1 00:00:00,480 --> 00:00:09,060 I'd like them to welcome our first speaker, who is Laurel Hicks, and Laurel is a research fellow at the Oxford Institute of Population Ageing, 2 00:00:09,060 --> 00:00:14,550 and she's got over two decades worth of experience in working in this field. 3 00:00:14,550 --> 00:00:21,630 Her particular interests, acute and long term integrated care service delivery models and financing. 4 00:00:21,630 --> 00:00:27,360 So three public sector and private sector models are both very, very important areas for us to consider. 5 00:00:27,360 --> 00:00:34,740 If we're thinking about old age psychiatry, I must say particularly intrigued that she's also worked in the office of the president and in America. 6 00:00:34,740 --> 00:00:41,310 So I think that sounds sounds great. And I'm imagining all sorts of the West Wing in all its glory. 7 00:00:41,310 --> 00:00:46,980 And what you might think of that. See, that probably probably just have to talk to you over coffee to find out about that. 8 00:00:46,980 --> 00:00:59,020 But you're very welcome. So thank you. I'm interested that you started the introduction by saying, you know, I really like what I do. 9 00:00:59,020 --> 00:01:13,290 It's really interesting. And I think that that's an important message because I got into ageing in 1983 and I really like what I do. 10 00:01:13,290 --> 00:01:17,640 I've done I've been able to do some really interesting things in the field. 11 00:01:17,640 --> 00:01:29,730 And so I you know, to the extent that this is this is the talk about opportunities, career opportunities, this is this is a good one. 12 00:01:29,730 --> 00:01:41,730 So as Charlotte said, I I'm a research fellow here and I've had academic appointments here in Australia and in the U.S. and 13 00:01:41,730 --> 00:01:47,070 about half of my time I've been in academia and half the time I've been in public policy and which is, 14 00:01:47,070 --> 00:01:54,210 I think, a little bit more common in the U.S. than it is here and in Australia, because what happens, at least in my field, 15 00:01:54,210 --> 00:02:02,160 which is health policy, is that when a president comes in that has as part of his, 16 00:02:02,160 --> 00:02:06,000 you know, what he wants to accomplish during his time as health reform, 17 00:02:06,000 --> 00:02:12,420 then all the people who have been sort of hiding away and think tanks and universities, 18 00:02:12,420 --> 00:02:18,870 we all come out and we work for the president and try and do, you know, try and work our magic. 19 00:02:18,870 --> 00:02:24,420 And then when it fails, which is what happened when I worked for President Clinton as the health reform effort failed. 20 00:02:24,420 --> 00:02:30,270 And then we all go back and to think tanks and academia and so forth. 21 00:02:30,270 --> 00:02:40,170 So with that, the other thing is that I would like to slightly change my topic from challenges to challenges and opportunities, 22 00:02:40,170 --> 00:02:48,570 because I think that this field is wide open with with opportunities, not challenges. 23 00:02:48,570 --> 00:02:52,230 Always seems a little little heavy to me. 24 00:02:52,230 --> 00:03:03,090 First, I'd like to describe some of the demographic measures that are commonly used and then link them to specific policy, 25 00:03:03,090 --> 00:03:11,790 challenge public policy challenges. And I'm going to do this in both sort of a theoretical way because, you know, 26 00:03:11,790 --> 00:03:17,310 I think you need some grounding in people's beliefs and values in order to think about public policy. 27 00:03:17,310 --> 00:03:22,560 But I'd also like to give a really a very concrete example, both from my interest, 28 00:03:22,560 --> 00:03:29,130 but which sort of links into some of the some of the the future speakers. 29 00:03:29,130 --> 00:03:43,410 And I'm going to touch on three public policy areas just really, really lightly, sort of once over lightly of that are that are common in this area. 30 00:03:43,410 --> 00:03:49,230 It's the future financing of health care and the implications of an ageing population on that, 31 00:03:49,230 --> 00:03:56,940 a future financing of pensions, also a big a big public policy area and then labour force participation, 32 00:03:56,940 --> 00:04:00,780 both older people moving in and out of the workforce, 33 00:04:00,780 --> 00:04:07,890 but also the the labour force issues around having sufficient numbers of people to take care of older people. 