Make a WISH: How we might create sustainable healthcare for us and our
children
I spent four of the most challenging and rewarding years of my professional life working to try to
sustain England’s universal National Health Service through a period of financial constraint. The
independent evaluation of that work was entirely fair. We made real short term cost and efficiency
gains to buy time for deeper transformational change. But we substantially failed to use that time to
gain momentum on the deeper change that would enable longer term financial sustainability.
And of course, the five to ten year challenge we were facing as a result of the global financial crisis
was really only a medium term presentation of the deep, long term problem of unsustainability
facing healthcare systems in all developed countries. Which is, that as a result of new technology
and ageing populations, healthcare, however funded, is consuming a greater proportion of the
economic output of countries every year. For most countries, the current healthcare model, over the
long term, is financially unsustainable.
Given how important healthcare is for individuals and societies, and the self-evident nature of the
approaching crisis, perhaps it is surprising that in England, as in so many countries, really deep
transformational change in the model of healthcare is hard to achieve. In part the apparently well
motivated interests defending the status quo; doctors, institutions, communities, politicians have to
date been powerful enough to drive temporary fixes to the economics. I think this well intentioned
action is sleepwalking towards a crisis in our children’s lifetime. Sometimes protecting the present is
the worst action to protect the future.
And these sleepwalkers are smart people. It is remarkable how pervasive the basic model of
healthcare is in people’s mindsets – and how hardwired it is on the ground. People are well until
they are sick. They go to see doctors who diagnose them. Really sick ones are given intensive
interventions in hospital based on their disease. Less sick people are treated largely with
pharmaceuticals or advice and go back to relatively unsupported self-management. Older people
with multiple morbidity challenge the systems which largely fail to meet their needs through to
death - which is often handled very intensively.
Driven by the pervasiveness of the current model, most of the “transformational” work I was
involved in was, in reality, just trying to produce slightly more efficient versions of this current
model. Of course this was important incremental improvement, and might be enough to see us
through the next 10 or so years. But at best it is slowing the rate of cost growth and so is very
unlikely to produce generational sustainability in healthcare. For that we need to think whether a
complete redesign of healthcare is possible – transforming its cost base – and if it is how we get
there.
This needs white space thinking from the best brains in the world. We need to find the people and
places to start that thinking and action and begin the work. And to set the ball rolling here are five
personal suggestions about deep long term change for sustainability to provoke debate,
engagement, opposition and even derision. They may not be right, or appropriate, or even desirable
– I am not really trying to persuade you that these are the right solutions. I am trying to encourage a
debate in which some such solutions emerge. What matters is that the real debate gets going and
brave pioneers start the necessary innovation.
STARTING FROM SCRATCH: A SUSTAINABLE HEALTH CARE SYSTEM FOR THE NEXT 50
YEARS
Component 1: Hyper prevention
The battleground of disease has shifted significantly from infectious disease to lifestyle disease.
There is widespread consensus that this requires a public health response. In the UK the public
health profession has probably saved more lives than any other branch of medicine, largely through
the two extraordinary but very long established interventions of civic hygiene and vaccination. It is
an appalling tragedy that the public health specialism is currently often held in low esteem in the
informal medical hierarchy. We need to find the next epoch making intervention(s) and I would
suggest we start by using existing technologies at scale to deliver approach of hyper prevention. An
intensive effort to identify at the earliest opportunity the health risk factors for individuals, an
infrastructure for remotely monitoring through technology, and the use of algorithms to prompt
early interventions – many of which to be delivered through technology or non-medical
professionals. This could include:
•
•
DNA risk factor screening for the whole population
Use of implantable or wearable health monitoring devices for whole population or at least
the whole at risk population
•
Development of a secure data collection and remote analysis infrastructure – monitoring the
output of those device through early warning algorithms – hundreds of data centres quietly
and proactively monitoring people’s health
•
•
Development or health improvement interventions in response to this monitoring
which can be delivered, where possible, through technology or personnel that are cheaper
than doctors.
