Reforming the Portuguese Healthcare system: Major Issues of Change Management EHMA Conference 2005...

Reforming the Portuguese Healthcare system:

Major Issues of Change Management

EHMA Conference 2005 – IESE Barcelona

J. Paulo Kuteev-Moreira PhD, University of Manchester

J. Paulo Kuteev-Moreira, PhD

Summary

• The 2002-2005 Reform Attempt• Elements of Change in Healthcare• Public opinion on health and well-being

isssues• Resource shortage: a theoretical basis • Change Management in Healthcare: theory

for governmental practice• Discussion (...)


2002-2005 a period of yet another attempt to ‘reform’ the Portuguese NHS

Ministerial interventions – measurable outcomes – unchanged problems

Promote Generic drugs consumption Special annual budget for tackling waiting lists for

surgery (e.g.: pay-per-surgery)• National Call Centre (imitation of UK NHS Direct) Creation of the National Health Regulation Agency Public – Private Partnerships – 10 new hospitals New hospital Management legislation (31 ‘Trusts’) (Imposed – ‘overnight’) – production fee-per-service

budget Remaining > 60 hospitals: good old management rules

– historical costs (annually increased budget) First ever National Health Plan -

• Politicised management• Centralised decision making• Hospital costs grew faster than productivity• 1 million citizens without GP• Emergency Care covers only 40% of the territory• Deficient HR planning: nurse and physician shortages• Poor and unreliable information systems• > 220,000 patients waiting for surgery (May 2005);

Special Budget disappeared into a ‘black hole’• 11% of generic drugs consumption (but increased

costs!!!)

Good Intentions (Political Rhetorics) Real Politik Challenges

Better Care (Quality) Better Access (Equity) Patient Needs Satisfaction Financial Sustainability Efficiency

• Public Budget Deficit/Debt (Euro Zone)• Hospital Based Care• Signs of Low Efficiency / efficacy• Lack of coordination of care between levels• Over 122,000 patients waiting for surgery (some for

more than 5 years)• A&E over-used – patient bypass of primary care


Simple solutions for any complex problem can be found...

... but they are usually wrong...

A Dilemma

for governmental intervention in healthcare management...


Elements of change in healthcare: • Science

• Technology• Organisation• Economics

• Politics• Ideology• Opinions

• The Media

Healthcare defined

A continuous complex process of change:

constantly combining new scientific facts with pharmacological products and caring services, technological solutions, organisational arrangements, economics, politics, philosophical and ethical debates, common-sense

individual/group opinions and media reports.


ANOTHER CONCEPTUAL CHALLENGE: Find Relationships between elements of change, stakeholders

and resource shortage dilemmas in healthcare

Elements of Change

Healthcare Stakeholders Resource Shortage dilemmas

Science Suppliers Extend governmental co-payments?More publicly funded research?

Regulators Sufficient Evidence? Evidence-based…

Technology Suppliers Purchase high-tech solutions?

Organisation Regulators Restrict free access to care?

Labour market Restrict access to professions? More attractive careers?

Non-care customers More non-clinical services?

Economics Purchasers/contractors Share cost with users? Share investment with private sector?

Competitors/rivals More fees ‘per act’?

Regulators Lower budgets? Lower public expenses?

Politics Regulators Reduce deficit? Reduce access?

Suppliers Facilitate access?

Ideology Suppliers Promise Freedom from disease and pain?

Regulators Universal healthcare?

Opinions Patients and service users Free universal access?

Trade Unions/professional associations More incentives? Better earnings/wages?

Organisations representing patients More quality? Rapid patient access?

The Media The Media SHORTAGE OF NEWS? SHORTAGE OF ‘squabbles’?


Healthcare

organization

Media

Purchasers/contractors

Regulators

‘Competitors’ / Rivals

Suppliers

Trade Unions and Professional associations

Labour market

Patients and service users Non-care customers

Organisations representing patients and service users

A contemporary healthcare corporation

Culture(s)?Needs / Interests?

Power?

Expectations? Perceptions?

Atitudes?

Challenges for The Health Manager:


Public opinion on health and well-being isssues

(An European example Portugal Marktest 2004)

Reduced waiting lists in hospitals/surgeries

14% Better diet/more information on food 4%

Better/retained local NHS/health services including cottage hospitals

14% Safer Communities including more police, less crime

4%

Increased investments/general improvement in NHS/health care

13% Less litter/dog fouling 4%

Improved employment opportunities 9% Less traffic/air pollution 4%

More NHS staff including doctors, nurses, matrons

7% More health informaion/education 3%

More Hospitals/beds 6% Better services/care for the elderly 3%

Better Education including Schools 6% Better wages 3%

Cleaner Environment 6% Cleaner rivers/beaches/seas and better sewage treatment

3%


Public opinion on health and well-being isssues: other findings I


Percentage identifying important action for various organisations in improving health and well-being, by social group

Social group Social group All

ABC1 C2DE

NHS 85% 75% 79%

Local Government 64% 54% 59%

National Govern. 60% 49% 54%

Individuals 52% 32% 41%

Voluntary Community groups

40% 25% 32%


Public opinion on health and well-being isssues: other findings II


Age groups considered a priority for action to improve health and well-being

School children (5-16) 61%

Elderly (75 years and over) 54%

Pre-school children (0-4 years) 48%

Young elderly (60-74) 41%

Young Adults (17-24) 30%

Adults (25-44) 19%

Older Adults (45-59) 19%

Questions: Public opinion vs political agenda setting? Whose influences on setting these pubic perceptions?


