Healthcare Delivery-Future Directions

(I originally published this article in Linkedin)

Recently, I was invited to be a panel speaker at a Healthcare Summit (this is to occur next month in Melbourne). A topic that has been suggested for discussion is "What's next for healthcare and where do we see ourselves in 15-20 years?" I have thought about this subject many times in the past but this invite reignited my dormant cogitation. So, I spent some time revisiting this issue through the prism of recent trends and published evidence. I now provide a summation of the analysis in this article.

At the onset, I must state I believe the future of healthcare is very much yoked to current healthcare investment, planning and delivery-the state of which presents both a pessimistic and optimistic picture.

Pessimistic, because I find a significant amount of focus on delivery of healthcare guided by political, pecuniary, professional and parochial interests. In many instances, planning to cater future demand for healthcare is in-sapient and neophobic. With the quantum of accessible big data, published epidemiological evidence and identified variability and disparity in healthcare service delivery, it does boggle one's mind how investment into healthcare service delivery can be so poorly channelled and implemented? Accepting there are financial, political, workforce and infrastructural limitations that pertain to each country's health system, there are yet fundamental activities (as they relate to access, minimisation of waste/variability in care and a patient centred approach) that each health system can easily adopt. However, a reactionary state of affairs, rather than a proactive and preventative approach, reigns in many countries. An OECD report released in January this year identified that of every dollar spent on healthcare in OECD countries, 20 cents is wasted. What this means the governments could have spent twenty percent less yet improved patient's outcomes. Also, the European Parliament has estimated that an estimated 1.4% of the GDP of European countries is lost because of health inequities (the amount lost is approximately equal to the Defence spending share of the GDP). While life expectancy increases across the globe, health disparities in both developing and developed countries persist at a significant scale. In a study published in Health Affairs this year, 38% of the US population were found to report "poor health" because of inability to access healthcare services. Further, the WHO estimates a shocking 150 million per year across the globe face catastrophic health costs because of user fees. So there is a lot to be concerned about how healthcare is being delivered across the world.

However, we do see a glimmer of hope when noting trends in health literacy, patient advocacy, investment in public health interventions, rapid uptake of mobile/pervasive technology and increasing use of shared assessment platforms. In a study published in Lancet earlier this year, which reviewed 'Healthcare Access and Quality (HAQ)' indices in 195 countries found nearly all countries improve their indices between 1990 and 2015. Also, the study found the Global HAQ improved from 40.7 in 1990 to 53.7 in 2015. In the same journal, a study assessing 33-health related Sustainable Development Goal (SDG) indicators in 188 countries across 25 years found pronounced progress with modern contraception, under-5 mortality, and neonatal mortality. There is also increasing investment in public health by both developing and developed countries. An economic evaluation of South Africa's investment in public health care over the period 2005 to 2014 identified that a direct association with significant improvement in under-five mortality rate. With the rapid increase in the use of mobile phones especially in developing countries ( for example, 283 million in China 125 million in India, 46 million in Indonesia, 35 million in Ghana) and the accelerated development of mobile health applications and cloud-based data accessible on mobiles, the WHO has actively been pushing a Global Digital Health agenda to capitalise on this momentum. The use of smartphone technology in the delivery of healthcare is increasingly reducing the cost of healthcare delivery. The US Food and Drug Administration just last year approved more than 35 digital health applications and the UK's NHS has pledged to incorporate digital innovation in its strategy for delivery of healthcare into the future.

Coming back to the original question, where do I see healthcare delivery heading into the future? When you analyse countries that show the strongest performance in their health indices you will see some common threads: Universal Health Cover, robust investment in primary/preventative health care, timely access to hospital care, and minimal variability in the delivery of healthcare services. In a systematic review of the Return on Investment (ROI) of national public health interventions published last month (in the Journal of Epidemiology and Community Health), it was found that the median ROI was 27.2 and cost benefit ratio was 10.3. Also, several studies have identified that schemes that minimise fee burden on patients not only improve their access to healthcare but also improve health outcomes of the community as such. Provisions or guarantees for timely access to hospital services are now written into legislation, for example California and Canada. Further, in a report commissioned by Philips where more than 25,000 patients and 2600 healthcare professionals across 13 countries were polled for their perceptions of their views on healthcare found patients and healthcare professionals highly value integrated seamless healthcare i.e. healthcare centred around the patient's needs. Based on the above factors, I outline key principles that should guide design and delivery of healthcare into the future.

At the System Level (DEFA):

Demographics: The demographic dividend that resulted from post world war in developed countries has now because of low fertility rates (it is estimated that 60% of the world's population is presenting this trend) transformed to a demographic recession. This means unless there is a replacement population strategy, an inverted population pyramid with an increasingly ageing population (because of increasing longevity) serviced (through taxes or otherwise) by a younger, but smaller, populace will emerge. Even in populous countries, like China, the dependency ratio for retirees is increasing rapidly (In China it is said to balloon to 44% by 2050). How does a healthcare system constrained by resources cope with this demographic trend? As assumed incorrectly by many, providing healthcare to an ageing population will not lead to rocketing of costs. A report published by the Australian Government some years ago identified that annual percent of health costs due to ageing alone would reduce from 2020 onwards. However, it is known that the aged rely on the government more than many other age groups and require complex care, which results in greater utilisation of health services than other demographic groups. So attuning of health service delivery to this demographic will be key in ensuring a responsive health service.

