Promoting Integrated Care, Understanding Complexity, and Advocating for Women in Medicine

Áine is Professor of Healthcare Integration and Improvement at University College Dublin, Ireland and a Consultant in Rehabilitation Medicine at the National Rehabilitation University Hospital in Dublin. She is Chair of the International Foundation for Integrated Care (IFIC) and Co-Director of IFICIreland.

Prior to this, she was National Director of the Clinical Strategy and Programmes Division in the Health Services Executive in Ireland. During her tenure, Professor Carroll established the Integrated Care Programmes to promote coordinated care and teamwork across services and specialties, ensuring that care is provided effectively and seamlessly to patients as they move through the system. Áine is known internationally for her expertise in integrated care, whole system change, complexity and implementation. She is passionate about person centred coordinated care,complexity theory in healthcare and the power of stories.

“We are wonderful systems of ‘organs’ but how we are currently design and provide our health care systems isn’t working for the whole of human beings. We recognized that we needed to start to do things differently and that brought me into the whole area of integrated care.”

What I really like your slightly oblique approach to traditional medicine. Áine, tell me about your career and your current job.

Áine Carroll: My name is Áine Carroll and, by background, I am a Consultant in Neurological Rehabilitation Medicine at the National Rehabilitation Hospital in Dublin, but I also wear a number of other hats. I am Professor of Healthcare Integration and Improvement at University College Dublin and I’m also current chair of the International Foundation for Integrated Care (IFIC) and, I’m co-director for the IFIC Ireland Hub. I have a lot of different interests. There’s a thread of integration that runs through them all but I’m also really interested, not just from an academic point of view but, in the practical application of knowledge to the day-to-day work that we do in health and care. So, I’m really interested in learning systems and health care being viewed as a complex adaptive system.

DMacA: Before we get on to changing the systems, tell me about integrated care and what it really means.

AC: Before I got very involved in IFIC, I was National Director of Clinical Strategy and Programs within our health system, which is the Health Service Executive, and at that time I would have been responsible for 35 clinical programs. Each of those programs was really important, really worthwhile, taking an evidence informed approach to how we were thinking about models of care. But each ‘organ’ had its own model of care and one of the things that I and colleagues came to realize is that we need to join things up. Our patients don’t present as a heart or a brain or a kidney. We are wonderful systems of ‘organs’ but how we are currently design and provide our health care systems isn’t working for the whole of human beings. We recognized that we needed to start to do things differently and that brought me into the whole area of integrated care. Even when you look at the literature in integrated care it is the most heterogeneous fuzzy thing imaginable. We’re not bound by any set definition, because it really does depend on your context, but having a shared understanding about what that means and, in its purest form, that means person centred coordinated continuous care that deals with the issues that matter to the individuals and their family.

“We’re also born and raised in this notion of linearity and positivity so that A plus B equals C. Whereas, real life is messy, it is unpredictable, and we need to settle into that uncertainty and unpredictability if we are to get further faster.”

DMacA: An aspect of that is the integration with primary care, and primary care doctors would say that they focus on personalized coordinated care. How does that fit with your model of integrated care?

AC: In the work that I’ve been doing, when you ask individual clinicians about how they provide care, the answer I get all the time is “sure, aren’t we doing that anyway”. Unfortunately, I wish that were true. But when we look at the evidence, and when we study how we’re currently providing our services, we’re not. I think it’s really important that we acknowledge that. There are some pockets of really good care and, when you talk about primary care, I immediately think about Ghent and the work of a Professor Jan De Maeseneer. (https://medicsvoices.com/jan-de-maeseneer-a-primary-care-leader-in-europe-africa-and-the-us/). The man is a legend. I’m a complete Jan fan. If everyone in the world could receive Primary Care the way Jan De Maeseneer and his team provide it, our patients would be happier, families would be happier, we as clinicians would be happier.

There are lots of really good examples of how to do this really well but, unfortunately, most of the time when we look at the evidence, it is disintegrated care, it is fragmented, and it’s certainly not organized around the needs of the people we proport to serve.

DMacA: That brings us back to one of your other interests and that is system change. How do we make that happen?

AC: Ah that’s the’ $64,000 question’. The IFIC nine pillars are, I think, a useful way of thinking about the areas that we need to consider when we’re thinking about integrated care. I’m going to concentrate just on integrated care and maybe then briefly touch on systems because, when integrated care happens in human systems, it happens for human beings who are human systems. So, the nine pillars are a very useful framework or a tool. These the things that we need to think about.

