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Gordon Moore
Professor, Harvard University Medical School and world renowned authority on the design and implementation of healthcare delivery systems 
 

'Instead of throwing more manpower at their problems, multiple industries are using information technology to offload work to the consumer, connect the participants up in real time, and create smart, real-time process support.'

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Curing the Problems of General Practice

The Royal College of General Practice (RCGP) and the Centre for Workforce Intelligence (CFWI) agree: too small a supply of GPs will meet a rising tide of demand.  In the UK, spotty shortages exist now, but will become widespread over the next decade.

The causes of rising clinical demand are well known:
  • Continued growth of the things medicine can do
  • Surge of lifestyle diseases
  • Burgeoning patient devices that collect data and require monitoring by clinicians
  • Increased public expectations for access to GPs 
  • Aging of the population
  • Emergence of multiple, complex chronic illness
  • Diversion of GPs to management activities such as commissioning

Little analysis of root causes
Less is known about the underlying causes of the shortfall of supply in GPs.   The RCGP cites lagging GP incomes as a source of dissatisfaction, with consequent dampening effects on medical student choices of general practice specialist careers.   The CFWI models GP supply, but offers little analysis of the root causes of the declining intake to GP careers.  

While both the RCGP and the CFWI repeatedly emphasize the need to make general practice more attractive and increase its uptake, they have few suggestions about how to do so other than promoting it better.  In the meantime, they advocate, as does the NHS, that larger, multi-skilled teams must grow to service the increasing need, and that the key barrier to effective teamwork is lack of integration.

Concerns
I want to raise two significant policy concerns about the direction that the UK is taking to mitigate the primary care “crisis”.  First, I postulate that the reason that medical students are not choosing general practice is less a matter of money than of increasing practice complexity and life style.   Second, I suggest that the “solution” of larger, better-integrated teams is unproven and, further, may actually diminish productivity, and worsen, rather than relieve, the stress of work on GPs while their satisfactions further diminish.  

Lifestyle challenges
There is little evidence that medical students will select GP careers if they earned more.  In fact, over the past five years, during the rapid upturn in GP incomes, dissatisfaction among GPs grew and fewer medical students, especially men, chose to enter general practice.  In the US, studies have shown that life style is an important factor in the diminishing number of medical students entering primary care.   At the same time, corporate primary care is growing, and larger practices with more salaried doctors are becoming the work choice of preference. 

This suggests that young doctors are put-off by the complexity, responsibility, the long hours, and the stress of general practice, and seek to transfer those risks to someone else.  Without fixing this, throwing more money at the problem is unlikely to reverse the trend.   Money, of course, is important, but it’s merely an enabler of career choice and a deterrent if too low. Compensation alone doesn't appear to be a sufficient incentive to chose primary care.   

Multi-purpose teams failing
The idea is seductive that integrated, multl-manpower teams are a solution to the GP shortfall. However, early evidence from America doesn’t suggest that the US-version of integrated, primary care teams (the patient-centered medical home) is achieving the efficiencies and improved care that they were touted to deliver.  Recent studies  (see: Friedberg M.W., 26th February 2014, Journal of the American Medical Association) show some small improvements in quality measures, but no change in cost-effectiveness in a group of enthusiastic early adopters.   

There are many reasons to doubt that simple team integration occurs by encouraging it among those working together, and much to suggest that the cost of integration is a major barrier to a cost-effective strategy to increase manpower.   Information technology, as a field, discovered years ago that taking complex tasks and dividing them among many different subgroups was dis-economic.

Additional manpower not the answer
As long ago as 1975, Frederick Brooks in The Mythical Man-Month argued convincingly that by, “adding manpower to a late project makes it later”.  No surprise then that when one counts the cost of personnel, the coordination mismatches, the communication time, the complexity of handoffs, and duplication of services, teamwork is more a theoretical concept than a practical working model. 

Adopt best practice
What, then, might one consider as a possible solution to the increasing stress, complexity, and uncertainty of life as a GP? What is needed to facilitate integration among and between team members and patients?  Surely, we can draw lessons from other industries.  Instead of throwing more manpower at their problems, multiple industries are using information technology to offload work to the consumer (think of Cash Points), connect the participants up in real time, and create smart, real-time process support. 

The role of technology
Digital infrastructure for general practice has failed to keep up with the rest of the world.  The electronic medical record documents what has been done but does little to help doctors and other health workers to do their work. There is no infrastructure to help patients. Information technology should be providing an infrastructure to make general practice easier and better to do. 

