the future of health care richard smith editor, bmj

The future of health care

Richard SmithEditor, 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


• “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


• 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: startingin1994 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


• 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?


• 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


• 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


• 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


• 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 chasmA new health system for the

21st century

Institute of Medicine, 2001

Report’s opening quote

Knowing is not enough; we must applyWilling is not enough; we must doGoethe

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


• A fragmented system characterised by unnecessary duplication, long waits, and delays

• Poor information systems; disorganised knowledge

• “Brownian motion” rather than organisational redesign


• 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


• 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


• 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

the future of health care richard smith editor, bmj

Documents

future slide

health slide

future heavier

future mean

privacy slide

energy slide

hoax slide

examples of future scenarios