Epidemiology: While dividing epidemiology into 'chronic disease' and 'infectious disease' camps is problematic, the scale of the global chronic disease burden (estimated by WHO to be a lost productivity of approximately US $84 billion) merits a specialised focus on its distribution and causation. A significant number of chronic diseases emerge through behavioural risk factors (smoking, poor nutrition, physical inactivity, excess alcohol consumption..etc). These risk factors are amenable to change through appropriate early interventions. A research report analysing chronic disease epidemiology in 23 countries that accounted for 80% of the global disease burden stated that just a mere 2% decrease in chronic disease death rates per year in these countries over the next 10 years would result in 24 million deaths averted and US $8 billion saved. Thus, health systems have to incorporate evidence backed public health interventions in their design and delivery and link them to the wider government's investment into social determinants like housing, education and transport.

Financing: Who needs to bear the responsibility of healthcare financing is a very emotive and political issue that immediately yields a bewildering array of opinions. However, I write here with the premise that studies have shown countries with universal health care systems perform better than heavily privatised health systems. Healthcare Financing is an important lever to achieve universal healthcare. Generally, healthcare financing is achieved through government payments, private health or social insurance plans and out-of-pocket payments. If we consider the role of the government in financing the health system, their ability is impacted by demographics, epidemiology, technological and workforce costs and performance of their country's economy. Noting current trends, these factors will continue to place 'stress' on the government's ability to finance healthcare. It will be easy for the government to shift the 'responsibility' to the users (social insurance) and/or the private sector. While there may be some pro's with the shift in the responsibility, there is significant evidence that spreading costs of healthcare to all production components and financing universal health care through a combination of progressive taxation of income supported by insurance and out-of-pocket payments not only yields the best chances for health system sustainability but also efficiency and equitable outcomes.

Access: in the healthcare context can be simply stated as the ease with which an individual can receive healthcare. However, there are several dimensions to this indicator. Authors Levesque, Harris and Russell in their article in the International Journal for Equity in Health outline 5 dimensions: Approachability, Acceptability, Availability, Affordability and Appropriateness. Contrary to generally held opinion, economic factors alone do not determine a patient's ability access to health services. Social, cultural, and geographic factors all play a role in access to health services. However, financial reasons outplay other factors in its scale, significance and relevance across health systems in determining access to healthcare. Studies have shown governments have the most influential role in ameliorating the barriers financial considerations place. The government also has a consequential role in ensuring equitable access to all segments of the population irrespective of their location, race, religion and culture. Yet, time and again, governments fail in ensuring timely access, equitable and appropriate care. While we can be quick to admonish governments for their failures, it is unrealistic to expect access in its truest sense to be achieved in a resource constrained and diverse geographical environment. Compromises and rationalisation need to be accepted along with a focus on preventing the conditions that create demand on stretched resources.

At the individual level (PPC):

Personalised Healthcare: This term encompasses more than personalised medicine, which involves the use of genetics and genomics to guide and deliver healthcare. Personalised healthcare is about using biological information to predict the risk of acquiring a disease or how a patient will respond to treatment. Very often lack of personalisation of care results in medical errors and in appropriate treatment. Not to mention the waste and costs. A personalised approach not only will result in the use of appropriate treatments but also considerably reduce the costs of care. The other advantage of personalised healthcare is involvement of patients in devising treatment plans. Because of the involvement of the patient in planning and sharing of information about their therapy, personalised healthcare also achieves higher compliance than many other models of care.

Proactive Preventative Healthcare: Many health systems across the world have become reactionary systems based on episodic, acute care models. The focus is on diagnosing and treating illnesses rather than preventing them happening in the first place. It is a 'wait and react' model i.e. wait for the patient to become sick and then treat. With the availability of big data, epidemiological data, technological innovations and evidence for the efficacy of early interventions, the excuses to continue with this model are fast running out. I am not blind to the challenges that emerge when shifting from a reactionary model to a proactive and preventative care model. The challenges include financing models that favour secondary and tertiary care, the barriers to integrating healthcare across multiple levels (horizontal and vertical) and the time taken to visualise results of investments. However, with ballooning healthcare costs and increasing uncertainty of current healthcare delivery models, there really needs to be a radical approach to shift the thinking around healthcare service delivery. Macintosh, Rajakulendran, Khayat and Wise in their 'Transforming Health Market' report discuss the catalysts for this shift to occur. The enablers include a decentralised approach to deliver healthcare, focus on health outcomes rather than outputs, collaboration across the system and empowered patients.

Customised Healthcare: With this approach, healthcare design and delivery is centred around the patient. There has been extensive discourse about patient-centered care (PCC) in the past many years to the point this term now sounds cliche. Yet, the shift of healthcare delivery to a patient centred approach has been slow-going. Patients continue to face challenges in navigating the healthcare system and receive timely and appropriate treatment. Some Scandinavian countries have established a seamless system to share patient data across providers (and to the patient themselves). The health care delivery model in these countries presents a great narrative as to how a publicly funded but privately delivered healthcare can achieve excellent health outcomes. In Sweden, a decentralised customised healthcare delivery model with controlled costs is the envy of the world. Healthcare Organisations do not need to wait for their country to adopt a Swedish model. A study of more than 3000 hospitals in the United States by the Armstrong Institute for Patient Safety and Quality identified elements common to hospitals, which adopted customised healthcare. These components include Hourly Rounds, Communication Boards in Patient Rooms, Bedside Shift Report, Discharge Folders, Post-Discharge Phone Calls, Multi-disciplinary Rounds, and Transparent Standards of Performance. As one can see these measures do not require a great amount of investment and can be mostly adopted with existing resources.

I end this article with this quote from Dr Louis Hugo Francescutti " Unilaterally cutting cost won’t eliminate the inefficiencies, unnecessary procedures and avoidable burdens on the system. But if we work together with fresh thinking and strategically-smarter spending, we can recast into a more and humane and efficient health care system and the lower overall costs to governments will follow."