Health Systems, Systems thinking and innovation.

Systems:

What is a system?

- An organised, connected group of components.

- A set of elements in interaction to achieve a specific goal
Features: inputs, process, outputs

Variable system dimensions:

- Exposure to external environment forces

- Complexity (more complex are larger in number of connections
between elements)
- Adaptive ability

System Thinking

Systems issue:

A problem arises because of issues inherent at some point or points in the

overall system rather than due to individual or isolated factors.

An issue that may occur in one area subsequently affects the other areas
in the system.

Systems thinking:

The diagnostic tool for the assessment of a problem – a subsequent

change to the structure, organisation, or policies in a particular system

Health systems play a critically important role in improving health. Well-

functioning health systems enable the achievement of good health by
efficiently using available resources.

- Critical in mounting effective responses to emerging public health

emergencies and addressing the burden of disease, ill health, and
poverty due to communicable diseases and cancers.

Several factors influence how health systems achieve good health

efficiently:
 - Skills and resources: the abilities of healthcare workers and the
quality of healthcare facilities are crucial.
- Strong leadership: consistent and effective management is needed
to guide and improve health systems.
- Adaptability: Health systems should be flexible and ready to take
advantage of new opportunities, like new medical technologies or
funding.

Several different determinants feed into health and well-being (life

expectancy, mortality) and then it interacts with all sorts of resources, and
then we come up with interventions that again feed into determinants,
and the cycle goes on…. This is what falls into the health system (broader
view that affects the health system)

How does systems thinking help?

- Identifies the issue within a system context.

- Promotes dynamic networks of diverse stakeholders.
- Encourages learning from one another.
- Allows efficient targeting of resources.
- Allows much more effective improvement and prevention strategies.
- Strengthens system function, productivity, and efficiency.

Health systems

Include:

- Services: provided by all health professionals

- Sites: hospitals, health networks, community facilities, home
services
- Alternative or complementary health services, e.g. naturopathy
- Home/self-care includes non-prescription medications.
- Public health initiatives

The health system framework:

System building blocks:

- Service delivery.
- Health workforce
- Information
- Medical products, vaccines & technologies
- Financing
- Leadership/governance
If they can get access, coverage, quality and safety, than they can meet
the overall goals:

- Improved health (level and equity )

- Responsiveness
- Social and financial risk protection
- Improved efficiency

Goal #1: Health improvement: Health improvement can be measured in

two ways:

Level: Average level of health

- Focus on improving the overall average treatment and control of

infectious diseases.
- Treatment and management of chronic non-communicable disease

Equity: Distribution of health

- Focus on reducing the disparity between groups within the

population.
- Priority of those with the poorest health, however, possible conflict –
may not improve the average.

Goal #2: Responsiveness

- The ability of the system to adjust and adapt quickly to sudden

changes in the environment (internal or external)
- Individual level of responsiveness – response to patient/staff needs.
- System level responsiveness – wider level response

Goal #3: Social and financial risk protection

- Individuals contribute funds to the system according to their ability

to pay.
- Financial risk is distributed according to the ability to pay, NOT the
risk of illness.
- Universal health care (Medicare)
- People who need treatment can receive it.

Level of ‘out–of–pocket’ expenses

Fair pre-payment system:

- Taxation
- Medicare levy
- Voluntary (private) health insurance
Horizontal equity:

There should be equal treatment for individuals or groups with similar

healthcare needs.

Vertical equity

The concept is that individuals or groups that have different healthcare

needs should be treated differently according to their needs.

E.g. ED triage, health care holders

Goal #4: Improved efficiency

- Assessing cost of resources (Limited incentive at present)

- Reducing waste
- Reducing duplication
- Reducing unnecessary imaging or procedure: ‘over-servicing’, e.g.
knee arthroscopies
- Allocate efficiency: distribution of resources to maximise population
benefit.
- Reduction of unsustainable practices e.g. Blueys
- Avoiding clinical errors – can result in costly morbidity.
- Whose responsibility is this?

Health care delivery – safe adds.

