01 January, 2012
Special note:This was written over the Christmas holiday in 2011. Readers can determine how the intervening time has affected the thrust of its key messages. A key perception that remains true in my own view is that the distinction remains between people who, in whatever walks of life, focus more on changing the landscape of health and care for the better; and those who concentrate more on managing the perceptions of people within that landscape. These latter are concerned with short-term managing of the symptoms of the malaise: they need to defend this year’s budget, or the share price, or their re-election hopes. Perhaps they feel that real solutions are beyond them. This is not so.
The NHS is dying on its feet. The most brilliant social innovation in British history – conceived for all the right reasons at a time of huge public need – is no longer able to do in 2012 what it was invented to do in 1948. The people who could save it by changing it fear to seem critical of this national treasure; and if they are in government they are petrified that it might fail “on their watch”.
Most of the problems that beset the Health Service are not directly of its making; and are most unlikely to be addressed via reforms from within either the Service itself or, more broadly, from the Department of Health.
The people who created the NHS over six decades ago could only be horrified at what has happened across the UK population within two generations: the rates of obesity, the steady climb in the populations of chronically ill; the steady rise in all costs of care but particularly with those arising from the explosion of the pharmaceutical industry.
Most critically, there would be dismay at the extent to which the traditional British virtues of enterprise and self-reliance have been overtaken in the wider population by passivity and a sense of entitlement. Everyone is now talking about people taking more “responsibility” for their own health as if they could not find the motivation and focus to sort this out for themselves.
Go to any strategically focused healthcare conference now, as I did in December with the World Health Care Congress in Abu Dhabi, and you’d think that two agendae were being pursued consecutively as distinct realities running along in parallel universes.
The traditional conference agenda talks of putting the patient first, optimising service standards and IT at the point of care, and committing more resources to preventative medicine – all the while characterising disagreements as either related merely to process issues or, if more significant, driven by political differences.
The “other conference” – still running as more of a shadow – is less concerned with the politics and is trying to identify what works, what can be afforded, and tries to identify what a world-beating health service might look like. How do we make this industry “great”? If our health economy were truly to put at its centre the people for whom it is designed to serve: what would we be doing that we are not doing now?
So what must we do?
Resolved: we must release the National Health Service from its historical, wholly honourable but now unsustainable objective of providing comprehensive health services free at the point of delivery to everyone entitled to receive them.
And more specifically?
- We need to relinquish our economic pre-occupation with the “point of care”. We cannot evolve from a reactive to a preventative health economy if we denigrate any investment anywhere in the world of health as a distraction if it is not focused on the “point of care”.
Of course this particular place will remain critical in the effective and efficient management of any health economy: the calibre of professional training, appropriate premises and equipment, intelligently applied information and diagnostic technologies – all must be maintained at optimal levels. What must change, and will change if we are not to die off as a civilisation, is the sense that investing in preventative health is a nice-to-have, rather than a priority in its own right.
This is not just a moral argument; it is starkly economic. The tide of chronic disease is a tsunami that is only now just beginning to breach the sea wall of our defences at the “point of care”. Living in 2012 as if it were still 1948 and blindly committing all our resources to this nexus point is akin to investing all our resources in paper towels to serve as flood defences in the growing cracks in that sea wall. This cannot go on.
- Insofar as the point of care remains critical as much to customer perceptions as to anything else, a new “philosophy of service” is required here. Those familiar with the atmosphere in the lobby of an exclusive hotel and in the waiting room of an Accident & Emergency ward would be surprised to see a sign in the former warning guests that assaults upon staff will be prosecuted; and yet they would understand the necessity of such signs in the latter place. While allowing for the basic differences in the service propositions of these two places, it remains possible to see how a less technocratic and more service-oriented atmosphere does make some A&E wards friendlier and more effective than others.
At the same time, and in keeping with the greater level of responsibility that people are being encouraged to take for their own health behaviours, it is wondrous that such a level of tolerance has built up in A&E wards for the volume of alcohol-driven demands on the resources of these places. Especially distressing for those who find themselves there for reasons more legitimate than just rendering themselves paralytically drunk in public, such incidents often lead to the confrontations that inspire those threatening signs. What better message could there be of the sea-change to come if people who showed up drunk in A&E were surcharged for the cost of their care?
