Abstract
Keywords
The epidemic of multimorbidity
Policymakers regard “the epidemic of multimorbidity” as the greatest threat to the sustainability of healthcare systems. They believe the solution is “integrated care”, “
Emergent outcomes do not have linear “cause and effect” relationships and can best be understood in hindsight. Emergent behaviours are highly sensitive to context; consequently, the “same” approach used by different agents in different contexts will not produce the same outcomes. Agents navigate toward mutually agreed outcomes by constantly adapting to evolving changes within the context of local constraints [2].
A complex adaptive system approach overcomes many of the dysfunctions in the current health systems, in particular the fragmentation of patient care [3]. Overcoming fragmentation requires continuous adaptation to changing circumstances – a constant challenge for patients, health professionals, community service providers, and policymakers.
How can the already overburdened primary healthcare services achieve these goals?
To address the complex challenge, we first must reflect on three key questions:
What is health?
What is disease?
What is multimorbidity?
Reflections on health, disease, and multimorbidity
Definitions of health are contested [4–6]. Health is a personal experience rather than an objective state. The subjective experience of health arises from the complex adaptive interactions from four sources: our body, mind, social context, and our sense-making processes about our experiences. The question, “How do you rate your health in general on a scale of ‘excellent’, ‘very good’, ‘good’, ‘fair or poor’?”, captures a person's health experience and closely correlates with future morbidity and mortality [7–9].
Diseases are socially constructed and re-constructed. For example, lowering “normal” blood sugar thresholds labels more people “diabetic”, and the creation of a new category between normal and abnormal blood sugar levels results in people being labelled “pre-diabetic” [10–12]. Notwithstanding labelling effects and ageing, most people remain unaffected by diseases throughout their life: about 10% of 65–74-year olds have five or more diseases, rising to 20% in 75–84-year olds, and to just over 30% in those aged over 85 years [13,14]. Similarly, the number of diseases does not correlate with health perceptions. The majority of aged people enjoy good health despite their multimorbidities (77% of 65–74-year olds, 70% of 75–84-year olds, and 63% of those aged >85 years) [15].
Viewed from a complex adaptive system perspective, the experience and clinical aspects of multimorbidity result from interconnected physiological disturbances of genomic [16], metabolomic [17,18], autonomic [19], and immunological network interactions [20,21]. Furthermore, an individual's internal coping mechanisms and external environment both modulate physiological function and affect the person's experience of health and illness (Figure 1 and Box 1) [22].
A network model of multimorbidity. The figure illustrates the network relationships between external and internal factors on the personal experience of health. Interventions that modify the person's health and health experience are highlighted. PNI, pscyhoneuroimmunology.
Health, disease, and multimorbidity: summary points.
Is a subjective state Is influenced by many external factors Good health perception is associated with lower mortality and lower health service use
Principally defined by doctors/bureaucrats An inevitable feature of the life trajectory Is non-linearly distributed across age brackets, i.e. most people are not affected Most people stay healthy for longer, and most have a short period of disability before dying Most people experience “good health” most of the time, independent of their morbidities
Appreciating healthcare through a complex adaptive system lens
The way we think reflects the way we see the world [23]. The way we view health, disease, and multimorbidity shapes how we act. Health professionals are acculturated [24] in institutions that view health through the prism of disease. They are disease managers, not optimizers of people's health, regardless of morbidities. Consequently, health professional–patient encounters are predominately disease-centric, and seldom focus on the person or the person's experience of health.
Adopting a complex adaptive system approach to health, disease, and multimorbidity recognizes the importance of managing the patient's quality of life as much as their diseases. This approach considers how medical interventions improve the patient's quality of life or detract from it, despite being “current best practice”. This process explores the impacts of physical, social, and emotional functions on the patient's changing experience of health.
Designing complex adaptive health systems
Given our deeper understanding of how the context of a person's life impacts his/her health, we have to redesign primary care to enable it to provide integrated care. Properly implemented integrated care addresses all of a person's emerging needs to achieve and maintain a good health experience.
Systemic problems require systemic solutions. Health systems must design adaptive healthcare organizations that respond to their patients’ changing needs (see NEJM Catalyst; catalyst.nejm.org). Using bottom-up approaches, engage all stakeholders to deliberate on designing integrated services. This calls for systemic change in the approach to redesigning organizations. It requires addressing four questions asking why, what, how, and how to? The systemic redesign of organizations requires them to address the following issues [25,26]:
Purpose (Why?)