Health Service categories

Public health services:

- Health promotion
- Health education
- Prevention
- Immunisation
- Pandemic management

Primary care and community health services:

- General practice activity

- Dental services
- Private sector allied health.
- Community Health
- Pharmacies
- Ambulance and RFDS
- Primary health care for first nations Australian

Hospitals:
 - Admitted patient care.
- Emergency department care
- Outpatient care
- Hospital in the home

Specialised health services:

- Specialised medical practitioners.

- Palliative care
- Specialised mental health services.
- Reproductive health services
- Alcohol and other drug addiction treatment
- Hearing services
- Aged care services
- Australian Defence Force Health Services

Goods

- Pharmaceuticals
- Oxygen

Equipment eg:

- Surgical devices
- Ventilators
- Pumps (IV, bypass, ECMO)
- IV fluids
- Blood products needs
- Syringes IV lines
- IV lines
- ETT, trache tubes
- Suture materials
- Dressing materials
- Thermometers
- Beds, bed linen, drapes, etc

Health services categories

Main levels of care: Primary health care

- First contact within the health system: (does not need a referral
Acute and chronic condition management, health promotion,
prevention gatekeepers of the health system e.g., GPSs, paramedics
- Usually community-based

Secondary health care

 - Specialist care – requires referral to specialist health
professional/department or specialist facility from the primary to the
secondary care provider.
- Primary carers make the decision about which specialist care a
patient receives eg. Pain medicine, paediatrics, cardiology,
psychiatry, surgery, etc

Tertiary Health Care:

- Highly specialised care – complex super–specialised medical or

surgical care
e.g. cardiothoracic ( anaesthetists and surgeons), neurosurgery
(anaesthetists and surgeons), trauma intensive care, etc

- referred by primary or secondary care providers (usually secondary)

- tertiary referral hospitals

Additional levels of care:

- Preventative health care: health education, health promotion,

immunisation, cancer screening etc – often considered part of
primary health care.
- Primary
- Secondary
- Tertiary
- Restorative health care occurs immediately after illness/injury.
E.g. Rehabilitation, district nursing, home care etc

Service types.

Types of health services:

- Curative – focus on treating (and curing) conditions.

- Preventative – focuses on preventing the condition from occurring or
preventing/mitigating the risk of complications of existing
conditions.
- Palliative – focus on easing of symptoms without attempting to cure.
- Advisory – provision of expert advice about an increasingly wide
range of social and family issues: drug abuse, sexuality, parenting,
etc
- End of life care: Victorian Voluntary assisted dying act 2017

Health care sectors:

Sectors of the system may be:

- Acute: usually institutional (not chronic)

 - Sub- acute: rehabilitation or extended care (not urgent
- Community (i.e., not institutional)

May include combinations, for example:

- Mental health: acute, sub- acute and community

- Aged care: residential and community- based (not acute)
- Rural health: acute, sub- acute and community

Key points:

- Health systems are complex, adaptive entities

System thinking:

- Prevents piecemeal approaches to adverse events.

- Assists in understanding and improving flow through health
systems.
- Some issues labelled as systems–related can include a degree of
individual responsibility.

Health systems have four over-arching goals, the most important of

which is to improve health.

Health care is delivered at several levels, through a variety of services

and sectors.

Contextual Factors:

- History: past decisions and existing structures influence how well

the health systems work today.
- Cultural Beliefs: People’s cultural beliefs and practices affect how
they use health care services.
- Economic environment: The country’s economic situation impacts
the funding and quality of healthcare.
- Country’s History: The overall historical context, including previous
health policies and social changes, affects current health systems.

These factors shape how effectively a health system can provide good
healthcare.

- Resource scarcity, coupled with the global economic crisis, has

necessitated the adoption of innovations in health systems to
sustain effective responses and improvements in health outcomes.

It's often unclear why many well-meaning health policies and decisions
don’t achieve the desired results, sometimes leading to unexpected
 problems. This can happen because health systems are complex, and
what works in one place might not work in another. Poor
implementation, unforeseen interactions within the system, human
behaviour, and resistance to change also affect these unintended
outcomes.

