Values-driven integrated people-centred health services: exploring the perspectives of stakeholders across European regions

Over the past years much knowledge has been developed on the functional aspects of integrated people-centred health services, such as information exchange, digitalization and e-health, organizational interventions and funding. However, to further develop integrated people-centred health services delivery and to transform health systems, we need to take a broader perspective and at the same time dive deeper into our understanding. In addition to the functional dimension, we also need an understanding of the normative aspects that drive change and contribute to integration. In order to gain more insight into this human factor, it is relevant to look at the values playing a role in integrated people-centred health services. Values are important, because they underpin stakeholder behavior, interaction and decision-making in integrated people-centred health services delivery. A framework of values provides a vocabulary to explore what matters most to the different stakeholders, and may form a frame of reference on which collaborating partners can build their joint efforts. In the ‘European Framework for Action on Integrated Health Services Delivery’ and the interim report ‘Global strategy on people-centred and integrated health services’ (WHO, 2015; WHO, 2016) the World Health Organization stresses the need for a unifying values framework for integrated people-centred health services. This study contributes to the further development and refinement of such a framework, and provides insight into the different viewpoints of stakeholders on values. A systematically developed list of values is used to investigate the value priorities of stakeholders in integrated people-centred health services delivery across the European region. Our identification of value priorities is based on a quantitative study, assessing an 18-item set of values developed through a systematic review and Delphi consensus study. European service users and informal carers, health professionals, policy and decision makers, and researchers in integrated people-centred health services were invited to participate in an online questionnaire. First, the importance of each value was assessed with a 1-9 scale (‘highly unimportant’-‘highly important’). Second, respondents had to choose their three most important values out of the set of 18. In order to construct scores that reflect their importance, mean scores and interquartile ranges for each value were calculated. In order to investigate differences between stakeholder groups and European regions, multiple statistical tests were carried out (e.g. binary logistic regression, Cramer’s V, Chi-square, Spearman’s Rho). Participants were offered the opportunity to add additional values that they may have missed. For these values qualitative thematic analysis was conducted. Lastly, a principal components factor analysis (PCA - Oblimin with Kaiser Normalization) was conducted to investigate relationships between or among the eighteen values. In total, 1,013 respondents from 42 European countries completed the survey. The number of respondents varied between both stakeholder groups (16% users and informal caregivers; 29% professionals; 28% policy and decision makers; 27% researchers) and European regions (25% Western Europe; 38% Northern Europe; 30% Southern Europe; 8% Eastern Europe). On the 1-9 scale, scores varied between 7.6 (value ‘Transparently shared’) and 8.6 (value ‘Co-ordinated’). When looking at the selection of the three most important values, the values ‘Person-centered’, ‘Co-ordinated’, and ‘Holistic’ were selected most. ‘Flexible’, ‘Transparently shared’ and ‘Reciprocal’ were selected least often. The key conclusions of this study are: 1. The importance of the full set of 18 values was confirmed across stakeholder groups and European regions 2. Three core values were particularly prioritized across stakeholder groups and European regions: ‘Person-centered’, ‘Co-ordinated’ and ‘Holistic’ 4 3. Service users and informal carers attach a significantly higher priority to the values ‘Trustful’, ‘Respectful’ and ‘Co-produced’ than other stakeholder groups. 4. Professionals attach a significantly higher priority to the value ‘Collaborative’ than other stakeholder groups 5. Policy and decision makers attach a significantly higher priority to the values ‘Co-ordinated’, ‘Shared responsibility and accountability’ and ‘Led by whole systems thinking’ than other stakeholder groups 6. Significant differences for six values were found across European regions: ‘Collaborative’, ‘Co-produced’, ‘Efficient’, ‘Led by whole systems thinking’, ‘Holistic’ and ‘Shared responsibility and accountability’ 7. The eighteen values can be clustered into two subgroups which we labeled as 1) people related and 2) governance and organization The conclusions of this study show that, although proposed values are seen as important by all respondents, there are also significant differences in the prioritization of these values across stakeholder groups and EU regions. Furthermore, within the full set of values, a distinction in emphasis can be made. We identified two complementary subgroups and labeled them as ‘people related’ and ‘governance and organization’ values. For practice this implies that it is relevant to take a broader perspective and have eye for different value orientations and prioritizations in integrated people-centred health services delivery. Our study demonstrates that, although overarching intentions and shared goals may be the same (such as integrated people-centred care) different value hierarchies of people - related to their role - are present. This is important, whereas underlying values often remain implicit in collaborative efforts for integrated people-centred health services settings, but do have impact in the success of the realization of integrated people-centred health services delivery. This report provides suggestions for tools and future activities contributing to the awareness of values and values-driven approaches in integrated people-centred health services settings, tailored to different audiences and target groups. Further expansion of this research to other parts of the world is recommended.