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Sometimes it seems that the hospital is the health system. Whether in popular culture, such as the American television series ER, in political and popular discourse, with its focus on opening and closing of hospitals, in statistical databases that give prominence to numbers of hospital beds, or in budgetary breakdowns, showing that the bulk of health service spending is concentrated in hospitals, it is clear that the hospital is seen as being at the heart of the health system (McKee & Healy, 2002). Even when the many other components of the health system are recognized, the hospital typically sits at the top of the pyramid. This is perhaps inevitable. Hospitals are highly visible. They are large buildings, well signposted, and adorned with the symbols of health care, such as red crosses. When politicians wish to make a statement on health services, they typically find a convenient hospital as a backdrop. Hospitals are also important for the public, not just when they are ill, but by providing reassurance that they will be cared for nearby if they become ill in the future. They play other roles too, as settings for the education of the next generation of health workers and through their contribution to the local economy. So even though they are only one part of the overall health system, they are an important part, and are recognized as such by almost everyone.
Almost every aspect of society today has been shaped by technological developments. Take the nature of the modern state. The historian Philip Bobbitt describes how the introduction of gunpowder to Europe rendered the medieval city states, protected by high walls, obsolete. Gutenberg’s invention of the printing press, allowing for the cheap distribution of information to the masses, paved the way for the Reformation and later for revolutions. The discovery of magnetism, and thus the compass, made it possible to establish global networks, enabling exchange of people and ideas and, ultimately, the system of international trade that prevails today. The invention of the steam engine, powering both railways and mines, paved the way for the industrial revolution and, with it, the growth of major cities. These examples illustrate how technological advances have created huge societal changes that rippled out into further cycles of innovation, driving the shift from local feudalism to a global post-industrial society.
As the notion of person-centredness of health services and systems is becoming more established in national and international policy declarations and commitments, there is a need to better understand and clarify the use and usefulness of relevant strategies and approaches that seek to improve the position of individuals, their families and communities in the health system.
This book takes as a starting point the various roles people take in health systems, while recognizing that these roles overlap and may be performed simultaneously (see Chapter 1). Indeed, as Coulter (2002) suggested, the 21st-century health service user is at once “a decision-maker, a care manager, a co-producer of health, an evaluator, a potential change agent, a taxpayer and an active citizen whose voice must be heard by decision-makers” (p. 6). Viewed through this lens, a greater person focus can contribute to advancing equity, efficiency and the responsiveness of health systems.
Overcoming care fragmentation remains among the key challenges facing health systems globally (Nolte & McKee, 2008; Saini et al., 2017; Schoen et al., 2011). This has become particularly acute against the background of a changing disease burden and the rising number of people with multiple health problems. Policy-makers have recognized this challenge and countries are exploring new approaches to health care delivery to enhance the coordination of care and so better meet the needs of those with chronic and multiple health problems and optimize service use (Nolte, Knai & Saltman, 2014; Wodchis et al., 2015; World Health Organization Regional Office for Europe, 2016). The focus has tended to be on the service provider side, with the introduction of innovative care models such as through strengthening multidisciplinary team work, the use of care coordinators or case managers, co-location of different providers, and shared pathways, among other developments (Nolte & Knai, 2015).
As we have seen in the introduction to this book, there remains a lack of consensus about the actual meaning of patient or person ‘centredness’ in the context of health systems. There is considerable overlap with concepts such as ‘empowerment’ and ‘participation’. Some view empowerment as a core principle or dimension of patient-centred care (Docteur & Coulter, 2012; International Alliance for Patients’ Organizations, 2006), while others define centredness as a foundation or prerequisite for achieving empowerment (Castro et al., 2016; Lhussier et al., 2015).
A wide range of reviews have been carried out over the past two decades to better understand patient- and person-centred care and related concepts.