• Media• Patients and service users • Organisations representing patients and service users• Regulators (politics...)• Purchasers / contractors• ...

Promoting this ‘kind of survey’ on Public opinion on health and well-being isssues... . Influence/impact on which stakeholders?

So what?... Strategic Communication Options

for healthcare organisations?

• Reduced Waiting Lists (?)

• Children First (?)

• Elderly First (?)

• ‘NHS Forever’

Strategic Political appeal?

But before we discuss answers...


Meeting Citizen/voter Expectations?Or everybody else´s?... (Laing, Angus, 2002)...

Reengineering

Strong centralized leadership

Processual aspects

Professional alienation and resistance

Negotiated participation

Change process

Professional ownership

Outcomes

User empowerment

Reorientation service provision

Change healthcare delivery

Challenge professional expertise / autonomy

Resource utilization?

Individual ‘consumer’ concerns?

USER INPUT

Public sector collective concerns? PROFESSIONAL INPUT

Reconfiguring service encounter?

POLITICAL INPUT

GOV Message Content?


Strategic Thinking:The Resource-Based View (RBV) (Barney, 2001; Peteraf, 1993)

Resources • Specific Assets

• Human Competencies

• Intangible Abilities

Management role • Bundle resources

• Make this ‘bundle’ inimitable by competitors

Competition • Imitation through Resource accumulation• Differentiation (idiosyncratic resource

accumulation)

Performance• A function to obtain/deploy

unique/scarce resources

Whose performance goals?


Resource Utilization

Whose Performance Goals? (Short, Palmer & Ketchen, 2002)

Balanced scoreboards

Key stakeholders?

Strategic Thinking II:The Resource-Based View (RBV) (Barney, 2001; Peteraf, 1993)

Government Message Content?


Major Change Management Issues

• The resource dependence view, also maintains that the attempts to solve resource shortages, oblige the organisation to change the balance between its dependencies. As suggested by some authors (see Harrison et al, 1992; Pfeffer & Salancik, 1978), this new balance of dependency may be achieved by one or a combination of four strategic alternatives:

– Adapt to the conditions (e.g.: influence demand of services or its delivery) – Alter its interdependencies (e.g.: merger with an organisation that controls

some of the scarce resources or growth by developing new services/products so that the organisation is no longer dependent)

– Negotiate environmental conditions (e.g.: create partnerships to deliver joint services or share resources for instance with social services, voluntary NGOs or even the private sector)

– Change by political action (e.g.: lobbying politicians to obtain subsidies, favourable regulation and contracts)


Elements of change in healthcare

Healthcare stakeholders

Resource shortage dilemmas

Organizational Strategic alternatives:

AdaptAlter

NegotiateChange

STRATEGIC COMMUNICATION

GOV Message Design

Major Change Management Issues


Two Paradigms of contemporary Healthcare

and Government Message Design… yet another challenge

Old Paradigm of Healthcareand public health

New Paradigm of healthcare in the context of health promotion - WHO HFA XXI

Treatment of symptoms• Specialised Emphasis on efficiency Professional should be emotionally neutral (scientific

values)• Pain and disease are wholly negative• Primary intervention with drugs and surgery Body seen as machine in good or bad repair• Disease or disability seen as an entity• Emphasis on eliminating symptoms • Patient is dependent• Professional (e.g.: the medic) is authority Body and mind are separate; psychosomatic illnesses

seen as mental; may refer to psychiatrist; Mind is secondary factor in organic illness• Placebo effect is evidence of power of suggestion• Primary reliance on quantitative information

(including charts, tests, dates)• Prevention seen as largely environmental: vitamins,

rest, exercise, immunisation, not smoking

• Search for patterns, causes• Integrated, concerned with the whole of the patient• Emphasis on human values Professional’s caring is a component of healing Pain and disease may be valuable signals of internal

conflicts• Minimal intervention with appropriate Technology,

complemented with full armamentarium of non-invasive techniques (e.g.: psychotherapies, diet, exercise)

• Body seen as a dynamic system, a complex energy field within fields (family, workplace, environment, culture, life history)

Disease or disability seen as process• Emphasis on achieving maximum body/mind health• Patient is (or should be) autonomous• Professional is therapeutic partner• Body/mind perspective: psychosomatic illness is the

province of all health care professionals;• Mind is primary or co-equal factor in an illness• Placebo effect is evidence of mind’s role in disease

and healing• Primary reliance on qualitative information, including

patient reports and professional’s intuition; Prevention synonymous with wholeness: in work,

relationships, goals, body-mind-spirit

In Moreira, JPK (1998)


There are simple solutions to all complex problems...

... but they are usually wrong...

A Dilemma of healthcare management...

... Yet, do managers have time to ‘think’?...


THANK YOU!

Reforming the Portuguese Healthcare system: Major Issues of Change Management EHMA Conference 2005...

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