34 00:04:07,890 --> 00:04:18,030 So the care sector and as a sort of an overarching theme or concern, 35 00:04:18,030 --> 00:04:27,270 I'd like to I'd like for us to think about all of this in the context of all of this social contract, 36 00:04:27,270 --> 00:04:31,620 this generational contract between workers and older people, 37 00:04:31,620 --> 00:04:42,990 and how public policy is about figuring out ways to share the burden and and and and our nation's resources. 38 00:04:42,990 --> 00:04:50,190 I mean, I think that's really the what all of this is about ultimately. 39 00:04:50,190 --> 00:04:58,230 So let's start with the first measure of demographic change, life expectancy at age 65. 40 00:04:58,230 --> 00:05:12,060 So hooray. Right. Fantastic, we've in the last 30 years, men live five years longer, women live four years longer. 41 00:05:12,060 --> 00:05:17,750 So now life expectancy is about 83 for men and 86 for women. 42 00:05:17,750 --> 00:05:23,790 Hooray. Right. And it's so interesting that so much of this is is not couched in hooray. 43 00:05:23,790 --> 00:05:26,910 I mean, I think this is amazing that we've made this sort of progress. 44 00:05:26,910 --> 00:05:37,140 And this is just in the last 30 years, you know, beyond a lot of the sort of issues of the past. 45 00:05:37,140 --> 00:05:45,870 But but again, you know, it doesn't always get met with that sort of response. 46 00:05:45,870 --> 00:05:54,780 So let's dig a little deeper, a little. Let's look at a maybe a slightly more meaningful measure of demographic change. 47 00:05:54,780 --> 00:06:03,990 And that's that all of those extra years that we added, they're not always healthy years, and that's where the public policy challenges come in. 48 00:06:03,990 --> 00:06:07,680 So instead of Harare, it's more like Umrah. 49 00:06:07,680 --> 00:06:18,090 We've half of those years, half of those extra years actually aren't aren't lived and in good health, mental or physical health. 50 00:06:18,090 --> 00:06:30,030 So a lot of policy challenges around that. They that after age 65, health care costs go up, social care costs go up. 51 00:06:30,030 --> 00:06:32,100 Well, actually, 52 00:06:32,100 --> 00:06:40,860 the I think it is important to say that actually what we're doing is delaying those costs more than than sort of having them go up the scare. 53 00:06:40,860 --> 00:06:44,880 Again, the scarcity of labour in the care sector really important. 54 00:06:44,880 --> 00:06:47,880 And so the big public policy challenge, 55 00:06:47,880 --> 00:06:58,710 the big goal of public policy is to increase that the share of those extra years that are lived and a healthy a healthy way. 56 00:06:58,710 --> 00:07:14,070 Third measure of demographic change is life expectancy after pensionable age and pensionable age being a slightly more meaningful term than age 65. 57 00:07:14,070 --> 00:07:21,390 Obviously, age 65 is kind of a social construct or a public policy constructed age. 58 00:07:21,390 --> 00:07:25,920 It's no reason why 65 is when people retire. 59 00:07:25,920 --> 00:07:34,110 So pension pensionable age is a little bit more fluid and a little bit more meaningful. 60 00:07:34,110 --> 00:07:41,220 So the challenges, when you think of it in the context of how many years are you going to live after you stop working, 61 00:07:41,220 --> 00:07:47,010 has a lot of implications for the cost of pension systems. 62 00:07:47,010 --> 00:07:59,100 And I think this next point at the bottom is that ageing ageing is in a lot of ministers portfolios, unlike other issues, 63 00:07:59,100 --> 00:08:06,840 say maybe education, which is fairly concentrated in one portfolio age ageing crosses a lot of boundaries. 64 00:08:06,840 --> 00:08:16,110 And so I think it's really important to while most of the challenges fall in health, labour and pensions, 65 00:08:16,110 --> 00:08:25,740 that the ageing population will show up in an awful lot of portfolios in Westminster. 66 00:08:25,740 --> 00:08:35,580 Now, the those extra years, I think it's also really important to think about in in a public policy way, 67 00:08:35,580 --> 00:08:46,020 is it not all of those years are are healthy and not everybody has the same sort of experience in terms 68 00:08:46,020 --> 00:08:54,420 of their and in terms of their physical health after retirement is kind of a harsh way of putting it. 69 00:08:54,420 --> 00:08:57,690 But death is death is not democratic. 