Wednesday, 3 August 2016

The central challenge for healthcare: avoiding the avoidable

One of the key questions facing health services today can be summed up in three words: avoiding the avoidable.

This is an international problem. I’ve been working around the healthcare sector, mostly in England but also in France, Germany, Switzerland and Spain since the mid-1980s. Much of the time, I was working for American companies through which I also gained some knowledge of the US system.

The graph below shows how expenditure on healthcare has grown, decade by decade, in those countries over that period (based on figures compiled by the OECD). The rate of growth is not the same in all of them, and the starting and end points are different, but they all show the same inexorable climb. Nor, despite all the moves to reduce expenditure – the NHS in England is on a five-year plan to save £20bn – there’s no sign of the upward pressure ending any time soon.

Notice that back in the 1980s, the US was spending a little under 10% of its income on healthcare. Today, it’s one dollar in every six.

The inexorable upward pressure on healthcare expenditure
(source OECD)
The reasons for that pressure are not hard to find. It is becoming possible to treat a constantly increasing range of diseases, which is wonderful for the patient seeking relief. Financially, however, it is far more problematic, as all those treatments have to be paid for, and many are expensive.

At the same time, life expectancy continues to grow in the advanced economies, so far higher numbers are reaching the period in life when there’s a much-increased chance of acquiring long-term diseases such as arthritis, heart disease, diabetes and so on. Many of these conditions are also influenced by lifestyle: this is the case of obesity and heart disease, for instance.

More to the point, many of our ageing population find themselves suffering from more than one long-term condition (LTCs as they’re commonly called, in a field that just loves three-letter abbreviations or LTAs). Take obesity: as well as being a dangerous LTC itself, it can also lead to coronary heart disease (CHD, of course) and type 2 diabetes. The patient may have arthritis too and perhaps the beginnings of dementia. Suddenly, as well as being a human enjoying a longer life than used to be possible in previous centuries, he or she is also a mass of conditions each of which needs treating.

Thereby hangs another tale. Western medicine has grown up in specialties. But how do you handle a patient with a heart, endocrine and rheumatic condition simultaneously? We need new models of care, based on multi-disciplinary cooperation.

When talking about new models of care, however, one that has to be right at the top of the list is a model that focuses on keeping patients out of hospital where possible. Hospital care is the most expensive form. Where in the past it was perhaps not a major issue for a patient to show up at a hospital because they were worried and no GP was available, today with the system creaking under the strain, that’s really no longer viable.

Here’s how it works. In England, to visit a General Practitioner incurs a cost of roughly £80. If that patient went to an Emergency Department instead, the cost would be nearer £150. Now imagine the situation where in that Emergency Department, the patient, an old man running a high temperature and coughing uninterruptedly, is being seen by a relatively junior doctor on call late at night. Will he have the courage to issue some medications and tell the patient to go home and see his GP in the morning? Or will he admit him, just in case?

If he does admit him and the patient ends up staying over two nights, we’re talking about a cost in the region of £1500.

That’s what I mean about avoiding the avoidable. If the patient doesn’t really need the hospital care, you’re talking about saving 80-90% of the cost of the treatment if you can avoid the admission.

In the next in this series, I’m going to talk about some of the ways in which that can be achieved.

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