Merely throwing non-GP manpower at their problems will make the life of the GP more complicated and less satisfying.   It is time to invest in true infrastructure innovation in the NHS.  It won’t be cheap, but it is the only answer to the threat that general practice will fail to meet the needs of the population in future.    
 
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Gordon Moore
Professor of Population Medicine
 Harvard University  Medical School

'We must tap into the largest unused source of manpower: the patients themselves.'


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Meeting the challenges of affordable quality healthcare

Health care systems throughout the world are about to be hit by a tsunami.  Dramatically escalating GP demand is driven by the growth of life-style-related chronic illness, the surge of baby-boomers, a primary-care doctor shortage in some countries, and, in America, the surge of unmet needs now paid for by Obamacare. Either the current system will seize up, or new ways of caring for patients must be found.

Traditional responses unsustainable
Typically, healthcare systems respond to increased demand by adding manpower: usually nurses and other health workers. Increasing manpower reduces the potential for economies of scale in which increased volume reduces costs. Even worse, with additional workers added to a healthcare practice, efficiency actually decreases as downtime, communication costs, turnover, coverage, duplication and re-work increases. 

Healthcare systems must find a way to reduce the costs as they struggle to meet this surge of demand.  The old manpower-based responses, which at first seem attractive solutions, are unsustainable in the long run.

4 musts
What are the answers? 
  • First, we must tap into the largest unused source of manpower: the patients themselves.  Anyone who cares for patients with diabetes, smoking, or high blood pressure knows that the best plans of GPs often are not carried out despite many repeated visits to the doctor or nurse. 
  • Second, to activate patients, care support for them must be truly patient-centred.  Patients need help to gain confidence necessary to take control of their own therapeutic pathways. Such a system of support requires “having your doctor in your pocket”, which should be entertaining, engaging, educational, available 24/7, continuously helpful, personalized, and safe.
  • Third,having your doctor in your pocket,” can only be achieved if IT is used in new and innovative ways.  The most cost-effective avenue by which we can move patients with chronic illnesses to become more actively involved in their own care is through the Internet, where dramatic shifts in user interfaces, devices, and process interactions are taking place almost daily. By transferring expert knowledge to patients and thereby creating a truly patient-centred system, caring for ones’ own illness will be no more difficult than using a cash machine or mastering a smart phone.  
  • Finally, if the Internet can facilitate the transfer of knowledge from the medical system to the patient, then also it can facilitate the transfer of expert health knowledge to lower the cost of all clinical personnel from doctors to nurses to health coaches.  If guidelines, such as those produced by NICE in the UK, are built into the process of care that health professionals use, we would have developed a system that significantly extends the capacity of health professionals while maintaining the safety and quality aspects of care that increasingly people expect and demand.  An apt analogy is the way that today’s cockpit technology enables all pilots to be as good as the best.  Through the use of technology, we can do the same in medical care.
The past is no indication of the future
Today, healthcare is largely using IT to reproduce what doctors have done in the past. The electronic record is little different to paper records.  In the evolution of any new technology, its application development goes through this stage. However, we must put IT to use in doing new things, in innovation that reduces our dependence on expensive manpower and in producing more value for less money.

Making such a transition will not be easy or inexpensive.  But the costs of remaining the same and trying to meet escalating healthcare demands by adding more costly inputs are higher and more threatening in the long run.  We should be investing in the future, not tinkering with the present.  
 
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Evidence from a recent survey of people with diabetes, suggests patient outcomes will improve if GPs provide healthcare information in video clips rather than paper pamphlets.

Traditional patient information is failing
"An indication that the current paper and web-based diabetes information is failing to improve patient outcomes is the fact that the incidence rates of diabetes in the UK are escalating. Currently, a plethora of diabetes information is provided either in paper pamphlets or as digitalized text on websites, but patients want healthcare information in video clips, and greater connectivity with their health providers," says Dr Seth Rankin, managing partner, Wandsworth Medical Centre, who conducted the survey.

Despite the NHS spending £10 billion each year on diabetes care, between 2006 and 2011 the number of people diagnosed with diabetes in England increased by 25%: from 1.9 million to 2.5 million. Today, 3.8 million people have diabetes, and this number is expected to increase to 6.2 million by 2035. In 2013 there were 163,000 new diagnoses of diabetes in the UK, the biggest annual increase since 2008, and the five-year recurrence rates of diabetic foot ulcers are as high as 70%. The population increase over the past decade only explains some of these increases.
 
 
Improving outcomes
Organizations treat the distribution of diabetes information as ends in themselves, and report the quantity of information distributed, but not the impact it has on outcomes.
 
By simply asking patients with diabetes how, when and where they would like to receive information to help them manage their condition provides an important missing social link between health professionals and patients, and can help to improve outcomes.
 