70 00:08:57,690 --> 00:09:08,160 And so the physical health of someone and probably in our our sort of cohort, which would be a high grade occupation, 71 00:09:08,160 --> 00:09:19,560 the physical health of one of us at 70 is is approximately equal on average to the physical health of someone who's 62 and at a low grade occupation. 72 00:09:19,560 --> 00:09:27,960 In fact, in Australia, the differential between white, Anglo, 73 00:09:27,960 --> 00:09:38,940 older people and the Aboriginal population is is so endemic that the the eligibility 74 00:09:38,940 --> 00:09:45,690 to that eligibility age for benefits is actually 55 for Aboriginals instead of 65. 75 00:09:45,690 --> 00:09:53,400 They've just systematically, you know, said you can have benefits 10 years earlier than everybody else. 76 00:09:53,400 --> 00:10:02,550 These inequalities come from a lifetime of advantages, different differences and advantages and disadvantages from birth and death. 77 00:10:02,550 --> 00:10:09,090 And so sort of a really big public policy goal or a challenge is how do you 78 00:10:09,090 --> 00:10:14,460 redistribute resources at the end of life to make up for a lifetime of differences? 79 00:10:14,460 --> 00:10:19,830 That's a really, really big picture sort of public policy goal. 80 00:10:19,830 --> 00:10:30,690 The fourth measure, which you probably hear about a fair amount is this old age dependency ratio. 81 00:10:30,690 --> 00:10:34,710 And I think that, you know, again, this sort of harkens back to that, you know, 82 00:10:34,710 --> 00:10:41,580 the earlier comment that I made about the generational contact and sharing the burden and resources. 83 00:10:41,580 --> 00:10:50,250 How do you how do you how do you work that out? And so what you see here is that this old age dependency ratio, 84 00:10:50,250 --> 00:11:01,950 which is basically a ratio of working people to people who are retired today, you've got 25 working people support a way. 85 00:11:01,950 --> 00:11:11,340 Excuse me. Anyway, the ratio is 20, 25, whereas it's going to go up 70 percent in 50 years. 86 00:11:11,340 --> 00:11:18,900 So a lot more burden on the working people to support support old age. 87 00:11:18,900 --> 00:11:31,890 So part of this is is really how to how to look at the pension systems and the and Labour labour 88 00:11:31,890 --> 00:11:42,720 regulations and labour practises to to either discourage or encourage people to be part of the workforce, 89 00:11:42,720 --> 00:11:52,260 to stay in the workforce and into older age. So this is a fourth measure, this old age dependency ratio that you see, that you see quite a lot. 90 00:11:52,260 --> 00:12:00,330 And I actually think that as a measure, it's, you know, again, 91 00:12:00,330 --> 00:12:09,720 it's it's it's it's really attached to this sort of burden of of ageing sort of discussion, 92 00:12:09,720 --> 00:12:17,940 you know, again, talking about this in terms of a burden instead of hurray, we've got lots more people living, living to longer ages. 93 00:12:17,940 --> 00:12:22,540 It's the burden of workers and and who they need to support. 94 00:12:22,540 --> 00:12:32,670 So it's sort of a sort of an alarmist way of describing demographic change. 95 00:12:32,670 --> 00:12:39,030 And the other piece of this is that you need you really need to think about the other way. 96 00:12:39,030 --> 00:12:44,370 It's not all about economic formal employment. 97 00:12:44,370 --> 00:12:53,640 It's it's about some of the non-economic transfers that occur in society, grandparents taking care of their grandchildren, 98 00:12:53,640 --> 00:12:58,500 other sort of meaningful and productive activities that older people are involved in. 99 00:12:58,500 --> 00:13:03,960 I'm sure the AMA will be talking or perhaps we'll be talking about that in 100 00:13:03,960 --> 00:13:08,100 the context of the Alzheimer's Association and the sort of volunteer efforts. 101 00:13:08,100 --> 00:13:18,840 So this this this burden, I don't think I think it's more meaningful if you measure it, not just in economic terms. 102 00:13:18,840 --> 00:13:24,370 Now, there's also the public policy discussions are. 103 00:13:24,370 --> 00:13:26,950 Influenced by two things. 104 00:13:26,950 --> 00:13:38,470 First of all, it's sort of what's on offer, what are the what are the different policy changes and how how are they different options, 105 00:13:38,470 --> 00:13:46,270 how they play out, what their what their impact is in terms of efficiency and effectiveness in targeting and and so forth. 