shifting the boundary between health and disease [9]."

Over-treatment is also a problem in two critical and concurrent senses, as follows:

Developed health systems Need to transform to health promoting, educational, preventive, self-caring systems.

Developing health systems Need to prevent the inheritance of commodified health care and over-treatment.*

Alber et al. also provide a useful diagram preceded with more background:

"In primary care, the “quaternary prevention concept” [11] was introduced (see Fig. 1 ) in order to protect individuals from unnecessary investigations and treatment. Quaternary prevention is a “new term for an old concept: first, do not harm” [12]. It refers to actions “taken to identify [a] patient at risk of overmedicalisation [= in the sense of medical overuse, author’s note], to protect him from new medical invasion, and to suggest to him interventions, which are ethically acceptable” [13]."

Fig 1

The concept of quaternary prevention. Source: [11] Kuehlein T, Sghedoni D, Visentin G, Gérvas J, Jamoulle M. Quaternary prevention: a task of the general practitioner. PrimaryCare. 2010;10:350–4, and [12] Jamoulle M. Quaternary prevention, an answer of family doctors to overmedicalization. Int J Health Policy Manag. 2015;4:61–4

Without being dismissive of screening and its relation to health and well-being, I have removed myself from this particular mailing list.

At some point I must really apply Hodges' model to this discussion. The model is ideally suited to navigating and arguing this debate; from self-care, primary care, prevention, population and global health. I have posted previously about the damaging ideal of the comprehensive health record and the way that records seem oriented to assessment and risk reduction with outcomes and relapse prevention an after-thought. This defensiveness is critical for public safety, professionalism and accountability, but as a thread on twitter shows it can have a negative impact too.


*There is an additional confounding factor at work in developing nations, the incursion of digital technologies from outside.


Alber, K., Kuehlein, T., Schedlbauer, A., & Schaffer, S. (2017). Medical overuse and quaternary prevention in primary care - A qualitative study with general practitioners. BMC family practice, 18(1), 99. doi:10.1186/s12875-017-0667-4

Tsoi, G.W.W. (2014). Update On Prevention - An Introduction to Quaternary Prevention, Medical Bulletin 19, 11, NOVEMBER 2014.

Ack.
I am subscribed to a mail list that is an invaluable resource on the status of medicine and health care, with contributors including, Mohammad Zakaria Pezeshki, Juan Gérvas, Karenleigh A. Overmann, Gene Tsoi and others.

MOT: Ministry of Transport test

Primary Health Care Specialist Group (PHCSG) Summer Conference 2009: Patient Safety – who cares?!

Patient Safety – who cares?!

Primary Health Care Specialist Group (PHCSG) Summer Conference 2009

29th June – 1st July at Chesford Grange Warwickshire

The event attracts a wide group of people including GP’s, other practice staff, nurses and allied health professionals, ICT staff, PCT staff, system suppliers and researchers.

UKCHIP Accredited towards Continued Professional Development (CPD)

Programme and online booking available at http://www.phcsg.org/

Programme Topics include:

• Clinical Risk Management
• Clinical Safety Testing of the Care Record, and Information Governance
• The Future of NHS IT: life after NPfIT in primary care
• Patient Confidentiality – the current legal position
• Practice Accreditation
• Data Extraction from Primary Care Systems (GPES)
• Updates on GP2GP and EPS
• NHS Resources Centre – free training for staff
• Care Pathways- peril or profit?
• Use of Clinical Indications
• Medication Safety Alerts
• RCGP Guide – Making IT work for you

Exhibition - As well as the formal programme the conference provides an excellent opportunity for networking and is supported by an exhibition, which features many of the established IT suppliers to primary care alongside suppliers with exciting new products and services. Come and chat to exhibitors and hear how they are developing and promoting their products or services to enable “Patient Safety”.

Interested in Exhibiting or Sponsorship Opportunities, or need further information?
Contact Jill Riley email jill at phcsg.org

Workshop & CfP: The post-Fordist Care Regime

A workshop series organised by the Centre for Philosophy and Political Economy (CPPE), School of Management, University of Leicester, UK
Workshop 1: The Business of Care

Keynote Speaker: Silke Roth (Southampton)

