The future of health care

1
The future of health care

• Richard Smith
• Editor, BMJ
• www.bmj.com/talks

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The possible agenda

• Dangers and difficulties of looking to the future
• Why bother then?
• How best to think about the future?
• What is Foresight?
• Drivers of the future
• Three scenarios
• Pictures of the future of health care
• Two reports on the future of health care
• What does the future mean for now?

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Dangers of predicting the future

• I never make predictions, especially about the
  future.
• Sam Goldwyn Mayer

4
Predictions of Lord Kelvin, president of the
Royal Society, 1890-95

• "Radio has no future"
• "Heavier than air flying machines are impossible"
• "X rays will prove to be a hoax

5
Looking to the future common mistakes

• Making predictions rather than attaching
  probabilities to possibilities
• Simply extrapolating current trends
• Thinking of only one future
• People consistently overestimate the effect of
  short term change and underestimate the effect of
  long term change.
• Ian Morrison, former president of the
  Institute for the Future

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Why bother with the future?

• "If you think that you can run an organisation in
  the next 10 years as you've run it in the past 10
  years you're out of your mind."
• CEO, Coca Cola

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Why bother with the future?

• The future belongs to the unreasonable ones, the
  ones who look forward not backward, who are
  certain only of uncertainty, and who have the
  ability and the confidence to think completely
  differently.
• Charles Handy quoting Bernard Shaw
• The point is not to predict the future but to
  prepare for it and to shape it

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How best to think about the future?

• No answer to the question, but one way
• Think of the drivers of change
• Use the drivers to imagine different scenarios of
  the future
• Imagine perhaps three each should be plausible
  but different
• Extrapolate back from those future scenarios to
  think about what to do now to prepare

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What is Foresight?

• Foresight is a method of thinking about the
  future in order to think about what should be
  done now
• The British government has conducted two rounds
  startingin1994 and 1999
• The first round was concerned mainly with
  informing research policy the second was much
  broader, including social impacts

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The aims of Foresight

• To produce a report on how the future might look
• To provide material for central and local
  government and public and private organisations
  to prepare for the future
• To shape the future
• To get a whole lot of people thinking about the
  future

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The methods of Foresight

• Decide on subjects
• Gather a group together--diversity is important
• Ask them to think about the future, using
  whatever methods they want
• Oblige them to think along way ahead
  (2020 in the latest round)
• Oblige them to be bold and creative (hard)
• Try and persuade them not to be too linear (hard)
• Oblige them to think about scientific,
  organisatiomal, political, social implications
• Ask them to make recommendations on what should
  happen now to prepare for the future
• Disseminate with energy

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The Foresight panels 1999

• Healthcare
• Ageing population
• Crime prevention
• Manufacturing
• Built environment and transport
• Chemicals
• Defence, aerospace, and systems

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The Foresight panels 1999

• Energy and natural environment
• Financial services
• Food chain and crops for industry
• Information, communications, and media
• Materials
• Retail and consumer services
• Impact of e-commerce on future business models

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Healthcare task forces

• Public and patients
• International influences on health and healthcare
• Older people
• Organisation and delivery of healthcare
• Information
• Delivering the promise of the human genome
• Pharmaceuticals, biotechnology and medical
  devices
• Neuropsychiatric health
• Transplantation

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Drivers of change in health care

• Internet
• Beginning of the information age
• Globalisation
• Cost containment
• Big ugly buyers
• Ageing of society
• Managerialism
• Increasing public accountability

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Drivers of change in health care

• Rise of sophisticated consumers
• 24/7 society
• Science and technology --particularly molecular
  biology and IT
• Ethical issues to the fore
• Changing boundaries between health and health
  care
• Environment

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Examples of future scenarios for information and
health
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Three possible futures titanium

• Information technology develops fast in a global
  market
• Governments have minimal control
• People have a huge choice of technologies and
  information sources
• People are suspicious of government sponsored
  services
• There are many truths

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Three possible futures iron

• A top down, regulated world
• People are overwhelmed by information so turn to
  trusted institutions--like the NHS
• Experts are important
• Information is standardised
• Public interest is more important than privacy

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Three possible futures wood

• People react against technology as against
  genetically modified foods
• Legislation restricts technological innovation
• Privacy is highly valued
• Internet access is a community not an individual
  resource
• There are no mobile phones

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Pictures of the future of health care
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Pictures?

• Asking people to draw pictures can free up their
  thinking as well as those who look at the
  drawings
• Its the conversation around the drawings rather
  than the drawings that matters
• Having said that, here are two pictures of the
  future of health care that I carry in my mind.
• The first is from Tom Ferguson, an acute observer
  of the digital age, and the second from Uwe
  Reinhart, professor of economics at Princeton

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(No Transcript)
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Fee for service for the rich
Marks and Spencer style managed care for the
middle classes
Safety net service for the poor
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Two reports on the future of health care
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Healthcare 2020

• Foresight Healthcare Panel
• Department of Trade and Industry, London
• www.foresight.gov.uk

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Selections from Healthcare 2020

• 42 recommendations
• Institutionalise thinking about the
  future--otherwise, as with genetics, the future
  may take longer to realise
• More rolled back healthcare--more community and
  home based healthcare with IT support
• Chronic disease management will be a cornerstone
  of future healthcare
• Diagnosis needs to be made more rational--as the
  Cochrane Collaboration has done for treatment

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Selections from Healthcare 2020

• Patients and the public will come to the heart of
  healthcare--but how will this happen with the
  public?
• Improving health through innovations in social
  policy rather than through high tech
• Putting health at the centre not the edge of
  politics
• Regeneration medicine will become a major
  component of healthcare--use of stem cells,
  xenotransplantation, tissue engineering, induced
  regeneration, modulation of the ageing process