106 00:13:46,270 --> 00:13:56,590 But but the other thing that we that I'd like to sort of gloss over kind of quickly is that there are beliefs that undergird 107 00:13:56,590 --> 00:14:07,180 these discussions and and and and policy paradigms that do sort of drive the way people think about the public policy options. 108 00:14:07,180 --> 00:14:18,830 Not today. The sort of more popular policy paradigm is this active ageing paradigm where it says here from the World Health Organisation's definition, 109 00:14:18,830 --> 00:14:23,290 it's the process of, you know, optimising opportunities. Right. 110 00:14:23,290 --> 00:14:35,620 It's it's a much more holistic that that ageing is more than just working and being economically productive. 111 00:14:35,620 --> 00:14:44,360 It's about it's about enhancing quality of life. And it's probably one of the terms that you've heard or will hear is quality adjusted life years. 112 00:14:44,360 --> 00:14:48,040 You know, it's more than just about the economics of it. 113 00:14:48,040 --> 00:14:57,190 And this that policy, that active ageing paradigm has replaced the earlier paradigm, which is productive ageing. 114 00:14:57,190 --> 00:15:09,130 Like how how how much do you bring in terms of production to the to the the discussion here now 115 00:15:09,130 --> 00:15:19,570 the example of this sort of active ageing versus productive ageing paradigm played out in, 116 00:15:19,570 --> 00:15:32,140 you know, over the last 60 years or so in the context of the labour shortages or just the labour dynamics in in the UK. 117 00:15:32,140 --> 00:15:39,580 So one of the you know, I think that one of the things that raises the question of whether or not old age is as 118 00:15:39,580 --> 00:15:49,480 socially constructed and and and here the example that seems quite relevant is in the 1950s, 119 00:15:49,480 --> 00:15:52,270 what happened is there was there was a lot of labour shortages. 120 00:15:52,270 --> 00:16:02,410 And so the the there were a lot of government appeals to older people to, quote, not sink into premature old age. 121 00:16:02,410 --> 00:16:10,690 In other words, they're saying, please, we need you to stay in the labour market because there's a lot of shortages in the 1950s, by the 1970s, 122 00:16:10,690 --> 00:16:21,670 with rising unemployment, you know, the the reverse happened and there were all these appeals to people to retire, 123 00:16:21,670 --> 00:16:25,150 to free up good jobs for younger people. 124 00:16:25,150 --> 00:16:34,950 And that's probably a slightly more familiar refrain to to you all is this idea that the job release schemes get out, 125 00:16:34,950 --> 00:16:38,770 make opportunities available to to younger people. 126 00:16:38,770 --> 00:16:46,990 So so the you know, what's interesting is that, you know, 127 00:16:46,990 --> 00:16:54,280 your experience with older age seems to be at least somewhat constructed by the needs of the environment. 128 00:16:54,280 --> 00:17:04,320 Do you do you want me to work or do you not want me to work? And the and the active ageing paradigm sort of says, let's create choices. 129 00:17:04,320 --> 00:17:08,710 So people who do want to work that the opportunities are there. 130 00:17:08,710 --> 00:17:17,860 People who don't want to work, they'll they won't fall into a situation where they you know, 131 00:17:17,860 --> 00:17:21,580 where they're impoverished and without resources and so forth. 132 00:17:21,580 --> 00:17:32,140 So creating meaningful, meaningful activities for people outside of retirement and supporting them, but not treating them as a homogenous group. 133 00:17:32,140 --> 00:17:40,030 The eight, the elderly. Interestingly, you might you might have a different perspective on that as we start the day. 134 00:17:40,030 --> 00:17:48,820 Perhaps by the end of the day, you'll realise how heterogeneous older people really are. 135 00:17:48,820 --> 00:17:58,150 Now, the the other thing that will be discussed and a bit more later in the in the day is this 136 00:17:58,150 --> 00:18:07,780 notion that also that active ageing cuts across a lot of interrelated policy areas. 137 00:18:07,780 --> 00:18:16,030 And I had sort of talked about health policy and social care policy and pension policy and and so forth. 