We’ve already touched on the need for a shared vision and purpose around what it is that we’re doing when we’re thinking about any change initiative.
And then we need to think about that happens within a population health context and also in unique contexts. We can have a whole discussion on what context means but everyone has an innate understanding of context, so it is really important that we think about context.
The next area that’s really important is of people as partners in their care. And, meaning that, rather than this is what we’re going to do to you or here’s the thing that we’re going to plan to do. A real partnership co-production so, true partnership.
Then, resilient communities. I know resilience is a real buzzword at the moment but resilience is really important and especially within the context of our communities. And looking at the roles of those third sector organizations and all those community-based assets that we have that we are not utilizing to their full potential to support our neighbours and people in our neighbourhoods.
Then, of course, our workforce. Have we got a workforce that’s designed for modern healthcare? No. We’re still being educated in disciplinary silos. We really need to bring those worlds together because at the moment we magically expect people to come out of their undergraduate career and work in teams. We need to do a lot more about interdisciplinary education at an undergraduate and a postgraduate level.
System wide governance and leadership. We talk about leadership a lot without clearly articulating what that means. I look at leadership as a group endeavour with people that are working together towards a common goal. That’s leadership. Not this notion of traits and born leaders and that nonsense. That needs to be consigned to the pages of history.
The importance of digital. In our health system, we are really stymied by the lack of the ability of our information systems to connect together, or even to have information systems in the community. GPs are really good. Over 90% have got one computer system that they use that doesn’t talk to anyone else. So how can we use digital to help. It’s the glue and the grease of integrated care and any other type of care.
And, the payment system. We currently fund our health and care in silos. What more can we do better together if we do not only align but truly integrate our payment systems.
The last is, of course, learning systems, transparency of results. Sharing knowledge, sharing information in real time is about – how is it for you as utilizer of our healthcare services. How is it for me as a provider of those services. How is it from a KPI point of view. How is it from the point of view a carer or family member. There are tools and approaches that you can take to have access to that type of information in real time. There are just very few organizations and entities that are brave enough to be willing, to be curious enough about that type of data in real time. To me that could be truly transformative, if we are courageous enough to take that step.

So, how do we do that. We’re also born and raised in this notion of linearity and positivity so that A plus B equals C. Whereas, real life is messy, it is unpredictable, and we need to settle into that uncertainty and unpredictability if we are to get further faster. And, if we do that and we’re curious and we’re getting all sorts of data to inform the decisions that we’re making then, I believe, that will really transform not just how we think about health and care but how we really embrace all of our citizens and residents in our different countries, and make the very most out of the resources that we have, and treat all of our assets as really precious, and bring those things together. If we do that, and if we are willing to develop those types of relationships and trust people, then something really magical could happen. And where you have those ingredients, and where you have that curiosity and that openness and that understanding of the complexity of health and care systems, then that’s where you see that those magical results emerging from people who are curious and open and willing to do things differently.

“The future is unpredictable. Complex adaptive systems theory recognizes certain principles of certain systems so, in its simplest form, you can divide systems into complex physical systems and complex adaptive systems. Complex physical systems respond to the usual laws of physics but, complex adaptive systems absolutely don’t. So complex adaptive systems are more organic natural systems like human systems.“

DMacA: I love the idea of this circular orbit of integrated care with primary care on one side and slightly semi-detached but on the other side and drawing on that is government policy. I’m interested in how government policy is can affect this and I know you have particular interest, because you have written, for example, about government policy on road safety and how affected your own work.

AC: In countries where they have had policy around integrated care you can move things further faster because you can say- here is the policy, this is government policy. Interestingly, I was just talking to a colleague from Lithuania and their Ministry has now got an integrated care policy and they see that as a huge lever for change. But, having said that, in Ireland we started doing integrated care programs without policy. The policy followed, the Sláintecare policy (https://www.gov.ie/en/campaigns/slaintecare-implementation-strategy/) followed the work that we had already started in the integrated care programs. It’s good that we’ve got cross party agreement about the need to move things into the community and to become more person centred. Politics can be a barrier but it can also be a very key enabler.

And, to talk about road safety, that was a huge game changer from a road safety point of view. There are issues with the numbers at the moment, we can’t deny that, but that takes me nicely back to complex adaptive system. Yes, it was fantastic that the numbers came down but then you need to adapt to the changing circumstances and think- okay, what do we do next, how do we adapt to these changing circumstances, what is it that we need to stop doing, what do we need to start doing that we haven’t thought about, and the technology in any health care system, including road safety. The technology is mindblowing. It’s absolutely extraordinary what can be done to vehicles to make them much safer, to help support you as a decision maker driver, and about the things that you do. We need to work with that technology to see how that works.

But the other thing, from a road safety point of view, is a five point belt. I think everybody should have a five point belt.