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Selections from Healthcare 2020

• Physical and engineering sciences will become
  much more important
• whole systems engineering
• mimicry of sensor/effector pathways
• image analysis
• predictive modeling of biological behaviour
• clinical decision support

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Selections from Healthcare 2020

• We have done badly with neuropsychiatric illness,
  but it will become steadily higher profile with
  rising prevalence and a sharp increase in
  diagnostic and therapeutic possibilities
• Dementia may eventually strike 85 of the
  population
• A greater emphasis is needed on prevention
• Beyond electronic patient records to health
  biographies
• Cyberphysicians
• Moving from information to knowledge

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Information and health technological developments

• Think for itself hardware and self-generating
  software by 2020
• Wearable computers intelligent clothing
• Personal agents-- digital butlers smart
  sensing
• Electronic circuitry can be connected to nerves
  and tissues

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Cyberphysicians the problem

• Healthcare is a knowledge based business but
  information is poorly delivered
• Doctors now suffer from the information
  paradox--drowning in information but cannot find
  the information they need
• Patient information is often neither evidence
  based nor easily accessible

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Cyberphysicians

• The number and form of infomediaries--knowledge
  brokers will proliferate
• All the information available to professional
  will be available to patients
• Cyberphysicians will look after peoples health,
  detecting changes through sensors, prompting
  preventive activities and treatments

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Infomediaries doc.coms

• People will be able to use doc.coms to
• Ask questions
• Interact with others with similar interests
• Use software that will help with health risks
• Use decision support systems
• Consult with professionals
• Access their own health records
• Buy health related products

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Health records the problem

• Current health records are
• Paper based
• Disorganised
• Often illegible
• Lost
• Scattered
• Poorly linked

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Health records

• Health records might be
• Electronic, lifelong, perhaps recording all food
  and drink consumption, exercise, etc
• Accessible from anywhere
• Linked to other records, like social care
• Multimedia
• Collect information from sensors in the body or
  home
• Data mined
• But beware Big Brother

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Crossing the quality chasmA new health system
for the 21st century

• Institute of Medicine, 2001

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Reports opening quote

• Knowing is not enough we must apply
• Willing is not enough we must do
• Goethe

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IOM report the problem

• Between the health care we have and the care we
  could have lies not just a gap, but a chasm
• A system full of underuse, inappropriate use, and
  overuse of care
• Unable to deliver todays science and technology
  will be even worse with innovations in the
  pipeline

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IOM report the problem

• A fragmented system characterised by unnecessary
  duplication, long waits, and delays
• Poor information systems disorganised knowledge
• Brownian motion rather than organisational
  redesign
• A system designed for episodic care when most
  disease is chronic
• Health care providers operate in silos

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IOM report moving forward

• Commit to a national statement of purpose for the
  health care system
• Six aims
• safety, avoid injuries
• effective, evidence based
• patient centred, patient values guide decisions
• timely, reduce waiting and delay
• efficient, avoid waste
• equitable, care doesnt vary by gender,
  ethnicity, etc

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IOM report 10 rules for redesigning health care

• 1. Care based on continuous healing
  relationships--care whenever its needed, not just
  through face to face visits
• 2. Customisation based on patient needs and
  values
• 3. The patient as the source of control
• 4. Shared knowledge and free flow of information

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IOM report 10 rules for redesigning health care

• 5.Evidence based decision making
• 6. Safety as a system property
• 7. The need for transparency--all information
  available, including the systems performance on
  safety, evidence based practice, and patient
  satisfaction
• 8. Anticipation of needs
• 9. Continuous decrease in waste
• 10. Cooperation among clinicians

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IOM report getting started

• Concentrate on the conditions that account for
  most health care (cancer, heart disease, mental
  health)
• Produce plans that will lead to substantial
  improvements--like Englands national service
  frameworks
• A fund for innovation

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IOM report six challenges for health care
organisations

• 1. Design seamless, coordinated care
• 2. Make effective use of IT, including automating
  patient records
• 3. Manage knowledge so that it is delivered into
  patient care

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IOM report getting evidence into health care
delivery

• Ongoing analysis and synthesis of medical
  evidence
• Delineation of guidelines
• Identification of best practices in design of
  care processes
• Better dissemination to professionals and public
• Decision support tools
• Goals for improvement
• Measures of quality for priority conditions

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IOM report six challenges for health care
organisations

• 4. Coordinate care across patient conditions,
  services, and settings over time
• 5. Advance the effectiveness of teams
• 6. Incorporate measurement of care processes and
  outcomes into daily practice

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What will survive as the world changes
completely

• 1. Clear ethical values
• 2. Being clear about our mission
• 3. Putting patients first
• 4. Constantly trying to improve
• 5. Basing what we do on evidence
• 6. Leadership
• 7. Learning

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Conclusions

• Patients will have the same access to knowledge
  as professionals
• Self care or rolled back care will become
  steadily more important
• Professionals and patients will become much more
  equal partners
• Evidence will become steadily more important
• Health care systems will increasingly be
  concerned with chronic not acute disease
• Health will increasingly be at the centre not the
  edge of politics

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Conclusions

• There is a chasm between what health care could
  do and what it does do
• Some things--ethics, learning, leadership--will
  continue to be important whatever happens
• The future is highly unpredictable
• Nevertheless, it is important to think about the
  future those who do prosper
• A good way to think about the future is to
  imagine different futures, usually called
  scenarios
• Two reports, one American and one British, have
  had similar thoughts about the future