138 00:18:16,030 --> 00:18:25,330 But the but the the important point is that if we really want to. 139 00:18:25,330 --> 00:18:31,330 Increase those extra years in terms increase the sort of good physical and mental health 140 00:18:31,330 --> 00:18:37,030 and those extra years that you really need to look across quite a few boundaries. 141 00:18:37,030 --> 00:18:43,480 A lot of policy boundaries to to to achieve that. 142 00:18:43,480 --> 00:18:49,420 And I'm going to elaborate that on that. And in the next couple of slides, 143 00:18:49,420 --> 00:18:59,050 and this is sort of a topic sort of near and dear to my heart is how hospitals and GP practises and nursing homes and community care, 144 00:18:59,050 --> 00:19:06,460 how those things work together, how the acute and the long term care systems work together. 145 00:19:06,460 --> 00:19:09,760 Now, why do we know why is there a push for this? 146 00:19:09,760 --> 00:19:21,250 Besides just demographics, the chronic health conditions are becoming much more prevalent amongst amongst the young and and the old. 147 00:19:21,250 --> 00:19:27,280 So all these, you know, heart disease and stroke, cancer and so forth are all much more prevalent. 148 00:19:27,280 --> 00:19:34,660 But what's really interesting about chronic disease, as opposed to the more acute types of diseases, 149 00:19:34,660 --> 00:19:48,850 is that these disabling conditions are are much more the outcomes of those conditions are much more dependent on the, 150 00:19:48,850 --> 00:19:56,980 you know, sort of what's what's around them said things like vulnerability in terms of frailty, social isolation, 151 00:19:56,980 --> 00:20:05,170 mental mental illness and lots of other social advantages really exacerbate chronic care conditions. 152 00:20:05,170 --> 00:20:11,470 And so you can't really separately treat the chronic condition without looking at the context that it's occurring. 153 00:20:11,470 --> 00:20:23,260 And so it's, again, this sort of the need for a more holistic view when you're looking at when you're looking at chronic conditions. 154 00:20:23,260 --> 00:20:30,580 And a lot has been written about about acute and long term care and how they don't work well together, 155 00:20:30,580 --> 00:20:40,420 how people are are are left in hospital beds because it's hard to discharge them to care homes. 156 00:20:40,420 --> 00:20:42,940 Why people aren't getting the sort of care they need. 157 00:20:42,940 --> 00:20:50,020 Some of the acute services they need in a care home wind up in hospitals, you know, that sort of thing. 158 00:20:50,020 --> 00:21:00,280 And and, you know, again, thinking about that active ageing paradigm, is it ultimately this journey, patient journey? 159 00:21:00,280 --> 00:21:07,330 What a lot of people now are talking talking about in the context of person centredness 160 00:21:07,330 --> 00:21:15,130 is that patients should be actively involved in their decisions and in their journey. 161 00:21:15,130 --> 00:21:23,860 And then how? As a chronic condition, as a person with a chronic condition, how how this will play out. 162 00:21:23,860 --> 00:21:27,880 This is especially true, I think, in the end of life care. 163 00:21:27,880 --> 00:21:36,940 And and too often and these are some quotes that I had read from the from the UK press about how the NHS operates, 164 00:21:36,940 --> 00:21:43,690 that it revolves that care that revolves around buildings or historical practise instead of people. 165 00:21:43,690 --> 00:21:53,560 And that's the sort of sort of thing that really bumps up against the idea of active ageing and that patients often 166 00:21:53,560 --> 00:22:00,910 fit their needs and lives around services on offer rather than experiencing flexible and responsive systems. 167 00:22:00,910 --> 00:22:13,270 So these are the sort of sort of things that I you know, I pulled out of the press about how the NHS works and how it's in conflict with integrating 168 00:22:13,270 --> 00:22:20,830 health and social care and doing this around the needs of of the older person. 