Six lessons for a successful substitution of care

The healthcare landscape is changing. The number of people relying on health care due to chronic and/or complex conditions is steadily increasing. People continue to live at home for longer and after being admitted to hospital they return home as quickly as possible. In addition, technological developments and new views on illness and health are leading to a changing demand for care. The result is that some of the care tasks are shifting. This is called substitution of care. In practice, however, many substitution projects fail. In this blog we show why and what it takes to achieve a successful implementation.

What is substitution of care?

The Federation of Medical Specialists defines substitution of care as follows: “the deliberate and purposeful replacement of (part of) an existing facility with (part of) another type of facility, while continuing to perform the original function and doing so for a similar patient population.” In practice, this means that a shift is taking place, with low-complex basic care being provided in the first line (the district) and high-complex specialist care being provided in the second line (the hospital). Substitution of care can be organised in all sorts of ways: from medical specialists who give consultations in the neighbourhood to scaling-up and specialisation in the hospitals. And from nurse practitioners who take over certain tasks from the GP or medical specialist to teleconsulting between GP and medical specialist. There are plenty of initiatives, but – as mentioned – the vast majority fail prematurely. Getting substitution of care off the ground turns out to be a huge struggle.

Why do 80% of initiatives fail?

The majority of initiatives – however well intentioned – fail because the complexity of healthcare is not sufficiently recognised. Healthcare is not a supermarket. It is an industry in which life and death are at stake and in which various parties with divergent interests view problems and solutions from the perspective of their own perceptions. Healthcare includes many elements between which many relationships exist. As a result, problems often have multiple causes at the same time and everything interacts with each other. This means that if, for example, a problem causes a cutback at location A, this can lead to an increase in costs at location B. A consequence that was not foreseen, because the overview was lacking and there was too much focus on the company’s own situation. This is also shown in research. Studies show that common bottlenecks are: a lack of understanding of the problem, a lack of an integral vision, no common language, not expressing interests and no alignment in the areas of strategy, innovation and change management. All this is necessary to successfully break through the barriers of costing, legislation and regulation and data management in a substitution approach.

Six lessons for a successful approach

There are six key lessons that can significantly improve the success of substitution projects.

Lesson 1: To regulate is to fragment

We make policy on it and it’s settled’, that’s often what happens in the Netherlands. But if there is one thing we cannot do, it is make integrated policy. The Dutch ‘box-ticking’ policy leads to fragmentation and often to failure. Instead, we should strive for an integrated legislative framework and financing system for the prevention, care and welfare sectors. Healthcare will not become better or more patient safe if managers and policy makers set more rules, regulate more eagerly, or introduce more IT systems from their own silo. In fact, it is one of the biggest barriers in our healthcare system.

Lesson 2: One size fits no one

Successful substitution projects are standard customization, with an emphasis on customization. A method developed in Groningen and successful there cannot be implemented in Amsterdam on a one-to-one basis. All successful improvement processes are adapted to the local context and based on existing organisational networks between professionals. It is this ‘colour local’ that determines whether a substitution project will be a success or a failure.

Lesson 3: Make use of the intrinsic motivation of healthcare professionals

Innovation must come from within the primary process, otherwise there is no chance of success. When policymakers set change processes in motion, these rarely connect to the world of healthcare professionals. For example, consider together with a GP how more space can be created in the consultation room. Then you make the general practitioner enthusiastic to be able to realize substitution in the practice. By taking into account the drive of the healthcare professional, you increase the chances of success of substitution projects. Policy changes never have the same impact as clinically driven changes.

Lesson 4: crack the black box

International research shows that successful change processes are based on small scale, collaboration, mutual data exchange and a focus on the patient. The trick is to crack the black box. That is, reducing a successful initiative to small chunks – the magic ingredients that made it successful – and translating them into a different context. The patient is at the centre and each participant assumes the role that belongs to him/her. That is: the healthcare provider as he is trained for, the patient as manager of his own health and administrators and government creating conditions.

Lesson 5: Small is beautiful

Practice shows that large-scale initiatives sometimes have little or no effect, while small initiatives sometimes produce unexpected results. So start small in substitution projects, but have a broader plan ready at the outset. Think of three implementation strategies in advance. If the first one fails, you can immediately switch to the second. And make an integral business case in which you calculate the financial effects for each partner and also determine the social return on investment.

Lesson 6: Embrace a new way of working

Perhaps the most important lesson is that we need to embrace a new way of working, recognising the complexity of healthcare systems and understanding that change is unpredictable and takes time. The process is often tortuous and requires standard customization. For this we need smart, creative people who can think out of the box and in a holistic way, and who can see how various aspects fit together. People who can see through the layers and oversee the relationships between processes. This can help us initiate changes that benefit all parties involved and thus lead to success.

Download the free e-Book to learn what other steps are needed to make substitution of care a success.

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dr. Pim Valentijn

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