The futures of health care - BMJ resources

clatteringlippsBiotechnology

Dec 5, 2012 (4 years and 10 months ago)

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The future of health
care

Richard Smith

Editor, BMJ

www.bmj.com/talks

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?

Dangers of predicting the
future




I never make
predictions,
especially about
the future.



Sam Goldwyn
Mayer



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”

Looking to the future: common
mistakes


Making predictions rather than
attaching probabilities to
possibilities



Simply extrapolating current
trends



Thinking of only one future

Looking to the future: common
mistakes



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

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


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

Why bother with the
future?




The point is not to predict the
future but to prepare for it and
to shape it

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

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:
startingin
1994
and
1999


The first round was concerned
mainly with informing research
policy; the second was much
broader, including social impacts

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

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)


The methods of
Foresight


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, and social
implications


Ask them to make recommendations on
what should happen now to prepare for the
future


Disseminate with energy

The Foresight panels
1999


Healthcare


Ageing population


Crime prevention


Manufacturing


Built environment and transport


Chemicals


Defence, aerospace, and
systems

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

Healthcare task forces


Public and patients


International influences on
health and healthcare


Older people


Organisation and delivery of
healthcare


Information

Healthcare task forces


Delivering the promise of the
human genome


Pharmaceuticals, biotechnology
and medical devices


Neuropsychiatric health


Transplantation


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

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

Examples of future
scenarios for
information and health

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”

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

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

Pictures of the future of
health care

Pictures?


Asking people to draw pictures can free up
their thinking as well as those who look at
the drawings


It’s 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

Fee for service for the rich

Marks and Spencer style managed

care for the middle classes

Safety net service for
the poor

Two reports on the
future of health care

Healthcare
2020

Foresight Healthcare Panel

Department of Trade and
Industry, London

www.foresight.gov.uk


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


Selections from
Healthcare
2020


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


Patients and the public will come to
the heart of healthcare
--
but how will
this happen with the public?

Selections from
Healthcare
2020


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

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

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

Selections from
Healthcare
2020


Beyond electronic patient
records to “health biographies”


Cyberphysicians


Moving from information to
knowledge

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

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

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 people’s
health, detecting changes through
sensors, prompting preventive
activities and treatments

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

Health records: “the
problem”


Current health records are:


Paper based


Disorganised


Often illegible


Lost


Scattered


Poorly linked

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

Crossing the quality chasm

A new health system for the
21
st century


Institute of Medicine, 2001

Report’s opening quote

Knowing is not enough; we
must apply

Willing is not enough; we
must do

Goethe

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 today’s science
and technology; will be even worse
with innovations in the pipeline

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


IOM report: the problem


A system designed for episodic
care when most disease is
chronic



Health care providers operate in
silos

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 doesn’t vary by gender,
ethnicity, etc

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

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
system’s performance on safety,
evidence based practice, and patient
satisfaction


8
. Anticipation of needs


IOM report:
10
rules for
redesigning health care


9. Continuous decrease in
waste


10. Cooperation among
clinicians

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
England’s national service
frameworks


A fund for innovation


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


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

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



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

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


Conclusions


Health care systems will increasingly
be concerned with chronic not acute
disease


Health will increasingly be at the
centre not the edge of politics


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


Conclusions


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