On networks and silos


A brief comment this morning, as I’m struggling with sinus problems and hayfever (oh the joys of spring!).

I was thinking about the need to develop networks between groups of health providers working in different settings and different systems.  It seems sensible to me at least that we should be aware of what other providers have available within our communities – at least so we know the options for the people we are working with, even if we can’t directly refer to those providers because of funding issues.  But this is a vexed question because I work in a public facility, and traditionally the relationships between public and private facilities in New Zealand have been at arms-length.

The managers of public facilities seem to view private practices as places of lush finances where money is no object and therefore somewhat suspect.  At the same time, private facilities look at public clinics as places where efficiency isn’t necessary because there is a steady flow of money coming in from Government…

Of course my experience might be a little idiosyncratic, but having worked in both public and private facilities, I find that private organisations seem able to justify spending money in order to be efficient, effective and to support their staff to achieve goals – simply because if the organisation isn’t efficient and effective, it will go out of business.  Superficially at least, it seems much easier to get funding for training, equipment such as, for example, computing and data projection, biofeedback, workbooks – the tools of my trade!

Public organisations run on the bare bones of people’s good will.  There is inefficiency but it’s borne not from clinical lack of efficiency, but simply because of the size of the organisation and the multiple layers upon layers of attitude and accounting and policy and – well, let’s face it, it’s hard work making change or doing things in an innovative way in a large public organisation.

One of the things that makes me most frustrated is the silo mentality that occurs in public health facilities.  For example, it might be wonderful to hold a clinic for a group of patients with pain who are typically seen within, for example, orthopaedics.

A good example would be people having limb amputation.  Even though it would make sense to have a team from a chronic pain management centre become involved from early on in the person’s management (knowing that a majority of people with amputations develop phantom sensation and often phantom pain) – this can’t happen.  Why? Because there is no funding –

Who would pay for the chronic pain team to become involved – the orthopaedic team?

No, the patient ‘belongs’ to orthopaedics, and they are funded simply for the surgery and immediate rehabilitation.

Unless they happen to have thought about developing their own pain management service, and out of their budget pay for someone to see the patient, there is no-one to pay for the services of the chronic pain team.

The chronic pain team can’t simply ‘donate’ their time to the Orthopaedic Department, because this means loss of time and availability to see patients referred to the Pain Management team.

Oh bother.  And of course, the patients can’t be referred by the orthopaedic team to the pain management team without relinquishing control (and funding) for their patient.  Somehow integration doesn’t happen easily.

Of course, you could replace ‘orthopaedics’ with ‘oral health’ or ‘women’s pelvic pain’ or ‘non-cardiac chest pain’ – and pain management could be any other service accessed across traditional diagnostic or ‘body systems’ lines.

I’m not sure of the best way to change this – but at some point, someone will need to see that allocating budgets in silos isn’t good for patient care, and that networks between organisations with different cultures and attitudes will lead to changes that may just benefit the people we work with.

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