I. Healthcare Models
If you go to the USA a lot of the people there are unhappy with the state of their healthcare system. They feel that it’s too expensive, that they pay way more than any other country in terms of percentage of GDP compared to the rest of the world and yet there are tens of millions of people who don’t have any form of medical insurance. “Let’s face it guys, we need a one payer system, because if you look at Canada and Europe their healthcare is so much more accessible with equally good health outcomes.”
If you go to Europe then you will meet a lot of people who say that we need to get rid of socialised medicine. There are too many patients who see their doctors for no good reason, the public are wasting resources, the government is too inefficient, there’s too much bureaucracy… “We need to go to the American model of multi-payer, private healthcare.”
How can there be such a paradox? How can so many people belonging to different healthcare models all be so upset at the care they are receiving? If this was a scientific experiment that you had set up in a lab, you would think that by now there would be a definitive “answer”. We would have reached a conclusion that says that one type of healthcare is certainly better than the other.
When we think of healthcare, I think we all think along pretty much the same lines. You develop a symptom that you’re worried about, you go to see a doctor, the doctor gives you some treatment or you get referred for some more specialised care from a specialist.
I know that this is what you think of when you think of healthcare, because this is how it’s delivered everywhere in the world. Whether you are in rural India, the wealthiest state in America or anywhere in between; this is what people have experienced and have come to expect from healthcare.
Although it is widely accepted that healthcare is probably the most complex service delivery channel in the world, there are still parallels with other industries that are worth considering here when thinking of how things are currently done.
Let’s take for example a HP computer. If you were to open up a HP computer and had a look inside, you are likely to find a number of components inside. You will find a graphics card, a hard drive, a CPU etc. Now say you got a Dell computer, opened it up and looked inside. You’re likely to find a graphics card, a hard drive, a CPU etc. Very similar to one another. In fact computers are often designed so that these different components can be interchanged with one another so that computers can be upgraded.
But what would the opposite of this system look like?
Say for example you got a computer which was designed by a company to be very small and very powerful at the same time. If you opened it up you would likely find similar looking things to the above example. However, the computer was designed to be small and powerful, as such, its components were specifically designed for this computer. So although the components are the same as the above example, they are interdependent on one another to work. Take one bit out and it’ll cease to work.
Healthcare is like the former example. You can think of each facet of healthcare as a separate component of healthcare. For example your primary care physician, the radiologist, the phlebotomist etc, are all different components. These components are all interchangeable rather than interdependent. This means that it doesn’t matter whether you go to London or Leeds for your MRI knee – the report and scan will be exactly the same with a similar radiology report attached to it.
This is essentially why people feel so much discontent towards healthcare from around the world. When people think of healthcare models they often think of how healthcare is funded. However, the real reason people are not happy with healthcare is not because of how healthcare is funded (private vs socialised), but rather, it is because of how healthcare is delivered to the patient. This is the real type of healthcare model people should be discussing.
Because of this model of healthcare the patient experience looks like this: See Primary Care Doctor about symptom –> Get some treatment –> Treatment unfortunately didn’t work –> See Primary Care Doctor again –> Refer to specialty –> Get seen by specialty doctor –> have some Imaging and blood tests –> get seen by specialty again –> Hopefully you’ve now been treated.
In the above example you may have a lot of missed diagnoses, a lot of waiting, a lot of tension, missed work, lost income, strain on relationships etc. Not a good patient experience thus a lot of angry patients calling for a new model of healthcare.
In the above example each one of those components are interchangeable. You may see a different primary care physician second time round, you’ll get a specialist that has been randomly selected, not someone with a thorough understanding of the condition you’ve been referred for, you’ll have to go to a different department for your imaging and get a radiologist looking at your scan with no understanding of why you’re really having the scan in the first place.