Convened by Vanessa Beck, Steve Brown and Fabian Frenzel

CPPE, School of Management, University of Leicester, UK

Date: 10th December 2015

Certain transformations in our political economic landscape can be distilled according to regimes of care. Fordist care was provided primarily by female ‘free labour’ within the family context, while the state played a large role through institutions like schools, pensions, prisons and hospitals. By contrast the private sector role was rather limited although, of course regimes are uneven and varied across different countries and social sectors. The post-Fordist regime of care was triggered, in part, by a rebellion against the invisible and unvalued nature of female ‘free labour’ in the care domain, for example in housework or child care. Demands for more autonomous, neither market nor state based forms of care were made and realised in new social and urban movements that pursued attempts to create new forms of social reproduction and care in communes, housing co-ops or self organised childcare. Despite the progressive impetus of many of these initiatives, it is possible to see, with hindsight, how demands for autonomous care were subsumed within the general move away from state provision and towards privatisation as well as individualisation of care responsibility. In the post-Fordist regime the provision of care is increasingly organised around the needs of capitalist valorisation. This drive towards privatisation is ostensibly about efficiency and budgetary restraint, the underlying motives, however, may well be more diffuse, pointing to the opening of new sources of surplus value capture for a growing sector of market oriented care provision.

Yet as the State outsources care jobs (in prisons, health, schools, etc), the organisation of markets has taken on specific characteristics. This includes the internationalisation of the care regime with transnational businesses of care, a transnational labour force and the expanding mobilities of care receivers. A further aspect is the increasing financialisation of care, which includes the creation of ever-new financial vehicles, from Private-Public Partnerships to social impact bonds that aim at ensuring efficiency in the care sector but often do the exact opposite. Both nationally and internationally we witness the renewed mobilisation of ‘free labour’. Unlike in the Fordist regime of care, this now aims at volunteers across age and gender groups and framings such as the ‘big society’ and 'international volunteering'. Beside this unremunerated work we see increasingly precarious conditions of labour in the care sector, often migrant labour, on zero hour contracts and minimum wages. The precise composition of this labour market is another area of interest. What novel forms of organisation are emerging in response to our present regime of care? And what resistance is emerging?

Finally, although price is often taken to be the primary concern of post-Fordist care provision, the quality of care cannot be ignored, though it is difficult to measure. Beyond a private industry of care provision we also find a new ‘industry of measurement’ that claims to assess the value and quality of privately administered care. The organisation of these new organisational patterns and industries of care are the subject of this workshop.

We invite papers that interrogate the shift to a post-Fordist care regime. We are interested in a variety of scales, from local to global in which this shift becomes visible and invite contributions from across care sectors broadly defined, from health (including mental health) to housework, from medicine to (social) housing, from education to welfare. We are interested in analyses of businesses of care, including care evaluation and financialisation, in investigations of the labour of care, national and international, waged, ‘free’ and precarious and the struggles of this labour. Finally we are also interested in receivers of care and their responses to the post-Fordist care regime.

Organisation:
The broad scope of the call is intended to allow for a comprehensive investigation of the post-Fordist care regime. Some of the threads of this workshop will be picked up in two following workshops that chart ‘Alternatives of Care’ and the ‘Cosmologies of Care’, to be announced separately in due course.

Please submit abstracts of up to 750 words to describe your paper. Invited papers will be presented in Pecha Kucha style. Presentations consist of 20 slides that have to be presented in 20 seconds each. (Follow this link to find more information on Pecha Kucha). The organisation of the day aims to encourage shared discussion and the format of Pecha Kucha allows for succinct presentations. Papers will be commented on by our invited keynote Silke Roth as well as the three workshop convenors. We also invite all speakers to submit outline papers (of about 2000 words) to be shared among participants prior of the workshop.

Dates:Please submit abstracts to ff48 AT le.ac.uk by the 30th September 2015. We will respond by mid October 2015. Presenters should submit an outline paper (of max. 2000 words) by the 1st December 2015 to circulate among participants of the workshop.

We also plan to facilitate a publication of full papers from the event.

The workshop is free of charge, and refreshments and lunch will be provided during the day. A limited number of travel bursaries is available. They will be targeted at presenting PhD students and researchers without access to institutional funding in the first instance. Please indicate if you would like to be considered for a travel bursary as you submit your abstract.

---------------------
Dr Fabian Frenzel
Lecturer in Organisation
PRME Officer
School of Management
University of Leicester
LE1 7RH
UK

My source:

Dr Vanessa Beck via ESA-ALL AT JISCMAIL.AC.UK (some extra text also emboldened as relate to Hodges' model).

Harvard Medical School Primary Care Review

"I'm writing to invite you to contribute your
narrative stories of health, community, and equity!"

 

Dear Spirit of 1848:

I hope this email finds you well. I'm a Family Medicine Physician, Instructor at Harvard Medical School, and Editor-in-Chief of the Harvard Medical School Primary Care Review. I'm writing to invite you to contribute your narrative stories of health, community, and equity!

