Health professionals are living with paradox—they seem to have a dark future of financial decompression—but they also have, opportunities to use an emerging model of healthcare. They have to meet a new challenge of providing improved service for patients with long term medical conditions which seems to be an impossible mission —but so far from being hopeless better results are eminently attainable: the challenge is to break away from obsolete patterns of service and to use forces of innovation .
In the last thirty years there have been improvements in survival—the premature mortality rate has halved in the UK and infant mortality has fallen 70 per cent. In the US increased medical services have offset the potential effects on mortality of the higher rates of chronic illness with rates four times higher in the UK. Yet the proportions reporting restricted activity as a result of disability in most developed countries have shown little improvement and remain at around 40 per cent. We have improved survival but not very much the quality of life of those survivors who have long term conditions.
The new model has been emerging out of practice –from national strategies for CHD and for HIV-related conditions. It is also part of the urgent agenda in health services with little funding growth. Like all other areas of consumption buyers are looking to do more with less – sales at Aldi rose 28% in the last quarter. The new model already has a track record of success for improving outcome and in containing costs . It involves key stages:
Prevention. There is now clear evidence from Scandinavia and from the results of smoking cessation programmes that risk reduction and life style change can reduce morbidity. The social demand for healthcare can be contained—it is only infinite if provider incentives make it that way.
Early Diagnosis. In Coronary Heart disease identification of risk factors has shown that it is possible to improve outcomes. Ancel Keys and his work fifty years ago on cholesterol has been completely vindicated. Gains to earlier diagnosis are now clear in all major disease areas—cancer, heart disease, stroke, AIDS related conditions and others.
Active Treatment The coming of minimally invasive treatment and medium ticket diagnostics has made treatment much more accessible and lowered costs per case making it possible to improve access to care. Procedures such as cataract operation and cardiac procedures which were costly and difficult in the 1960s generating long waiting lists which impaired outcomes can now be done on a day basis. The insertion of stents on a day basis has substituted for 60 per cent of the long and dangerous CABG operations.
Care Programmes Improved outcomes from active treatment have created a new challenge of case management. The longer term experience means that communication with patients becomes a much greater part of care. Unless patients take responsibility for their own management costs of repeated consultations will put pressure on service standards.
The new model can use new digital technology to speed up diagnostics and improve communication with patients. Current health services spend vast amounts on services which are disconnected and obsolete—as with many of the 44 m outpatient appointments in the UK. A visit to A and E costs £140—a Skype contact (with staff costs) £17. Health services are the last stronghold of heavy equipment and big sites—with high costs in heating and maintenance.
This model is the core of the more successful programmes. In Finland the use of low cost prevention programmes has turned one of the unhealthiest populations in Europe in North Karelia into one with the lowest mortality Finland has also reduced hospital use for COPD patients by 38 per cent with a ten year use of a similar strategy. The new model shows that demand need not be infinite. In systems that use the model demand can be controlled; for example in Sweden hospital admissions rose 1 per cent from 2000-2009 compared to 36 per cent in the same period in the UK. .
The model can also be used to contain costs. It is a possible answer to the long running problems of cost escalation in health services. Even in the US—the world champion in healthcare cost escalation, total spending on CHD treatment has fallen in the last five year as result of the impact of statins in reducing disease and improvement of stents reducing the need for re-operation.