An interdependent system would look more like this: See a healthcare worker about symptom –> Get some treatment –> Treatment unfortunately didn’t work –> get referred to a specialist center –> Get seen by a specialist –> Have Imaging and blood tests –> further treatment
In this example the patient experience and health outcomes will be completely different. For example if you have a headache and get referred in this example case, to a headache center, you will get seen by a specialist with a special interest in this area and who is up to date with all the different medications, research and relevant medical evidence. Your CT head scan in this center would be carried out by a radiologist with a special interest, the scanning department would be set up to do only CT head scans increasing efficiency and the communication between the radiologist and the specialist would be far superior. After your investigations there would be counsellors etc available to help you with your diagnosis. Health outcomes would be better. Germany already have these headache centers set up. As a result, they found that patients didn’t have to take as much time off of work, they didn’t go to the ED (attendances for headaches went practically to zero), patients obviously had a better experience and it was cheaper to fund as well!
IV. The Transfer Of Work
It seems pretty obvious that having streamlined healthcare would produce better health outcomes as well as be cheaper. This is basically what Henry Ford discovered when he created his super efficient factories that did one thing really well. “Any customer can have a car painted any color that he wants so long as it is black”.
There are a lot of reasons why healthcare is not provided in this way already. Historical reasons – healthcare has been provided the current way for many years and political reasons – this is one of the main reasons most people think of “healthcare models” in purely economic terms. However, one of the main reasons that things are so stagnant is because of the attitude of healthcare providers and patients themselves.
If we are to really change the way we provide healthcare to an interdependent model, it means that the skills of different healthcare providers need to be embraced. This is where I may some things which are controversial, however as I have mentioned in my previous blog post; we are short of millions of doctors worldwide and this gap will only rise. The only way to meet demand, deliver good health outcomes and an acceptable patient experience is for healthcare systems to allow people who are adequately qualified (not necessarily doctors with a medical degree) to do more and more of the work.
Both patients and doctors may be weary of this happening. A lot of patients only like to be seen by a doctor and refuse to see other healthcare providers who would provide them with exactly the same care. For example, I have seen many patients who complain when they are made to see a nurse practitioner instead of a doctor in my own clinics. Many doctors also do not want this shift of work to occur. There has historically always been a fair amount of hesitation when “specialised work” from secondary care is transferred to primary care. However, there has never been a better time for this to occur and this should occur as soon as possible to improve health outcomes and reduce cost for all.
The reason why now is such a good time to shift care around is because of technology and our understanding of medicine itself. Reduced costs of medical devices and diagnostic tests definitely has had a massive impact. But the main reason is because of our understanding of medicine itself. Not too many decades ago medicine was performed by doctors relying a lot on intuition. There was a lot of theory, evidence and understanding that was missing. This has all increased to the point where we can now practice “evidence based medicine”. We are not quite at the stage where we have personalised precision medicine where we could take a patients symptoms, past medical history, characteristics, investigations, feed them into a computer to tell us exactly what treatment to give and exactly what health outcomes we would expect on an individual basis. But we are at a stage where if you have a heart attack or a migraine then your treatment plan would follow an algorithm based on a large set of data to increase the probability of good outcomes.
This new knowledge combined with new technology has allowed a shift to become possible. A pharmacist can now confidently diagnose you with a tonsillitis needing antibiotics using something like the Centor Score, give you the correct antibiotics and also rule out “red flags” which would indicate a serious medical problem requiring more specialised care. This would have a knock on effect where primary care doctors would look after the more complex patients in a specialty of their choice.
In the UK this has already slowly started to begin. We have GPsWSIs (pronounced “gypsies” or GPs with specialist interests). These GPs (primary care doctors) specialise in a field they find interesting, such as ENT (Ear Nose and Throat) and are able to do certain procedures and investigations which used to be the domain of the hospital specialist. So now GPs can perform a nasal endoscopy whereas previously this simply was not allowed to be done by anyone except a secondary care doctor. Some larger primarycare providers have started to realise this and are now creating larger practices where there are a number of different GPs with specialist interests in a whole range of different areas (almost lik a mini hospital!). When the majority of GPs are like this, the hospital doctors will be left with the most complicated and difficult patients to deal with.
There is no reason why this cycle of more work being done outside of the hospital can’t continue until one day, when we get to practice “precision medicine” you will very rarely have to go to the hospital and perhaps most of medicine won’t even be performed by a doctor. And why should it if health outcomes are not affected and is cheaper for all?