The Harvard Medical School Primary Care Review is an international community-facing publication, and our mission is to “Share stories to amplify the voices of health everywhere.” Publications are approximately 750-1200 words in length, and all references should have hyperlinks (rather than end- or footnotes). The following is a brief set of guidelines for the Review: https://info.primarycare.hms.harvard.edu/review/submission-guidelines. The following Review pieces are nice examples of the type of narrative and community health content we strive for:

• https://info.primarycare.hms.harvard.edu/review/trauma-informed-holistic-health-care
  
• https://info.primarycare.hms.harvard.edu/review/food-access-navajo-nation

Please also share this call with your community partners! We look forward to hearing from you!

Warmly,

Rebekah

-- 

Rebekah Rollston, MD, MPH  (she/her)

Family Medicine Physician, Cambridge Health Alliance

Instructor in Medicine, Harvard Medical School

Editor-in-Chief, Harvard Medical School Primary Care Review

--
Posted from the Spiritof1848 Listserv WWW.SPIRITOF1848.ORG #Spiritof1848

Musings on Integrated Care: A Visible and Invisible Matter

If measures for clinical outcomes, health literacy, patient satisfaction, benefits and many more present a challenge then a measure for integrated care falls into the category of a very steep peak.

It's a nebulous concept, we know what we mean, we recognize the principles and we even allow for variation in what integration and integrated care means for different people.

The January 2012 integrated care report by The King's Fund and Nuffield Trust (previous post) had me thinking about some of the ingredients that might contribute to measures of integrated care and our efforts to record it. What instruments and formats do we need - what mix of microscope (individual), telescope (population), strobe (snapshot), time lapse (series), objective - subjective? Some elements  then (in no particular order):

Breadth of the 'episode' (primary-secondary-tertiary-palliative)
Breadth across an individual's lifespan - as needs change and assuming person-centredness
The number of systems
  information - e-records
  commissioners
  datasets: total, number of gatherers, submissions of data, local, regional, national, global
Demographics: population profiles, housing provision, local need
The number of people - individuals involved
The number of 'responsible' organisations
 Primary organisational efficiency - Lean Standing?
The number of teams
The number of policies (policy touches)
 The number of interviews, assessments (paper, electronic, formal), care plans, reviews
Opportunities for communications
  potential
  actual
  media forms
  delivery forms (inc. technologies)
Number of handovers - communication
  weighted according to type?
Patient experience - measure
 (that is holistic across physical, mental health, social care?)
 staff attitude
 therapeutic relationship engagement (quality)
 therapeutic modalities (quantity)
 educational content, materials provided / information gains
 number of patient (carer) choice points (potential - exercised)
Incidents of positive risk taking
Increase in health literacy as this is a policy priority
 - a priority linked to integration of disease response and  prevention
Co-ordination effectiveness
Self-care - autonomy, decision making
Patient (carer) as budget holder
Patient as record holder and direct data source (telecare - data entrant)
Carer involvement
Health : Social care (main dependency, ratio, index)
The number of disparate care philosophies encountered
Diagnoses
Diagnostic investigations complex (location, time)
Declarative success: agreed plan - success?
The geographic encounter footprint: distance, travel, transport, environment
Duration of engagement
Follow-up - care continuity care
Care Disintegration - safety
 care interrupts^# (falls, errors)
 relapse, readmission
 dependency (deferred discharge)
Influence of public engagement - involvement in local health services^*

While many of the above might qualify as candidates for a measure of integrated care, you have to wonder whether in order to measure integration you must measure everything else. It appears here at least that integration and complexity are closely related. Several of the items above might individually represent - and no doubt do - indices of various kinds that also beg definition (e.g., co-ordination, success, philosophies, episode ...).

Although I've referred to 'numbers' you could no doubt refine the list by consulting the literature and considering the quantitative : qualitative mix.

Perhaps the key indicator of integrated care isolates the primary concepts for the person concerned and then fuses those within the INTERPERSONAL and POLITICAL care domains (policy touches would be one example)?

^*How does a measure of integration incorporate those socially excluded?
^#For want of a better word. 

Reflections: "Reimagining the nursing workload: Finding time to close the workforce gap"

Redesigning care models through intentional delegation and

potential tech enablement can free up nurses’ time.

I learned of this study through twitter (see below) and ongoing awareness of the work, contribution and debate regards management consultants over the years. The research study was conducted in USA and I have no work experience there. As stated many times on W2tQ: my context is UK-based and public sector - NHS. I have been seconded in the past to a project which engaged management consultancy companies, the work involving IT and communications. The latter was focussed upon (much needed) IT engagement and being 'on message'. 