Specific goals (What?)
Shared values (How?)
“Simple rules” (How to?).
Purpose and goal questions define the overall and specific objectives of an organization, and its shared values shape its culture. “Core values” remain stable in a constantly changing world. Values clarify what the organization is and articulate what it stands for. Values create a culture of safety and trust for learning together. They guide behaviours and interactions and influence the quality of personal and professional relationships.
Understanding purpose, goals, and shared values is pivotal in order to define a set of three to five “simple rules” (or operating principles) that guide the actions and behaviours within an organization. Statements regarding purpose, goals, values, and “simple rules” have an important function – they act as a reference point for decision-making and resolving unavoidable conflict; determining which options are most aligned with purpose, goals, values, and “simple rules”.
System malalignments
Specialists define their purpose and goals as managing organ-specific diseases (e.g. heart disease, kidney disease, or diseases of the nervous system). In contrast, general practice/family medicine views its role as optimizing “personal health experiences”. General practitioners (GPs)/family physicians (FPs) focus on minimizing patients’ illness experiences despite their multimorbidities. Minimizing patients’ illness experiences involves addressing their interconnected physical, social, emotional, and sense-making needs in resource-constraint environments.
Divergent purposes and goals are a characteristic in pluralistic societies. They interfere with designing complex adaptive health systems and organizations for integrated care based on health equity.
Many other entities, while providing important inputs to the delivery of care to individuals and communities, legitimately pursue different goals. The self-interests of corporations (pharmaceutical and device industry, for-profit health and indemnity insurers) and disease-focused advocacy groups drive their specific agendas that can run counter to a person-centred approach to integrated care.
Workshop feedback
The purpose, goals, values and “simple rules” framework were discussed with 80 GPs/FPs from across the world at the WONCA Europe conference workshop in Copenhagen, Denmark, June 2016. The group regarded the divergent purpose and goal statements amongst the different stakeholders as the root cause for the dysfunction of their health systems.
These doctors agreed with the person-focused purpose and goal statements for the health system. They shared remarkably similar views about the values that guide their approaches to patient care. Based on the experience of workshop participants, five “simple rules” to deliver integrated multimorbidity care were developed (Table 1):
The four core principles that achieve a complex adaptive organization: summary points.
The future of integrated multimorbidity management
GPs/FPs feel up to the challenges posed by their patients with multimorbidities. However, they are frustrated by the fragmented approach to multimorbidity management. Guidelines focus on individual disease and neglect to:
Take into account the patient's social and environmental context and the interactive effects between morbidities
Enhance the patient's and their family's abilities to manage the demands of treatment regimens
Address the psychosocial impacts of illness on the patient and their family.
To optimize integrated care, we must go beyond guidelines [27] and connect the healthcare system with other human service systems in order to improve all relevant outcomes [1]. We need to do the following:
Develop a complex adaptive healthcare system that puts the patient and their family at the centre of care [1,26,28–31]
Train physicians capable of treating patients’ multimorbidities as pathophysiological network dysfunctions
Educate health professionals to recognize and manage the patient's illness
Activate health professionals to engage in building health-promoting communities.
The workshop participants want a public discourse on how to:
Put the needs of the patient at the centre of the health system
Present a realistic picture about the nature of health and illness, the roles of self-care and medical care, and the abilities, limitations, and harms of biomedical interventions
Lead the practice-level changes required to create the time and space to manage patients’ needs in all its dimensions (embracing colocation of health and social services)
Implement a network-thinking approach to manage patients’ illnesses and diseases.
Leading health service and health system redesign
The current pessimism and discontent with fragmented multimorbidity care has emerged as a catalyst for a bottom-up movement to health service and health system redesign. Health professionals increasingly appreciate the interdependencies among the personal, emotional, social, and sense-making processes as the basis to optimize the health of patients with multimorbidity. We must advocate for the essential political, social, and environmental changes needed to optimize the health of patients with multimorbidity.
The “WONCA Special Interest Group Complexities in Health” 1 supports all health professionals to develop the necessary complex adaptive system skills for delivering person-centred integrated health (and social) care. This entails broadening the agenda to make health, notwithstanding multimorbidities, the center of a redesigned health system.
Footnotes
Acknowledgments
We are grateful to the participants at the 2016 WONCA Europe Complexity in Health SIG-workshop, “Integrated multimorbidity management in your practice: what are enablers and barriers to effective implementation?” for sharing their perspectives and insights.
The authors declare that they have no conflicts of interests.
None declared.
