PUB - Publikationen an der Universität Bielefeld

Western economies are facing unprecedented challenges in terms of healthcare management and funding. It is believed that one way forward is a stronger emphasis on primary and community care, rather than on hospital and specialist care. This transfer of responsibility is at the core of the idea of substitution. Substitution means thinking about where, by whom and how health services are delivered in the first place, and which setting, which professional and which communication medium can alternatively contribute to care delivery.
This cumulative dissertation proposes to synthesise and discuss findings from a series of 5 publications which explored the conceptual model of substitution with a focus on complex interventions and models of care in secondary and primary care, and at the interface between the two. Methods used are evidence synthesis approaches, international comparisons of health systems, case studies, qualitative expert interviews and economic modelling. All the publications included bring an international perspective to the research question. They focused on different points of the care continuum and different levels of the healthcare system.
We found that carefully designed and implemented substitution interventions are often effective, have the potential to be cost-effective, and are likely to improve patient experience. We also identified unintended outcomes, when substitution incurred an increase in the use of secondary services, or increases in waste or costs to the health system. As with all complex interventions, substitution does not “simply” require to transfer the delivery of care to a new setting, a new provider or to change the way care is delivered. A range of support tools, guidance materials and infrastructure are needed to ensure successful change. Education, support and mentoring are important. Substitution also requires a certain degree of coordination and therefore integration between providers and can be enabled by integrated or linked IT systems. Barriers to substitution include the lack of appropriate skill mix, fragmented health systems and siloed organisation of care and a lack of aligned incentives across providers.
Primary care-led multi-professional organisations appear as the best environment to promote, test, and validate substitution interventions. Such units take different forms and shapes across different European countries but have in common a flexibility with regard to duties and minimum set of services provided, and with regard to human resources management and composition of skill set. They are small units run by community-based providers and locally governed. An emphasis on primary care-led health centres would create the most fertile environment for timely change and intervention implementation.