If employed long enough in the UK public health sector, you will come across consultancy employees eventually (whoever is in government too). Through news, media, consultants (friendly, with wide experience, eager to engage and deliver) will be introduced to the team, on placement for several weeks to collect data through a series of meetings, and conduct a presentation about impending change. The management consultancy sector  often have a bad press, with ongoing critique and debate regards their role, across the Atlantic and globally. More on that to follow.

McKinsey: LinkedIn

A brief introduction to the study follows:

"We conducted a survey of 310 registered nurses across the United States from February 8 to March 22, 2023. Our goal was to understand nurses’ perception of time spent throughout the course of a shift and to identify existing and desired resources to help nurses provide high-quality care. Our sample focused on nurses in roles that predominantly provide direct patient care in the intensive-care unit, step-down, general medical surgical, or emergency department settings. Insights were weighted by length of shift (the minimum shift time included was six hours)." p.2.

To begin, I like 'reimaging' in the title. Healthcare should always be about imagination, envisioning, and action - on an individual and collective basis. Organisational reimaging is also what management consultancy is predicated upon. 'Care model' here, appears to refer to the care environment (and experience?) as found. Gap, also in the title is another positive. Gaps must be seen, to see how we might close, bridge and span them.

 

Over several decades a preoccupation with 'process' has been apparent: the nursing process and processes as events and sequential series in project management. But what is this? No 'process' but one instance of processes. While this was encouraging, as presented, emphasis is placed on activities and tech - both of which can engender reductive and task-based perspectives. Allied with tech, improved delegation is the stated aim of the study. 'What do you expect?' - might be the rejoinder. As per the twitter replies the study conforms to type, brief and 'message':

"Achieving this may require health systems to invest heavily in technology, change management, and workflow redesign.

Realizing these changes will require bold departures from healthcare organizations’ current state of processes. It will be critical for hospitals to bring both discipline and creativity to redesigning care delivery in order to effectively scale change and see meaningful time savings. Close collaboration beyond nursing is also paramount to ensure alignment across the care team and hospital functions including administration, IT, informatics, facilities, and operations." p.8.

Technology is often described as the catalyst, but the impact (and risks - safety?) are often missed - a case of 'wag the dog'?

 

There is a global shortfall in the nursing workforce. National governments take a local perspective tempered (we hope) with international agreements on overseas recruitment. From the shortage in the USA listed (below), to the potential time saving equivalence is a significant outcome:

"When we translate the net amount of time freed up to the projected amount of nursing time needed, we estimate the potential to close the workforce gap by up to 300,000 nurses." p.2.

I am a technology enthusiast outside of work, but a technology realist at work (I do enthuse with students and enjoy hearing their views and experiences - personally, at university, on placement). I've used two electronic health record systems in mental health over the past four years. It is usable, but - as ever - could be improved. Thoughts re. tech are currently clouded by the UK use of telecoms and IT as the access point for primary care. Unfortunately this acts as a 'gate'. More tech is not necessarily better. Can it be argued that the pace of technical change (hardware and software - cloud, devices, decision support ...) is so fast that it is constantly contested? New systems need to be re-evaluated for patient benefits, improvements in care, safety, fit for purpose and other desiderata. Many consultants and advisors point to the existence of disciplinary and (hence) knowledge silos. What is key, is how IT can disrupt existing practice through these silos, especially in the form of AI. 

To return to the study(!), it is primarily in-patient hence hospital based. Perhaps hospitals are the biggest silos of all? These management studies flow, forming a series, a work-stream that includes:

How ‘Care at Home’ ecosystems can reshape patient care

Virtual hospitals could offer respite to overwhelmed health systems

Nursing in 2023: How hospitals are confronting shortages

 

These are cross-referenced online, but what price integrated care - and person-centred care at home?

Prof Alison Leary's tweet highlights research that has demonstrated the improved patient outcomes when care is delivered by Registered Nurses. The importance of training, registration and need to study the 'work' of nurses and their workload is not new:

Robb, I. H. (1903). The Quality of Thoroughness in Nurses’ Work. The American Journal of Nursing, 4(3), 168–177. https://doi.org/10.2307/3401722

Plus, 

"One of the new applications for decision analysis derives from the realization that if physicians are to become effective advocates for quality health care delivery under the incentives engendered by the newer cost-containment strategies, a common language is required to permit communication between physicians, regulators, policy makers and patients relative to what comprises effective care and why physicians do what they do." Preface, v. (my emphasis)

Knoebel, S.B. (1986). Perspectives on Clinical Decision-Making. New York: Futura Publishing Co., Inc., Mt. Kisco.

