Not the Best of Times

An astute observer of the healthcare system used to commence his conference presentations with faux modelling of future healthcare demand and supply, predicting 50% of the population receiving care and the other 50% delivering it by 2050. Like all good comedy, there is more than a grain of truth to this parody, especially given the crisp eating (6 billion packets a year and counting), sedentary lifestyle of the average Briton today. While there is a myriad of social, economic, environmental, and educational determinants of population health, a well organised healthcare system can ensure timely access, quality outcomes and experience, and affordability. Conversely, a poorly structured system has the opposite effect, notwithstanding the best efforts of those working at the coal face, leaving government and private payors with unenviable choices: rationing of care, debt and deficit, starving other public services of funding, or higher taxes. In Britain today, we have all of the above.

Given the context therefore and having assembled an esteemed panel of Commissioners to suggest reforms to the healthcare system, it was underwhelming to read the recommendations detailed in the recent Times Health Commission Report. While many of these recommendations were directionally sound, the Report contained little, if any, system level learning from international markets that have superior structures, funding models, and regulatory regimes, and instead largely advocated for optimisation of the current system via a series of high level recommendations. For example, the Report recommends unified digital health accounts for patients, a goal that has been achieved by numerous healthcare systems globally many years ago. Yet there is no substantive discussion in the Report on the critical policy levers to deliver interoperability, digital enablement, and other key enablers.

Furthermore, while there is some tangential mention in the Report of using data to ensure care is predictive, preventative and personalised, there is no articulation of how this would occur in reality and what resourcing would be required to support it. There are numerous global examples of health systems and providers using data to identify gaps in care and predict morbidity with a high degree of accuracy (better than 90%). These same systems then implement a proactive recall, assessment, and treatment model to ensure that patients with identified risks don’t deteriorate to the point of requiring hospitalisation. The critical capability that these healthcare systems commonly possess, is not just unified, actionable data, but sophisticated data analytics teams and models, capability to engage and recall patients at risk (essentially a marketing rather than a clinical function), and the resources to manage these patients in the community and in their homes with a sophisticated, omnichannel care management model. Without these elements, the scourge of chronic disease, that drives much of the avoidable utilisation and cost in the healthcare system, will not be addressed.

Another example is the Report’s recommendation to introduce more high-intensity theatre lists and 7-day a week surgical hubs as a means to remediate the appalling surgical waiting lists. When most of the NHS’ hospital infrastructure was built, surgical technique was radically different to today. Hence, public hospitals were traditionally (and still are) configured with large numbers of wards and beds to accommodate post-surgery patients. Yet the rapid innovation and promulgation of minimally invasive surgery, coupled with substantial strides in clinical homecare, has changed this dynamic. Instead, we now require ambulatory surgical centres (ASCs) or ‘surgical hubs’ as the Report calls them, with large numbers of operating theatres and few beds, and where most patients are discharged either same day or next day with clinical support in the home if needed post discharge. Large acute hospitals should be reserved only for complex patients and procedures and for emergency presentations. While shorter stay in hospital is becoming increasingly common in the NHS, the recommendation in the Report to build more ASCs radically understates the detailed, complex work required on current and future infrastructure and clinical homecare requirements in both the public and private systems.

In a similar vein, the Report also contained relatively superficial promotion of virtual wards, despite its potential to shift many of the medical admissions out of the four walls of the hospital. What’s missing from the Report is the understanding that viable virtual wards (and broader clinical homecare services) are dependent on the tripartite marriage of efficient logistics (think FedEx), technology, and sufficient high-quality clinical homecare. Without sophisticated capability in all these elements, the cost and quality of delivery is prohibitive. It is easy to recommend greater penetration of virtual wards to remove medical admissions and associated bed block from acute hospitals, but this is meaningless without the detailed discussion of current barriers to, and requirements of, efficient and high-quality provision.

It is also curious that the Report doesn’t consider the role that PMI could play in the current system. The question is never asked as to why such a small proportion of the UK population holds private medical insurance when penetration rates are substantially higher in other countries, even those with a national health service. For example, nearly 50% of the Australian population buys private hospital cover and the majority of elective surgery is conducted in the private system. This was achieved by legislating a community (not risk) rated PMI system where everyone pays the same price for the same cover (the young and healthy cross subsidise the old and sick) and where there is cover for pre-existing conditions and no treatment preauthorisation process. There are also tax penalties for higher income earners who don’t purchase PMI and subsidies for lower income earners that do. This has created a PMI system where those who have greatest need of access to surgery (the old and sick) can afford to pay for insurance. Perhaps the prospect of markedly increased PMI uptake is so politically toxic in the UK that the Commission punted this to the long grass (anything to avoid the dreaded ‘two tier system’ vitriol)? Perhaps the belief that increased private provision starves the NHS of scarce clinical resources still permeates? The conga line of doctors and nurses heading down under would suggest that this view may not be entirely valid.

There are far better ways organise healthcare in the UK for the benefit of the population, the economy, and those that work in the system. However, it is hard to see where the thought leadership will emerge from in the UK to make this a reality, regardless of the outcome of the next election. At least by 2050 I’ll be in the 50% receiving care from the other half of the population (if my sedentary lifestyle doesn’t kill me first).