169 00:22:20,830 --> 00:22:33,820 Now, new developing new care models, innovation and so forth has dominated for decades the policy discourse and in and the UK. 170 00:22:33,820 --> 00:22:49,060 And I think it's quite interesting that the UK has taken this sort of let a hundred flowers bloom approach because they realise that local context, 171 00:22:49,060 --> 00:22:55,300 the talents of the strengths and weaknesses of local communities really matter a lot and 172 00:22:55,300 --> 00:23:03,400 trying to form and form new systems and that we really we really haven't figured out quite, 173 00:23:03,400 --> 00:23:13,660 quite how to do this. And so built into a lot of the efforts and particularly a relatively new effort in the UK, 174 00:23:13,660 --> 00:23:24,550 the innovation pioneers built into that as a process for evaluating the outcomes and then communicating what works and what doesn't. 175 00:23:24,550 --> 00:23:31,210 The communications strategy is very much a part of of, you know, these new, you know, 176 00:23:31,210 --> 00:23:42,090 hundred hundred flowers blooming around the U.K. But all of this, of course, the the devil is in the details. 177 00:23:42,090 --> 00:23:47,860 That's my that's always been my favourite term in the context of health reform. 178 00:23:47,860 --> 00:23:55,540 You might have these great ideas, but operationally, how they play out is really is really important here. 179 00:23:55,540 --> 00:24:01,030 So, of course, near and dear to my heart financing, how do you sort out the money? 180 00:24:01,030 --> 00:24:07,390 And and there's been a lot of discussion about pooling budgets, 181 00:24:07,390 --> 00:24:16,720 bringing together the acute or the health and the social care budget at the level at the level of the community. 182 00:24:16,720 --> 00:24:21,910 Quite a lot of counties are trying to do this because they see, you know, 183 00:24:21,910 --> 00:24:28,360 two different systems with two different pots of money that are that are funded in really different ways, 184 00:24:28,360 --> 00:24:39,790 whether they're local council taxes or coming from coming from the bigger central government. 185 00:24:39,790 --> 00:24:45,730 So, you know, getting the money right does involve as a first step, 186 00:24:45,730 --> 00:24:54,220 putting the putting the money that a person is eligible for together into a single pot and trying to figure out what to do with that. 187 00:24:54,220 --> 00:25:04,390 But it's also really important to to get the right incentives built in to the way the money flows out. 188 00:25:04,390 --> 00:25:15,730 And and ultimately, what you're trying to do is to provide for people the the right services and the least restrictive excuse me, 189 00:25:15,730 --> 00:25:23,290 least restrictive setting. So it's sort of like the downward substitution of care where you can take care of someone in the community. 190 00:25:23,290 --> 00:25:28,000 You should do that instead of having them go to a care home where you can take 191 00:25:28,000 --> 00:25:34,030 care of somebody in a rehab unit instead of in a in a more acute setting, 192 00:25:34,030 --> 00:25:37,390 you should try and do that and to align the incentives, 193 00:25:37,390 --> 00:25:44,950 the financial incentives in such a way that you can that you can achieve those those sorts of goals. 194 00:25:44,950 --> 00:25:57,130 And and it's really important that the financing system doesn't reward activities that may increase the incomes of the people, 195 00:25:57,130 --> 00:26:06,880 that you're not rewarded for providing more services, but instead you're rewarded for providing better outcomes. 196 00:26:06,880 --> 00:26:11,200 So one of the ways of doing this is, is through a capitated system. 197 00:26:11,200 --> 00:26:21,490 And, you know, I could spend the whole day talking to you about the sort of the technical difficulties of upsetting capitation rates. 198 00:26:21,490 --> 00:26:27,730 But so that's sort of the first the first level to me is getting getting the money straight. 199 00:26:27,730 --> 00:26:34,960 The second is is getting in place those mechanisms that help you integrate care 200 00:26:34,960 --> 00:26:41,470 and those involved care management and and also involve information systems. 201 00:26:41,470 --> 00:26:47,080 And there's a lot again, this is another hundred flowers bloom sort of thing. 202 00:26:47,080 --> 00:26:56,560 There's a lot of care systems, our care management systems and information systems that are there to support and 203 00:26:56,560 --> 00:27:04,180 to to help to help bring together the care needs in a sort of person centred way. 204 00:27:04,180 --> 00:27:12,910 But the couple of really important lessons to learn from from decades of experience in these areas 205 00:27:12,910 --> 00:27:19,180 is that it's really hard to try and fund those mechanisms to try and pay for those mechanisms. 206 00:27:19,180 --> 00:27:30,490 With savings, you really need to build into your reform money to buy an information system rather than saying we'll 207 00:27:30,490 --> 00:27:39,140 pay for it with the savings we get out of becoming more efficient and more effective providers. 