Much of the technology to achieve this already exists, from wearable devices through to interpretive
algorithms, and its cost is plummeting. It has not been put together into a preventative system at a
population level. Perhaps because to some this is an Orwellian nightmare. But most or all public
health interventions at populations scale attract some version of the trade-off between
individual/population health and personal freedom of choice. There is no point pretending that
there is not a difficult deal here between complete personal privacy and some protected trading of
that to enable a sustainable healthcare system. I imagine in most democracies this a difficult road,
and one probably achieved through incentives on the cost of healthcare cover. Nevertheless I
suggest it.
Component 2: Long term social design for the elimination of calorific surplus.
The tidal wave of obesity is capable alone of driving healthcare systems into an unsustainable
position – and its current growth is massively accelerating that problem. We are not just eating
ourselves to death – we are almost literally eating our health care systems. Just as the sustainability
problems around energy and climate have led to deep structural changes in every part of the energy
generation and usage system, so we need to intervene at every level of social design to seek to
return calorific input and output to balance over the next 20 years. This is likely to include the
application at scale of:
•
•
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More intensive regulation of the food industry
Ambitious design of more physical exercise into all buildings, civic planning, work
and leisure – if cities can be designed to have a low carbon footprint then they can be
designed to have a high “footprint footprint”
•
•
Active incentivisation of individuals around weight
Powerful incentivisation of employers to achieve workplace health
Again, this pushes hard up against frontiers of individual freedom of choice, business interests etc.
But the belief that we can do whatever we want to our bodies and affordable healthcare will exist to
pick up the pieces is no longer a sustainable premise.
We can agree the trade-offs – but not pretend they don’t have to be faced.
Component 3: The automation of medical knowledge, allowing people direct access to that
knowledge and doctors doing very different jobs
Doctors are why I came into healthcare and love working in it. They are overwhelmingly smart,
committed, value driven, engaging, great people. But…
•
The pace of knowledge growth means they can no longer hold current medical knowledge –
even for restricted medical sub-specialties – in their heads
•
Notwithstanding this, patients can really only reliably get at that medical knowledge through
doctors – they are a wonderful but narrow door.
•
They are required to undertake a whole range of craft skills alongside the application of
highly expert knowledge – a very unusual work combination
•
They are relatively expensive (although probably underpaid on an individual level for their
level of expertise) and growing them proportionately to need in healthcare systems is part of
the unsustainability problem.
So I suggest we need:
•
An international automated system of applied medical knowledge in terms of best practice,
diagnostic algorithms, treatment pathways etc.
•
A citizen accessible interface to that system allowing patients direct access to selfassessment and diagnosis (particularly as supported by the hyper-prevention described
above) wherever possible. I don’t want online access to my medical record. I want online
access to automated medicine.
•
And where the human skill and interaction from doctors is necessary; this system passing on
to doctors trained as the channel for more serious diagnostic and treatment pathway
management with the patient
•
Doctors organised to provide access to patients using modern communications – breaking
wherever possible the current geographical and time constraints of all doctor/patient
interactions needing to be in the same room at the same time
•
The transfer of as many craft skills as possible – including elements of physical tests, surgery
and other interventions to technology based or high craft skill non-doctors at lower cost.
This challenges so much that we value in the personal and professional interaction we value as
doctors and patients. But in truth that interaction has long since begun to be undermined by time
and workload pressures caused by trying to sustain a model being destroyed by the demographics
and economics. We need to reserve the very personal interactions with a known and present
physician for when we need it most – where the level of human skill and compassion is irreplaceable.
Component 4: redesign basic care with a combination of technology and shift to
individuals, families and communities
If the availability and cost of the highest cost medical skills are a sustainability problem at one end of
the spectrum, then the cost of the sheer volume of basic nursing and personal care required by
older, frail and other vulnerable people is at least as great. Whether in their own homes or
residential facilities, the current model is based on interaction from large numbers of basic carers,
nurses and other professionals. Again it is understandable that human contact and care for
vulnerable citizens is the basis of the care model – but again it is being undermined by the
demographics and the economics, making it difficult to find and/or afford the people to do this at
the scale required.