- This happens because the methods used to analyse health systems

and make management decisions are often too simple for such
complex systems.

Health systems, dynamic complexity and systems thinking.

Definition and purpose:

- Health systems serve societal needs.

- They can be adjusted through policy to improve outcomes.

Open systems:

- Health systems have interconnected components.

- These components interact within the context of the health system.

System properties:

- The whole system has properties beyond individual parts.

Feedback mechanism:

Interactions within the system can have:

- Positive (amplifying) feedback

- Negative (balancing) feedback

This feedback collectively determines the system’s behaviour.

Complex Interactions:

- Health systems have many parts that are connected and depend on
each other.
- Because of these connections, the effects of an action can be
delayed or not immediately clear.

System Thinking:

- It looks at the entire health system as one big picture rather than
focusing on individual parts.
 - It considers how different parts work together and how changes
affect the whole system over time.

Decision–making Issues:

- Often, decisions are made based on limited information and simplify

the system’s complexities.
- This can lead to missing important factors and unexpected results.

Consequences:

- Decisions that are too simple can cause problems that weren’t
anticipated.
- Policies might not work as planned and could even face pushback.

Benefits of systems thinking:

- It helps understand how all system parts are linked and influence
each other.
- It allows for better preparation and anticipating potential problems
instead of just reacting to issues as they arise.

Systems thinking in practice:

- Consider consequences: Think carefully about the possible

outcomes of policies and actions.
- Group work: Use team discussions and joint thinking to explore
different scenarios.
- Understand interactions: Consider how different parts of the health
system interact and how the context affects them.

System Dynamics Modelling: Computer models simulate the system's

behaviour under different conditions. This helps with:

- Testing ideas and scenarios

- Enhancing group learning and understanding of problems

Benefits:

- It helps predict outcomes and plan better by simulating different

scenarios and improving teamwork.

Health Innovations:

- Type: New medicines, diagnostic tools, technologies, practices, or

organisational changes.
- Importance: Essential for improving health outcomes in both
wealthy and less wealthy countries
Factors influencing innovation adoption:

- Context: The specific conditions and environment where the health

system operates can affect how innovations are adopted
- Health systems Characteristics: The structure and functioning of the
health system itself play a role.
- Institutions and Individuals: The readiness and ability of healthcare
institutions and individuals to adopt innovations matter.
- Problem perception: How the innovation aims to solve the problem
is understood by everyone involved and affects whether and how
quickly the innovation is adopted. If the problem is not recognised or
well- understood by the people, institutions, and systems that need
to use the innovation, it may hinder the adoption process.

Challenges with adoption:

- Technical issues: Innovations may not work effectively if they have

technical problems or are incompatible with existing local
infrastructure. For example, equipment might not function correctly
due to differences in power supply or other technical standards.
- Infrastructure weaknesses: Weak or inadequate health systems and
infrastructure can prevent the proper implementation and use of
innovations. For instance, if health facilities lack the necessary or
support systems, new technologies or practices may not be adopted
effectively.
- Cultural and political barriers: Socio-cultural beliefs or lack of
political support can affect how well innovations are adopted:
For example: health equipment may sit unused if it doesn't match
local technical standards.
Effective HIV treatments may be underused due to stigma or
inadequate health care systems.

Systems Thinking:

- Holistic View: Looks at the entire health system, considering how all
parts work together.
- Understand interactions: Helps to grasp how different parts of the
health system interact and affect each other.
- Anticipating challenges allows for better planning and preparation
by predicting potential issues rather than reacting to them.

Benefits of systems Thinking:

 - Comprehensive Understanding: Provides insight into how various
factors in the health system influence each other.
- Improved adoption: Facilitates the effective introduction and scaling
of innovations by addressing all relevant aspects of the system.

Conclusion:

- Need for complexity: Simple solutions often don’t address the full
complexity of health problems.
- Effective Responses: Systems thinking helps create effective
strategies by considering the entire health system and its
complexities, reducing the risk of missed factors and unexpected
outcomes.