Whether 'physician', 'doctor' is cited as the user - an electronic health record should cohere across disciplines including nurses - the multi-disciplinary team; even as disciplinary system use may have its own signature (subsets). We are still seeking a language. For me this remains SOCIO-technical.

Innovations are mentioned in the study, but the specifics are not stated in explicit nursing terms, but related to the role of technology, electronic health records (yes, a care record is critical), building on existing tools and reducing implementation risk. Sadly, the informational environment (body politic?) appears to place constraints on the nursing 'care models' referred to here.

On delegation, the following makes a lot of sense: "While nurses report wanting to spend more time overall on direct patient care, there are specific tasks that could be delegated both vertically and horizontally to ensure that the work nurses perform is at the top of their license and promotes professional satisfaction." p.5. (my emphasis)

INDIVIDUAL

|

INTERPERSONAL    :     SCIENCES               

HUMANISTIC --------------------------------------  MECHANISTIC      

SOCIOLOGY  :   POLITICAL 

|

GROUP

Nurses thinking of leaving - reasons include: "not feeling valued by their organization and not having a manageable workload." with additional settings inc. home care and long-term care facilities. This is a common expressed wish by nurses: "spend more time with their patients" but how often is it qualified psycho-socially?	310 subjects - nurses ".. estimates still suggest a potential shortage of 200,000 to 450,000 nurses in the United States, with acute-care settings likely to be most affected." Settings include: intensive-care unit, step-down, general medical surgical, or emergency department.
Direct patient care - relationship building, empathy and rapport?	effectiveness, efficiency and equity* The politics of health systems and health service delivery globally.

In the 1990s organisational hierarchies were flattened, middle management roles were reduced. Technology played its part, but there are many other factors:

https://www.nber.org/system/files/working_papers/w9633/w9633.pdf

At a time when applied AI is increasing, nursing is open to innovation, but synergy and assurance of high quality, safe, person-centred care is essential. 

Socially we also need to preserve forms of work that have a role in well-being and community health - care of older people. Hierarchies and the services they 'deliver' will be flattened further and rationalised - if as nurses we are sufficiently passive. Consider the thoughts of Prof. Acemoglu, Economist, MIT:

"He [Acemoglu] imagines a day when teachers could use AI to create individual lesson plans for every student, or nurses might be able to take on much greater roles in, for example, diagnosing disease. 'Why is it that nurses cannot prescribe medications? Why must everything go through this very hierarchical approach where you have to call a doctor [to do that]?' As it is today, the people who spend the most time with patients - nurses, not doctors - are those who are paid and valued the least." p.3.

Foroohar, R. 'When mistakes involve powerful technologies, you're going to have trouble', Lunch with the FT: Daron Acemoglu, FT Weekend, Life&Arts, 20-21 May, 2023, p.3.

There is most likely a 'corporate' signature common to these reports as there will be to the posts here (2006 ... ). For nursing's sake - vested in the sustainable development goals, the determinants of health, and climate change - we need to preserve 'models of / for care' defined, applied and refined by nurses, the profession and professionalism, registration and holistic bandwidth.

See also:

Moisoglou, I., Galanis, P., Meimeti, E., Dreliozi, A., Kolovos, P. and Prezerakos, P. (2019), "Nursing staff and patients’ length of stay", International Journal of Health Care Quality Assurance, Vol. 32 No. 6, pp. 1004-1012. https://doi.org/10.1108/IJHCQA-09-2018-0215 (I have accessed the abstract only).

Kim, J., Lee, J.Y., Lee, E. Risk factors for newly acquired pressure ulcer and the impact of nurse staffing on pressure ulcer incidence. J. Nurs Manag. 2022 Jul;30(5):O1-O9. doi: 10.1111/jonm.12928. Epub 2020 Feb 25. PMID: 31811735; PMCID: PMC9545092.

[ Thanks to Phil Wilson: https://twitter.com/ph_wilson1/status/1667869284305977346?s=20 ].

By one of the big four. It does try to look at workload redistribution but seems to conveniently ignore the evidence regarding the improved outcomes of RN delivered care & bad tech. #Nursing
Big 4 really need to dump the Christmas tree models. https://t.co/2zrylhTZOo @McKinsey

— Prof Alison Leary 💙#ProtectNurse (@alisonleary1) June 1, 2023

*Apply the 3Es across the domains of Hodges' model.

Reimagining the nursing workload: Finding time to close the workforce gap

https://www.mckinsey.com/industries/healthcare/our-insights/reimagining-the-nursing-workload-finding-time-to-close-the-workforce-gap