futurepoints
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The future of health
care
Richard Smith
Editor, BMJwww.bmj.com/talks
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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?
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Dangers of predicting the
future
I never make
predictions,
especially about
the future.
Sam Goldwyn
Mayer
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Predictions of Lord Kelvin,
president of the RoyalSociety, 1890-95
"Radio has no future"
"Heavier than air flying
machines are impossible"
"X rays will prove to be a hoax
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Looking to the future: common
mistakes
Making predictions rather than
attaching probabilities to
possibilities
Simply extrapolating current
trends
Thinking of only one future
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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
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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
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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 tothink completely differently.
Charles Handy quoting Bernard Shaw
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Why bother with the
future?
The point is not to predict the
future but to prepare for it and
to shape it
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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 shouldbe plausible but different
Extrapolate back from those future
scenarios to think about what to do
now to prepare
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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:
startingin1994 and 1999
The first round was concerned
mainly with informing research
policy; the second was much
broader, including social impacts
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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
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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)
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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
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The Foresight panels
1999 Healthcare
Ageing population
Crime prevention
Manufacturing
Built environment and transport Chemicals
Defence, aerospace, and
systems
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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
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Healthcare task forces Public and patients
International influences on
health and healthcare
Older people
Organisation and delivery of
healthcare
Information
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Healthcare task forces Delivering the promise of the
human genome
Pharmaceuticals, biotechnology
and medical devices
Neuropsychiatric health
Transplantation
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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
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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
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Examples of future
scenarios forinformation and health
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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
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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
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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
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Pictures of the future of
health care
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Pictures? Asking people to draw pictures can free up
their thinking as well as those who look at
the drawings
Its 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
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Fee for service for the rich
Marks and Spencer style managed
care for the middle classes
Safety net service for
the poor
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Two reports on the
future of health care
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Healthcare 2020
Foresight Healthcare Panel
Department of Trade andIndustry, London
www.foresight.gov.uk
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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
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Selections from
Healthcare 2020 Chronic disease management will be
a cornerstone of future healthcare
Diagnosis needs to be made morerational--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?
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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 ofstem cells, xenotransplantation, tissue
engineering, induced regeneration,
modulation of the ageing process
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Selections from
Healthcare 2020 We have done badly with
neuropsychiatric illness, but it will
become steadily higher profile withrising 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
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Selections from
Healthcare 2020 Beyond electronic patient
records to health biographies
Cyberphysicians
Moving from information to
knowledge
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Information and health:
technological developments
Think for itself hardware and self-
generating software by 2020
Wearable computers; intelligentclothing
Personal agents-- digital butlers;
smart sensing
Electronic circuitry can be
connected to nerves and tissues
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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
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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 peopleshealth, detecting changes through
sensors, prompting preventive
activities and treatments
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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
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Health records: the
problem Current health records are: Paper based
Disorganised Often illegible
Lost
Scattered
Poorly linked
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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 thebody or home
Data mined
But beware Big Brother
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Crossing the quality chasm
A new health system for the
21st century
Institute of Medicine, 2001
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Reports opening quote
Knowing is not enough; wemust apply
Willing is not enough; we
must doGoethe
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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 todays scienceand technology; will be even worse
with innovations in the pipeline
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IOM report: the problem
A fragmented system
characterised by unnecessary
duplication, long waits, anddelays
Poor information systems;
disorganised knowledge Brownian motion rather than
organisational redesign
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IOM report: the problem
A system designed for episodic
care when most disease is
chronic
Health care providers operate in
silos
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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 doesnt vary by gender,
ethnicity, etc
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IOM report: 10 rules for
redesigning health care 1. Care based on continuous healing
relationships--care whenever its
needed, not just through face to facevisits
2. Customisation based on patient
needs and values
3. The patient as the source of control 4. Shared knowledge and free flow of
information
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IOM report: 10 rules for
redesigning health care 5.Evidence based decision making
6. Safety as a system property
7. The need for transparency--allinformation available, including the
systems performance on safety,
evidence based practice, and patient
satisfaction
8. Anticipation of needs
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IOM report: 10 rules for
redesigning health care
9. Continuous decrease in
waste
10. Cooperation among
clinicians
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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--likeEnglands national service
frameworks
A fund for innovation
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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 itis delivered into patient care
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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
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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 ofcare processes and outcomes
into daily practice
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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
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Conclusions
Patients will have the same access
to knowledge as professionals
Self care or rolled back care willbecome steadily more important
Professionals and patients will
become much more equal partners
Evidence will become steadily more
important
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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
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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 oneBritish, have had similar thoughts about
the future
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