- We must broaden the focus of attention of our health economy from “patients” to “customers”. People do not intersect with the world of health only when they are patients. In fact they are patients for only a tiny proportion of their lives, and too often as a result of not engaging responsibly with their health during the time when they are not patients.
The notions of custom and customers go far beyond a merely commercial relationship. The “customs” by which we engage with our health issues need re-examining. How as a society do we define what is “customary” as a means of working towards a definition of what is “desirable”? With this in mind we see that engaging properly with health means having the issues of one’s well-being, and that of one’s loved ones, at the front of our minds all the time, everywhere, woven into the fabric or our everyday lives.
Thus, attaining and maintaining good health is not just for patients but for everyone: parents with young children, grown-up children with aging parents, primary carers of the chronically ill; people with genetic predisposition to disease, people in dangerous or challenging occupations whose safety is at risk; and simply, everyone concerned with being healthy – too often thoughtlessly characterised as the “worried well” but more responsibly to be seen as the duly diligent.
This last is an important point: we cannot expect people to take more responsibility for their health and then complain when they actually do it.
A final vote for “customer” as our descriptor of choice is inspired by the growing trend to personalised medicine, as science tells us more about the individual expressions of illness arising from genetic and lifestyle differences of people, and our increasing sophistication in applying the data arising from people’s clinical and consumer interactions with their world.
Just as the idea of a “custom-made suit” has been part of our language for as long as tailors have been adept at cutting their cloth to suit the needs of individuals, so it will become more natural to think of customised health solutions arising from a more adept understanding of the personal needs of customers.
- There are billions of reasons why U.K. medicine must engage with the “digital agenda”, extending the clinical reach of our best doctors to a global population. Much is made of how the United Kingdom is competing in a new knowledge economy and this country is singularly well-placed to succeed in this area – particularly in medicine.
This country more than holds its own in terms of the excellence of our doctors and medical facilities, our academic and research establishments, our digital technology and media industries, and we are home to the language in which most doctors in the world are trained.
And this is more than a training opportunity. We are not yet exploiting the potential in “Social Media” at a time when the implications of chronic disease are pushing greater communities of interest online.
- Finally, and possibly most important of all, we need to understand, each of us, our own roles as health customers, as individual and as corporate citizens and, where appropriate, as leaders. None of what must happen will happen if we all continue as if the world of health could muddle along as a progression of what has been, rather than the necessary beginning of what must begin to be.
For politicians and health leaders, we need a more responsible engagement with the necessity of change, rather than private mumblings about the inefficacy of the status quo while saying in public that all will be well if we carry on with serially disruptive, enervating and essentially cosmetic re-inventions of the National Health Service that do not go to the root of the challenges it faces.
For our pilots of industry – particularly those of food, pharmaceuticals and health insurance – we need a more public and innovative engagement in defining their role as corporate leaders of a new health economy, understanding the huge benefits of improved public health not only for their workforces but for the communities in which they operate, for their businesses and brand images, and ultimately for their profits.
For hospitals and health professionals, there is a richer future in the articulation of a new role of engagement with well-defined local communities of healthy people, rather than as high priests of management of the sick, the terminally ill, injured and dying.
For the research, entrepreneurial and investment communities, there needs to be a greater and unapologetic commitment to the business of effective healthcare. Dedication to innovation must be inspired, driven by energy and promising of profit – but profit which itself is founded upon an understanding that there is no true wealth but life, and no greater dividend than a legacy of vitality passed on from our generation to the next.
Last but certainly not least, and for individual customers and responsible citizens, we need to look at our own relationships with our bodies, with our families and our communities – no longer in terms of entitlement but in terms of engagement. Good diet and a commitment to exercise are not the prerogative of the privileged, the educated and wealthy. Every health customer has it within their control to be their own monarchs; and nobody need accept the humble status of mere commoners, passive recipients of the learning or largesse of others.
A new and more effective, sustainable health economy depends vitally upon our re-defining the customs by which the condition of good health is understood, achieved and maintained. Not to do this will be financially ruinous to us as a civilised culture and criminally irresponsible as the ancestors we hope to become – whose legacy we must hope will be a celebration to our children and to all those who come after us.