Silos in health care: how can we master them?

A friend of mine recently had a baby.  Let’s call her Amy.  She lives in one of Australia’s many quaint country towns.

This week, in addition to managing the usual sleep deprivation and adjustment that comes with a newborn, she also had several appointments to attend.  She saw her midwife for her six week postnatal check at the local hospital.  She saw the child health nurse for her baby’s scheduled immunisations at the community health clinic.  She also saw her private GP to talk about a Mirena.

Amy saw three distinct health professionals in three separate locations in the same week to receive routine care.  Whilst she was grateful for the expert level of care and support provided by each professional, at the end of the week Amy lamented that she couldn’t get this type of care under one roof with one appointment.

Amy is a young professional with a supportive partner and doting parents who live nearby.  She owns a car and is financially well off.  She is organised and feels supported to access health services.  Now, imagine Amy with less social support, who relies on public transport and is struggling financially.  Suddenly, all of those appointments sound like a considerably harder task! (Even more so if she has to travel from her small country town to the next town for any of the aforementioned appointments).

Amy’s story demonstrates both the benefits and challenges associated with silos in health care.  In the context of an organisation, the term “silo” usually refers to a structure of departments that work independently of each other and don’t regularly network or share information. 

Health care consists of many silos as a matter of necessity.  For example, the skills and knowledge required to perform a heart transplant are different to those required to investigate and manage a public health outbreak.  So over time, we have developed expert teams to manage distinct problems.  Whilst this allows specialised teams to achieve more complex tasks, it can also lead to fragmented or duplicated health care which can be cumbersome for patients.  Just ask Amy. 

Similarly, health databases don’t communicate or integrate well with each other.  Health practitioners are reliant on a number of databases (eg. imaging, pathology, clinical records) and often have to look in varied locations to synthesise patient information.  This can be time-consuming and frustrating for the practitioner who doesn’t have access to pertinent details affecting the unwell patient sitting in front of them, as well as for the patient, who must retell their story over and over again!

Gillian Tett’s book “The Silo Effect” is a great read.  She portrays a couple of real-life examples about how silos can be detrimental to innovation, cause tunnel vision and conceal risks.   She also outlines how we can overcome or reduce some of the problems that are caused by silos.  Here are a few of her suggestions:

  1. Make team boundaries more fluid and flexible. 
    Facebook (the company) has a reputation for improving social cohesion and collaboration by rotating staff between departments.  Could we rotate midwives, child health nurses & GPs between teams to learn from each other, support each other and develop mutually beneficial professional relationships?  This would allow professionals to “generalise” their knowledge and skill sets.
  2. Encourage a culture of proactively sharing information.
    Shared information can be beneficial for patient care and this already happens in the form of multidisciplinary case meetings in many health services.  Could Amy’s three professionals meet on a regular basis to discuss and coordinate individual cases (with consent, of course), share updates in clinical guidelines and foster a safe environment to learn from each other?  
  1. Think about organisational structures and experiment with alternatives. 
    Organisational structures are often historic beasts that have evolved over time in reaction to various pressures (eg. funding, politics, personalities, limitations in infrastructure).  These structures are then inherited over time, without reform and can quickly become dated and irrelevant.  In the words of Eric Dishman (his TED talk here), “we have to go beyond this paradigm of isolated specialists doing ‘parts care’ to multidisciplinary teams doing ‘person care’.”  Could our three professionals experiment with a streamlined “Mums and Bubs” clinic once a week where they work collaboratively side by side under the same roof to see patients like Amy?

Our patients deserve coordinated and integrated health care.  Silos are a necessary part of that care, but they can also be burdensome to patients and cause unintended harm.  Obviously, Amy’s story is not unique to the rural context, however it’s well established that rural communities face barriers to health care that their city counterparts don’t experience, so additional pressure to navigate silos can compound an already difficult health care journey.  Even so, silos don’t discriminate between rural and urban areas and I’d argue that all clinicians should be mindful of their potential consequences.  Thankfully, Tett’s book has reassured me that we can master our silos by collaborating with each other, sharing information and working together as a team.  I challenge you to be inquisitive in your workplace (and beyond), to identify existing silos and to work towards mastering them!

The perils associated with silos can never be permanently defeated.  Mastering silos is a constant battle, because the world around us is constantly changing, pulling us in two directions.  We need specialist, expert teams to function in a complex world.  But we also need to have a joined-up, flexible vision of life.  Mastering silos requires us to walk a narrow line between these two contradictory goals. ~ Gillian Tett, The Silo Effect, 2016.

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