Papers 1 and 2 in this Series outline the scope of poor care from both overuse and underuse of medical services.
Drivers of poor care reside in three major domains: money and finance; knowledge, bias, and uncertainty; and power and human relationships. Drivers operate in specific contexts and contribute to the overall quality and quantity of care delivered. These contexts are best considered as different levels in an ecosystem of care delivery: global; national, legal, regulatory, and cultural; regional, institutional, and social; and the individual locus of the doctor–patient relationship.
Multiple drivers of poor care interact throughout this ecosystem. We aim to outline a navigational chart for addressing this fundamental problem of modern health care. Reducing poor care will require a well contextualised, multidimensional, and concerted effort by health-care professionals, policy makers, and the public. Previous definitions of quality of care have focused on evidence-based health outcomes of individuals and populations incorporating patient preferences.1 Our conception of the right care extends this definition further by including the importance of stewardship in the distribution of societal resources through what inherently is a political process.
Drivers at the global level affect multiple actors across all societies—for example, the mass media and multinational corporations. At national, regional, and local levels, variation in legal and regulatory regimes, power relationships among stakeholders, and cultural norms and traditions, act differentially. Social networks—of patients and families on one side and professionals and delivery systems on the other—act as local mechanisms of transmission of all drivers. Provider stakeholders, such as professional societies, operate locally, nationally, and increasingly, globally, to convey standards of practice, even as they legitimate clinicians' professional autonomy.
The creation and dissemination of knowledge occurs at various levels via multiple actors. However, care itself is initiated at the individual level from the centre of the ecosystem, where up to 80% of health-care costs are initiated.2 Here, the patient and the doctor sit, with their own individual and social identity, cultural and cognitive biases, and the cumulative influence of the forces surrounding them. These individuals also bring their experience, emotion, transference, and countertransference to the encounter.3
Numerous additional variables exist within this relationship, including the clinical calculation of benefits and harms, patient preferences, physician preferences, provider training and competence, available infrastructure, financial incentives, trust and understanding between patient and clinician, and the influences of others, both individually and through social networks. Clinical decision making emerges from this complex interaction. In this Series paper, we describe the major drivers of care and how they operate.
Key messages
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The biomedical model of the past century has been valuable for some aspects of medicine and is a necessary, but not a sufficient, component for the proper care of patients
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The biological, psychological, and social needs of patients and informed preferences must define desirable outcomes and appropriateness of care
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Greed, competing interests, and poor information are universal drivers of poor care that occur across all systems and settings
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Inaccurate knowledge and information of all stakeholders regarding effective and ineffective care is a key driver of poor care
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The levers for knowledge dissemination and adoption of health technologies are too often distorted by a fascination with innovation, which is reinforced by vested interests
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Systemic factors, cognitive frameworks, and cultural influences, particularly regarding health, health care, science, and technology, are important drivers of care and have to be understood to improve health-care decisions at all levels
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The way in which each health system is organised and financed, and how resources are allocated towards facilities and workforce, allows each of these drivers to have more or less influence
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The substantial economic interests of the health-care industry and the alignment of incentive structures within health services are major drivers of potentially biased knowledge generation and health-care delivery worldwide
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Failure to reinforce professional ethics and protect the therapeutic relationship from financial concerns distorts medical care
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Regulatory capture, disempowerment of communities and citizens, and a political aversion to priority setting all drive poor care
Understanding these drivers and the various ways in which they act across systems provides opportunity to increase the social and individual value of care