“… we’re still really attached to the notion that there’s a quick fix, there’s a simple solution, when there is not a simple solution to a complex problem. We keep looking for a consultancy firm or some ‘guru’ that’s going to give us this silver bullet. There isn’t a silver bullet. We need to embrace that uncertainty and that complexity and have that curiosity and that learning, thinking about what data we need, how are we going to collect it. “

DMacA: Let me bring you back to the integrated care because you described a beautifully organized structure and organization for integrated care but, you know what I’m going to say now… I know you are interested in complexity theory, which means that we have no control over this whatsoever?

AC: I wouldn’t quite say we have no control. The future is unpredictable. Complex systems theory recognizes certain principles of certain systems so, in its simplest form, you can divide complex systems into complex physical systems and complex adaptive systems. Complex physical systems respond to the usual laws of physics but, complex adaptive systems absolutely don’t. So complex adaptive systems are more organic natural systems like human systems.

Rika Preiser and colleagues in Stellenbosch University (https://www.ecologyandsociety.org/vol23/iss4/art46/ ) brought all the key ideas from a complexity point of view together and she pulled out certain organising principles, that I tried to add to in a literature review but I couldn’t because, actually, she had nailed it. She describes six principles, three structural, three process-ual. The three structural are that we’re constituted relationally and are radically open. So, like human beings, we are relational. No man is an island, as the saying goes. We work in human systems, we’re in families, we’re in work groups.

And, that they are constituted contextually. So, context is really important. Your context is unique, my context is unique, and our shared context can be quite similar but it has its own differences. You’ve got the structural, and the process-ual. They’re adaptive, they’re dynamic and when human beings interact with each other something very special can emerge from those interactions that’s not linear. It’s nonlinear so it can be quite dramatic. How we responded to Covid is, I think, a really nice example of that nonlinear response.

The health care system and human systems comply with those principles and, as you say, it does mean that the future is unpredictable. However, what we can do is to be curious at this moment in time, about what’s happening at this moment in time, and we can make sure that we are receiving data in all its forms to make the best decisions that we can. And, if we start to do that, we will start doing very different things. But, we’re still really attached to the notion that there’s a quick fix, there’s a simple solution, when there is not a simple solution to a complex problem. We keep looking for a consultancy firm or some ‘guru’ that’s going to give us this silver bullet. There isn’t a silver bullet. We need to embrace that uncertainty and that complexity and have that curiosity and that learning, thinking about what data we need, how are we going to collect it.

But key, and this is the big gap, is it’s not just about collecting it, it’s responding to it. What actions are we going to take. And, my experience of health care systems around the globe is that’s where we get stuck.

DMacA: Can I bring you to on to another area, to address very briefly another of your areas of interest, women in medicine and the gender change in medicine, which again requires systems adaptation.

AC: It certainly does. I am Secretary and Vice Chair of the ‘Women in Medicine’ group (https://www.wimin.ie/) which is led by my fabulous colleague Sarah Fitzgibbon. It was founded to try to address some of the issues that we had identified. Back when we started, I looked at the data from a number of different data sources and I looked at the transition of women in medicine from undergraduate to postgraduate. We have more women than men studying medicine at undergraduate level but, a couple of years postgraduate, that’s when you really start to see the changes in terms of the choices that women make and the opportunities that they are afforded. And why is that? Because women are not encouraged in certain disciplines.

The College of Surgeons in Ireland, for example, are doing a lot of work to try and address the gender issues in surgery but there are many other areas that need attention.

“there is accumulating evidence that female surgeons’ outcomes are better than males. I know that there are lots of hot debates about the data but I think there is enough accumulating data that we really need to be having grown-up conversations about why that is.”

With career progression, women drop out, so that you end up with a male top heavy situation especially at consultant level. It’s more balanced in general practice which is really to the good of general practice. Big thumbs up for general practice. But, we have a job of work to do in hospital medicine specialties. And, we cannot deny the fact that there is accumulating evidence that female surgeons’ outcomes are better than males. I know that there are lots of hot debates about the data but I think there is enough accumulating data that we really need to be having grown-up conversations about why that is. Rather than fighting about it, we need to think, that’s really interesting, why is that, and try to understand why that is the case. Initial evidence would say that women are more likely to comply with guidelines and with checklists and with evidence informed practice than males. That’s an interesting finding, so let’s explore that in a bit more detail, and look at how can we use that information to support all our trainees, not just at postgraduate level, but also at undergraduate level. Let’s talk about this stuff. Let’s be really honest about what it is that we’re doing and, let’s also be honest about how decisions are taken about career opportunities.

Let’s open our medical careers to everybody, not just from a gender point of view, but embracing diversity in all its rich colours, because we represent and we look after a population that is hugely diverse and a wonderful rich tapestry of humanity. Medicine should reflect that as well. We should make it as rich and as colourful as the environment and the citizens and residents that we serve.

DMacA: Áine, it’s always inspiring to hear you talk. Thank you. Its been an absolute pleasure totally to you today.