208 00:27:39,140 --> 00:27:47,260 So that's kind of like one key lesson from decades of experience in and looking at care management systems. 209 00:27:47,260 --> 00:27:58,840 The other the sort of third key lesson that that I would sort of put forth to the UK in terms of trying to get get it right, 210 00:27:58,840 --> 00:28:08,650 get it like a really practical level. Get this, pulling the system of acute and social health and social care together. 211 00:28:08,650 --> 00:28:11,500 First of all, not everybody needs care management. 212 00:28:11,500 --> 00:28:23,530 Not everybody to to have a case conference on someone whose needs are very simple is is a waste of resources. 213 00:28:23,530 --> 00:28:35,590 What you. You really need to do is try and target people with complex needs, people whose needs cross boundaries, cross settings, 214 00:28:35,590 --> 00:28:49,210 a few of the groups of people who integrated care works best for or are frail elderly people who are eligible for nursing homes but are in care homes. 215 00:28:49,210 --> 00:28:53,740 But you're trying to keep who you're trying to keep in the community. 216 00:28:53,740 --> 00:28:58,630 HIV AIDS populations there needs cross a lot of boundaries. 217 00:28:58,630 --> 00:29:03,520 And and those are sort of groups that would be targeted to this. 218 00:29:03,520 --> 00:29:12,670 In the U.K., there's been a lot of focus on specific diseases and creating care pathways for specific 219 00:29:12,670 --> 00:29:22,210 diseases and and sort of standardising the way the way care receives its prescriptive. 220 00:29:22,210 --> 00:29:24,220 But it can be, you know, the checklist. 221 00:29:24,220 --> 00:29:32,290 You know, if anybody's read the Atul Gawande checklist book, you know, it sort of speaks to that sort of thinking. 222 00:29:32,290 --> 00:29:40,810 The problem, of course, is what happens when you have multiple conditions. So which pathway do you take or how do you how do you merge pathways? 223 00:29:40,810 --> 00:29:45,100 Because often people do have more than more than one condition. 224 00:29:45,100 --> 00:29:54,580 And and in terms of getting it right, I also think, again, going back to the aligning the financial incentives, 225 00:29:54,580 --> 00:30:02,560 but also getting providers to be thinking about outcomes, not to be thinking about the process so much, 226 00:30:02,560 --> 00:30:06,580 but say, how am I going to keep someone out of the hospital? 227 00:30:06,580 --> 00:30:11,690 How am I going to keep a nursing home patient out of the hospital? 228 00:30:11,690 --> 00:30:21,880 What what's the best way to do that and how to get the money sort of lined up to to achieve that sort of that sort of goal? 229 00:30:21,880 --> 00:30:32,680 And then this is the kind of the piece for you all is where did doctors fit into this this new these new care models? 230 00:30:32,680 --> 00:30:40,420 This is sort of the fourth lesson, the take home lesson from some of my experiences looking at these issues in Australia, 231 00:30:40,420 --> 00:30:48,490 but in particular some of the efforts that have been that have been done in the 232 00:30:48,490 --> 00:30:57,010 in the U.S. And I spent quite a lot of time following a model in the U.S. years, 233 00:30:57,010 --> 00:31:02,560 quite a few years ago. But a model that's actually expanded quite a lot. 234 00:31:02,560 --> 00:31:09,700 And it's really, really important that doctors behave differently in these sorts of models. 235 00:31:09,700 --> 00:31:16,810 And in the U.K., this is probably less of an issue than in the U.S. I think doctors in general just are. 236 00:31:16,810 --> 00:31:23,080 In fact, what's really interesting is that us this is in some of its more recent efforts, 237 00:31:23,080 --> 00:31:30,490 is trying to replicate what the UK already does, but to do it without having socialised medicine. 238 00:31:30,490 --> 00:31:38,380 So the culture change, this whole notion of working in a multidisciplinary in a multidisciplinary team is really, 239 00:31:38,380 --> 00:31:43,930 really critical to the active ageing, integrated care. 240 00:31:43,930 --> 00:31:50,830 All of these all of these sort of big pictures that you're trying to achieve involves a lot of behaviour 241 00:31:50,830 --> 00:32:00,460 change and and working together in teams and respecting the that when you're sitting around the table. 