Brian Niven, Management Consultant at Mott MacDonald, discusses how the KSA clusters should examine the delivery of healthcare services through a strategic whole systems approach
Health clusters across KSA are being implemented to develop an integrated local network of healthcare providers under a single administrative structure. As such, the responsibility of these clusters will extend across primary care centres, general hospitals, and specialised services ensuring that beneficiaries within that cluster can access the required services through a single integrated administrative system, which is ultimately responsible for the leadership, strategic direction, management and governance of healthcare service design and delivery.
Moreover, these clusters will be responsible for having a focus on holistic, preventive care rather than solely on curative and treatment approaches. The overall aim is to deliver a modern model of care through managing the health needs of their community that achieve the highest levels of outcomes in terms of quality, efficiency, and prevention.
This ambition for the KSA health clusters provides a direction of travel, which is being mirrored across many other jurisdictions globally. It recognises that, within an overall framework for delivering care across the country, there is a need for a local focus on meeting the specific needs of communities and working with a range of stakeholders to achieve the best health and wellbeing outcomes for that population.
As an example, in 2023, the National Health Service (NHS) in England restructured its governance for delivering healthcare and improving local health outcomes. Integrated Care Systems (ICS) were introduced which have a similar aim to the newly developing KSA health clusters and, whilst serving a catchment population which is typically larger that the KSA health clusters, these ICS’s are now organising themselves into Placed Based approaches which provide a more localised planning for health and care services between different parts of the healthcare system and its external partners. This integrated systems approach is also well established in other developed nations of the United Kingdom and elsewhere globally.
So, given that this direction of travel for organising, managing and delivering services at a localised level has already been embarked upon by others, what are the key lessons that the KSA health clusters could learn to avoid any potential pitfalls through the implementation of their own journeys?
The need to focus on health outcomes
Findings from studies on ICS programme development over their first year of operation, including The King’s Fund report on the early precursor to ICS development, found that organisations spent the majority of their initial time building the foundations on which to improve health and care for their populations, including governance, leadership and staffing, and engaging with a wide range of stakeholders. Many also spent much of their time learning about systems working, including the need to lead differently to deliver their ambitions. Whilst there is service pressure across most healthcare entities within the health and care systems, the report found that there had been a focus on strengthening and integrating primary care and community services, and reviewing how specialist services are delivered in some areas.
The findings of the report are not entirely surprising and, as with the UK, time will be needed to allow the KSA health clusters to find their feet, establish their internal systems and processes, develop their governance structure and reporting mechanisms, and to develop their leadership to work differently, moving from independent provider organisations to more collaborate work systems.
However, prevention and the focus on achieving health and wellbeing outcomes and reducing health inequalities are missing through this new localised systems development. Healthcare systems are complex and improving integration and introducing new ways of working takes time, but the focus should be on health outcomes and not solely on healthcare outcomes.
Therefore, from my perspective, it would be important for the KSA health clusters to define early on their strategy and the direction of delivery for both population outcomes and services. This means addressing health inequalities and developing systems which best support individuals and communities. As such, it will be necessary to develop strategies and plans that shift the focus away from bricks and mortar of healthcare infrastructure and towards targeted investments into preventative services and sectors, which will have a more lasting impact on people’s health and wellbeing.
If this process is delayed or prolonged, or if there is an early focus on addressing current healthcare service delivery challenges with short-term fixes rather than a clear long-term preventative strategy, there is a risk that the KSA health clusters will remain trapped in this cycle. Future decisions and investments will end up being made around fixing existing current infrastructure and delivering incremental performance improvements to existing service models.
It’s like moving home: unless you begin the process to decorate or refurbish within the first few weeks, all your furnishings and fittings now fill the space and it becomes all the more challenging and difficult to be motivated to change.
Whole systems approach
Yet change is needed if the health clusters are going to deliver improved outcomes for the health and wellbeing of its beneficiaries and deliver long term sustainability. There is a need for a more radical shift in how health and care is planned and delivered, recognising the rapid advances in technology and medicines. There is also the shift in how individuals wish to engage and access care services, and their preferences in what works best for them in meeting their health and wellbeing needs. This means that the traditional approach to planning for health and care services needs to be completely rethought.
The health and wellbeing of communities and individuals is wrapped up into a complex system. The social determinants of health clearly show that the impact on individuals’ health and wellbeing is largely driven by the influence of a range of other sectors, including housing, education, employment, social infrastructure, finance and personal behaviours and attitudes. In fact, access to good quality healthcare is responsible for only around 15-20%. So if the KSA health clusters want to deliver outcomes that improve the health and wellbeing of its beneficiaries, it needs to work very differently and seek to engage more widely than solely across the healthcare system. While this system is important and will need careful planning, it should be seen as a sub-system within a larger system of systems, involving many stakeholders and sectors that are not typically considered in discussions about health and healthcare.
This whole system approach is the key to improving health and wellbeing outcomes and reducing health inequalities between individuals and communities. This means:
• Defining the changing future population demographics and underlying health needs
• Deriving the health and wellbeing outcomes to be achieved and by when
• Identifying those sectors and stakeholders which impact on communities and individual’s health and wellbeing
• Engaging to assess these sectors’ future policy and strategic direction and plans
• Developing a comprehensive map of the levers and impacts within these plans that affect population health, and assessing how to maximise positive influence or minimise negative impact.
• Using evidence-based literature and observational outcomes to model the potential impact and timeline of these levers, as well as impacts on health and wellbeing outcomes
• Assessing the subsequent impact over time of these lever impacts on the future profile of demand for healthcare services
• Developing the evolving models of care and service models that will manage this demand and converting this to healthcare capacity requirements
• Mapping this healthcare capacity requirement to infrastructure needs
• Defining the gap in future infrastructure needs and planning for future capital investment.
• Scenario testing of healthcare capacity requirements across this timescale and identifying any short terms pressures.
All this is not easy and should not be under-estimated. Yet globally, if we are ever going to improve health and wellbeing outcomes, it is only through undertaking such detailed exercises that we can truly aim to deliver a whole systems approach that improves health and wellbeing for our populations. It is vital to properly size healthcare infrastructure to support those whose care needs cannot be met by preventative strategies.
This approach is a bold and radical step. But unless we start to plan for health and wellbeing outcomes from the population perspective rather than the traditional route of assuming a ‘left shift’ from hospital care into alternative primary healthcare and community care settings, we will never achieve the goal of holistic, preventive care.
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