For the first time in human history, infections do not head the WHO list of biggest killers in the world. Long-term conditions – such as diabetes, cardiovascular, airways and kidney disease and mental illness – are bigger threats. This is, paradoxically, compounded by the improved survival rates thanks to the 20th century’s medical advances.
This is overwhelming healthcare systems, as they struggle to cope with this massively growing burden and unsustainable costs. Something needs to change.
To date, innovation in disease management has tended to be incremental, with ever-diminishing residual gains via costly refinement of diagnosis and treatment. This cannot be the most effective route to improving global health. Indeed, the United States just experienced its third consecutive year of falling life expectancy – unique in the developed world – and this is in the country that spends at least 30% more per capita on healthcare than any other country.
We have fundamental choices to make. Healthcare innovation can go in two directions: increasingly expensive treatment for the few, or cost-effective healthcare for the many.
‘We’ve always done it this way’
Smart, mobile, connected technologies are the potential saviors of healthcare systems worldwide. The only possible solution to the global challenge of healthy ageing is to exploit the connectivity of our consumer devices as diagnostic and monitoring tools.
But medical data have traditionally been the preserve of the healthcare professional in the patriarchal doctor-knows-best systems of care that perpetuate patients’ helplessness and dependency. Breaking this cycle will not be easy, particularly in the transitionary period in which the current middle-aged patient did not grow up in the era of everyday smart technologies, and the current middle-aged healthcare professional may have become dependent on their patients’ dependency.
How do we break this behavioural cycle? The answer can only come from incremental changes driven systematically towards an idealized model of care. Each step in the process needs to be framed in simple terms for both the recipients and deliverers of care as an improvement to the existing service. This is evolution rather than revolution – conveyed as the same but better, not different.
There are many pathways in conventional healthcare that, though universally followed, are universally unfit for purpose. The long-term conditions, all of which are increasing in prevalence, are all characterized by periodic crises such as heart attacks, strokes, chest infection in airways disease, requiring emergency care and hospital admission. Despite optimal in-hospital care and stabilization, many patients bounce back into hospital in the first 30 days after discharge. Yet the majority of these readmissions are entirely avoidable – 80% of readmitted patients have had no healthcare contact since hospital discharge. This appears both ridiculous and obviously remediable. Measures as simple as automated daily text messages or phone messaging as a reminder to take tablets would have an impact, as the evidence now shows. A next level might be to request a simple response to indicate stability or deterioration, triggering a pre-emptive pathway.
This systematic approach to change by progressive improvement not only provides acceptable and workable routes to implementation of better care, but will also be cost-effective and scalable, across geographies, diseases and patient groups.
Phones v carbs
The current obesity-diabetes global epidemic is not surprising given the primitive drive of humans to crave carbohydrates and to consume this once-scarce resource when available. But we surely need to address this problem at a more fundamental level than by government legislation to reduce sugar content in foods. Despite irrefutable evidence of a link between obesity and the long-term health conditions, weight-loss programs are rarely implemented or effective.
What if this stalemate were broken by the public, patients and their trusted carers if they receive meaningful and actionable representations of health data via their personal consumer devices? Smartphones are already capable of showing how consumers are doing, guiding them to better health and rewarding them for achieving goals.
Indeed, in the age of smart consumer technologies able to monitor and measure behavior, and providing a route to reward the citizen for healthy choices, even if more subtle behavioural techniques fail, hard cash – representing a share of healthcare cost savings – could serve as a compelling motivator.
For example, one private healthcare specialist in the UK offers an Apple Watch Series 3 for £9 upfront: a fraction of its standard price. Customers taking up the offer pay nothing more if they stay active and track their activity to earn “vitality points”. Crucially, lack of activity will incur a monthly cost of up to £11.25, depending on activity during the previous month. It’s the carrot and the stick in the context of healthy choices.
Free at the point of care – the UK NHS at age 70
As the world grapples with how best to improve the health of the population cost effectively, there is a growing fascination for experiences in the most famous and biggest socialized healthcare system in the world – the NHS, serving 60 million people in the UK.
Asked by a growing number of interested US and global organisations, physicians and now citizens to give talks, I often feel welcomed Yoda-like. There’s typically an expectation that experience as an NHS physician will unlock the sustainability challenges facing healthcare worldwide – and in the US in particular as it agonizes over healthcare reform. Requested talk titles (e.g. ‘The American Healthcare System is Too Wasteful: What the Brits Can Teach the World’) hint at both the desperation that surrounds this challenge and the sense of my representing life in a mysterious parallel universe.
To some extent, this is the case: physicians and other healthcare professionals do operate in something of a parallel universe. It might go without saying that the expectation of healthcare delivery is always that health of the population becomes progressively better and more cost-effective. Maintaining health and wellness is indeed incentivised by NHS-style “socialised” medicine – in which both the funding and delivery of care are provided by a unified single-payer system – and therefore motivated by disease prevention and maintenance of wellness. Such a system obviates the perverse incentives inherent to a fee-for-service financial model motivated by highly profitable treatments for the sick, rather than preventative measures.
And so the solution lies in harnessing connected technologies and innovative pathways to maintain good health and disease stability in a unified healthcare system in which a healthy population is the political, social and economic driver.