242 00:32:00,460 --> 00:32:11,200 And one of actually one of the great example in this this model in San Francisco's Chinatown is that they would have at the time, 243 00:32:11,200 --> 00:32:13,270 the care conference table. 244 00:32:13,270 --> 00:32:25,060 They would have the doctors and the nurses and the therapists, but they would also have someone who represented the transportation people, 245 00:32:25,060 --> 00:32:30,550 the people who brought brought the older people into this day health centre. 246 00:32:30,550 --> 00:32:34,360 And of course, this is San Francisco's Chinatown. 247 00:32:34,360 --> 00:32:40,540 And some of these older people were quite small and would live and walk up like would live on a fourth floor, 248 00:32:40,540 --> 00:32:46,210 walk up and and and some of the transportation drivers would literally pick them up, 249 00:32:46,210 --> 00:32:53,170 pick up the elderly and take them down the stairs and put them in the transport to bring them into the day health centre. 250 00:32:53,170 --> 00:33:04,300 And those transportation workers, those drivers could tell you a lot about that person just by picking them up. 251 00:33:04,300 --> 00:33:12,280 So here you are at a case conference and they'd say and, you know, transportation, what can you say about Mrs. X? 252 00:33:12,280 --> 00:33:19,180 And they they could actually have really meaningful input into she seemed more or she seemed less or, 253 00:33:19,180 --> 00:33:23,950 you know, when I looked at her house and it wasn't clean and it was always clean before and so forth. 254 00:33:23,950 --> 00:33:33,980 So so as the doctor sort of valuing the input of other disciplines is a really critical piece, a really critical lesson here. 255 00:33:33,980 --> 00:33:42,580 And again, I I'm going to I'm sort of sort of going to leave you with with a quote from from a paper. 256 00:33:42,580 --> 00:33:46,480 This is from this is 1994 and it is in the US. 257 00:33:46,480 --> 00:33:59,380 So or it's based on us doctors. But I think it's worth it's worth you know, just pulling out as a closing words is that, you know, 258 00:33:59,380 --> 00:34:11,350 a lot of physicians are uncomfortable not being the the pre-eminent or the dominant voice at the table. 259 00:34:11,350 --> 00:34:20,260 And that I'm sorry, but extra different is not paid to their rank, which is what we wrote. 260 00:34:20,260 --> 00:34:23,950 And I do think that this is much more of a US phenomenon than here. 261 00:34:23,950 --> 00:34:32,770 But the notion of of them being able to be members of a multidisciplinary team and to not be 262 00:34:32,770 --> 00:34:40,780 and to not and to have the sort of characteristics that that requires in terms of controlling 263 00:34:40,780 --> 00:34:48,930 resources and and and and letting the sort of financial incentives be part of the way 264 00:34:48,930 --> 00:34:54,820 they they make decisions as there is is really critical in terms of forming these teams. 265 00:34:54,820 --> 00:35:01,510 Those sort of characteristics are really are really key and things that you should kind of keep 266 00:35:01,510 --> 00:35:06,310 in the back of your head as you're as you're making decisions about moving into this area. 267 00:35:06,310 --> 00:35:10,620 So that turn it over fact. 268 00:35:10,620 --> 00:35:18,580 Sure. Thank you. I think it's very interesting what you're saying about integrated care and the role of the multidisciplinary team, 269 00:35:18,580 --> 00:35:25,360 because I think that's something that in psychiatry, especially old age psychiatry, we really hold dear to the core of our practise. 270 00:35:25,360 --> 00:35:29,590 So I think in terms of psychiatry, the and the integration agenda, 271 00:35:29,590 --> 00:35:36,520 I hope that we're slightly ahead of the curve compared to some of the more traditional specialities. 272 00:35:36,520 --> 00:35:41,290 I think what your total is very nicely onto Chris talk. Who's coming next? 273 00:35:41,290 --> 00:35:46,600 So you talked about integrated care and the need for services to be flexible and responsive. 274 00:35:46,600 --> 00:35:52,060 And I think you also with your sort of speaking about the finances and the other elements, 275 00:35:52,060 --> 00:35:56,110 touched on how political this area is and how there are so many people who have 276 00:35:56,110 --> 00:36:02,103 got a stake in deciding how integration should happen and what is the best thing.