There also things that have been lost in this model – most notably the loss of responsibility of many
families and communities for the care of their relatives. When I have been privileged to visit those
countries where families and communities still regard it as a basic responsibility to care for their own
when they are sick and frail I realise that we have lost something very deep and important. And I
have sometimes thought when reading examples of failures of care in professional institutions, that,
however inexcusable, they are in part a projection of the lack of care and respect for vulnerable
people in the wider community.
So in response to this we need to:
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engage actively in the technology developments to support care, including taking the next
steps in the availability at low cost of telecare and following the lead of the Japanese in
particular (who seem to have understood the scale of the care problem) in developing and
deploying capable and emotionally engaging technologies for care situations;
•
work on developing home environments in which simple technology supports independence
for frail people by allowing food preparation and hydration, supporting mobility, preventing
accidents etc is further developed and deployed;
•
•
support an international drive for new methods of care for people with dementia;
work to create incentives and training for family and community support for frail people
with appropriate safeguards - as well as seeking to develop a movement valuing the
provision of such care. Just how deep a problem this has become is perhaps exemplified by
the fact that the costs of older people's care in the UK already have a massive impact on the
inheritance of families - but this does not seem to encourage a desire to provide care. We
need innovation and experimentation. You might find elements of this vision
nightmarish...but if I could have some or all of this for my care when I need it – I might
choose to call it independence.
Component 5 – renegotiate our relationship with death
My father’s terminal care as he moved towards his death from COPD was wonderful. Within the
constraints of an unpleasant disease he died well. He died in the hospital I once ran, and I well
remember the moment when my wonderful and well intentioned physician colleagues asked if we
wanted Dad moved to intensive care to support his breathing. When I asked the simple question
“would you want that for your Dad?” the answer was a straightforward “No.”. I am so glad we did
not add the avoidable process of pointless mechanical ventilation to the unavoidable indignities of
Dad’s death.
It has taken a clinician of the huge international standing of Atul Gawande, to positively ignite this
debate in his wonderful book Being Mortal. It must be possible for us to find ways to break the cycle
of spending hugely to achieve bad deaths for ourselves and our loved ones. The growth of science
continually presents us with difficult questions about whether because we can do something, we
should do it. The enemy of medicine is not death – it’s bad death.
SO WHAT DO YOU THINK? WHAT SHOULD WE DO?
In a sense, I don't mind if you think the ideas above are mad, unimplementable, undesirable or just
plain wrong. You might be right.
I do mind if you think we don't need this kind of thinking or work. The fact of the long term
unsustainability of our precious healthcare systems (particularly the universal coverage systems)
given the current demographic and cost growth seems unavoidable to me.
As someone who has worked at a national level on matching sustained quality with financial
constraint I am a strong advocate of such work on efficiency inside or gradual change of the current
delivery model, but believe that even well implemented to reduce the pace somewhat of future cost
growth, it gives us another two or three decades before our systems fade or collapse. Selfishly I want
to work on deeper change because that collapse in healthcare availability might be in my own
lifetime. A little less selfishly - it's almost certainly in the old age of our children.
At any moment in time it is possible, and may even be right, to argue for more funding for any
particular system - as I write it's happening right now in England's National Health Service following
several years of financial constraint. But when these calls are accompanied by a lack of action on the
deeper change that must be required to meet the cost growth challenge it is the highest form of
intergenerational betrayal.
I am constantly drawn to the analogy with climate change, and the changes wrought in the energy
industry over the last 40 years. Those people inside the oil giants who recognised that they were
running unsustainable industries; that their highly successful and profitable industrial models had to
be transformed; that the relatively near future would see thousands of wind turbines, mainstream
electric vehicles and every building and device labelled for energy efficiency - were probably
regarded as mavericks, even dangerous. I guess they ploughed a lonely furrow. They turned out to
be right. My call is not for people to necessarily buy into the potential solutions outlined above, but
that individuals begin the process of thinking and acting on issues of deep sustainability in
healthcare, and that those individuals come together across the world to work on those solutions
and create a movement for change.
Could we start, if you agree with enough of what I am saying, by creating the Worldwide Institute for
Healthcare Sustainability? Joining together the mavericks, pioneers, thinkers and advocates who
want to work on this profound issue for our future. We may not be popular, or recognised, or agreed
with right now or for a while to come. But we might turn out to be right.