Funding:

- The publication of this supplement is supported by the Alliance for

Health Policy and Systems Research, World Health Organisation.

There is a strong need for comprehensive reform in Australia’s health system due to severe
issues like overcrowding in emergency departments (EDs), delays in patient care, and
inefficiencies in health service delivery. Recent concerns include:

 Hospital Crisis: Public hospitals are struggling with patients occupying beds while
waiting for aged care or disability services, leading to overcrowded EDs and long
waits in ambulances.
 Calls for Reform: Various groups, including state health ministers and the Australian
Medical Association, are advocating for significant investments in primary and
hospital care to address these issues.
 Mental Health Services: Reports highlight the urgent need for a complete overhaul
of mental health services.
 Governance and Funding Issues: The divide between federal and state governments,
along with a complex health system involving private hospitals and insurance, has led
to cost-shifting and inefficiencies. Blame and cost-shifting need to end, and better
coordination and funding are necessary.
 COVID-19 Impact: The pandemic has exposed and exacerbated overcrowding
issues, demonstrating the need for a collaborative approach to health care.
 Improvement Needs: Recommendations include improving access to senior clinical
decision-making, diagnostic tests, and integrated digital systems. There’s also a call
for better primary and community care, including access to GPs, subacute services,
and hospital-in-the-home models.
 Holistic Approach: Addressing these challenges requires a balanced and coordinated
approach across the entire health system, rather than isolated solutions. Collaboration
among various health professionals and policy makers is essential for effective
reform.
 Advocacy and Action: The Australasian College for Emergency Medicine is leading
efforts to advocate for reform and urges professionals in other specialties to join in
pushing for a more efficient and equitable health system.
Access block refers to a situation in which patients are unable to be admitted to an inpatient
hospital bed when needed, despite being assessed and needing hospitalization. This often
occurs when:

 Emergency Departments (EDs) are overwhelmed: EDs may become crowded,

leading to delays in finding appropriate inpatient beds for patients who require
admission.
 Hospital Capacity is insufficient: There may not be enough inpatient beds or
resources to accommodate patients, causing them to remain in the ED or other areas
not designed for long-term care.
 Delays in Patient Flow: The process of moving patients from the ED to an inpatient
bed is delayed due to various systemic inefficiencies, such as coordination issues
between different hospital departments or slow discharge processes.

Access block can lead to a range of problems including:

 Extended waiting times: Patients may experience long waits in the ED or other
areas.
 Compromised care quality: Overcrowding can negatively impact the quality of care
and patient safety.
 Increased strain on hospital staff: ED staff and other healthcare professionals face
added pressure due to the high volume of patients and the need to manage delayed
admissions.

Addressing access block typically requires a comprehensive approach, including improving

hospital capacity, enhancing care coordination, and streamlining patient flow processes.

System factors contributing to access block include:

 Overloaded Emergency Departments (EDs): High patient volumes in EDs lead to

delays in care and access block, where patients awaiting inpatient beds are held in the
ED.
 Insufficient Hospital Capacity: Limited availability of inpatient beds and resources
can prevent timely admission for patients who need hospitalization.
 Fragmented Care Coordination: Poor integration between different levels of care,
such as primary care and hospital services, can lead to inefficiencies and delays.
 Weak Primary Care Systems: Inadequate primary care services can result in more
patients seeking emergency care for issues that could be managed elsewhere.
 Aging Infrastructure: Outdated facilities and equipment may not meet current
demands, contributing to inefficiencies and access issues.
 Funding and Resource Constraints: Insufficient funding and resources for both
hospitals and primary care can exacerbate access problems and limit service
availability.
 Governance Issues: Misalignment between federal and state responsibilities and poor
management can lead to ineffective use of resources and delayed care.
 Socio-Cultural Factors: Community expectations and socio-cultural factors can
influence how and when individuals seek emergency care, impacting ED congestion.
 Policy Limitations: Ineffective policies or lack of comprehensive strategies to
address systemic issues can hinder efforts to resolve access block.