Patients' views neither sought nor acted upon
"When we ask patients living with diabetes," says Rankin, "we get a clear picture of what patients want. The fact that patients' opinions are rarely sought, and even more rarely acted upon, might help to explain why the incidence rates of diabetes are escalating. There's no shortage of resources and technical competences in the UK to treat and manage diabetes. However, communications between doctors and their patients living with diabetes throughout their therapeutic journeys are weak. This inhibits patient education, slows self management and quickens the onset of complications," says Rankin. 
 
Patient survey 
In 2014, 140 people living with diabetes from two London primary care practices participated in a six-week project to improve doctor-patient communications. Patients received regular video clips via email from their health professionals and fellow patients to help them improve the management of their condition. At the end of the project patients' opinions were sought in an email survey, which yielded 51 responses: a response rate of 36%.
 
Findings
  • 65% found video information about diabetes helpful
  • 72% prefer diabetes information from GPs via email
  • 70% want access to healthcare information anytime, anywhere and anyhow 
  • 52% prefer healthcare information in video format to paper pamphlets
  • 68% want more information about their condition
  • 14% visit Diabetes UK's website
  • 53% regularly search the Internet for information about diabetes care
  • Only 19% can distinguish between good and bogus Internet healthcare information
 
Takeaways
"Providing diabetes information in short video clips featuring local health professionals, which can be easily browsed by patients, creates greater connectivity between doctors and patients.
Unlike health professionals and paper pamphlets, video clips never wear out, and are available 24-7, 365 days a year. Further, any number of people can access them at the same time, from anywhere, on any device.
Our survey suggests that videos clipsare effective in increasing patients' knowledge of diabetes, and propelling them towards self-management. Video clips could be used for all manner of patient information on all manner of conditions," says Rankin.
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Keen to discover the effectiveness of short healthcare videos as a communication tool for patients, Dr. Seth Rankin, the managing partner of Wandsworth Medical Centre, London, emailed his patients living with diabetes short videos about their condition, and surveyed their opinions afterwards, which we report.
 
The clinicians
"Healthcare information in video format distributed directly to patients' mobiles is a more effective way to educate people living with diabetes, and propel them towards self management with an eye to slowing the onset of complications," says Rankin.    

According to Dr. Sufyan Hussain,an endocrinologist and lecturer from Imperial College, London, Clinical Lead on the Wandsworth project,  "Despite accounting for 10% of the NHS budget and 8% of UK's population diabetes healthcare systems still need considerable improvement, particularly in management, strategy and infrastructure. Communicating important health information via video, can help significantly to improve the quality of care and efficiency in an over burdened healthcare system."
 
Patient survey
 
During the six- week project, over 50% of diabetes patients opened the emails sent, and watched the information videos about their condition.
  • 75% of respondents say that they would like to have more reliable information to help them to manage their diabetes
  • 44% regularly search the Internet for healthcare information about diabetes, and 20% are undecided
  • Only 9% say that they can differentiate between good and bogus online healthcare information about diabetes
  • 68% found the video information they received by email helpful
  • 21% regularly visit Diabetes UK website
  • 71% want GPs to provide more healthcare information via email
  • 50% prefer to receive healthcare information about diabetes in video format, and 23% are undecided
  • 71% believe it's important to access healthcare information about diabetes at anytime, from anywhere and on any device.
It's important for me to quickly access premium and reliable healthcare information about my condition at anytime, from anywhere and on any device
NICE relaxing guidelines
These findings, if indicative of patient views, are significant. Recently, the National Institute of Health and Care Excellence (NICE) issued new draft guidelines to make more people eligible for weight-reduction surgery. According to NICE, such surgery would reduce the debilitating complications associated with type 2 diabetes.

Until now, people with type 2 diabetes only could be considered for weight loss surgery at a BMI of 35. The new guidance could mean that more than 850,000 people could be eligible for a stomach-reduction surgery if their doctors think they are suitable.

A costly therapy
Over the past five years, there has been a significant increase in the number of people receiving weight loss surgery. According to the UK's Health and Social Care Information Centre's latest report: in 2012-13, about 8,000 people received stomach-reduction surgery for potentially life threatening obesity when other treatments failed.

A mounting body of evidence suggests such surgery improves symptoms in around 60% of patients, which in turn, may result in a reduction in people taking their type 2 diabetes medications, and even in some cases needing no medication at all.

Stomach-reduction surgery, which costs between £3,000 and £15,000, does not mean that type 2 diabetes has been cured, and there are raised concerns that the NHS will not be able to afford the treatment, even if there are savings in the longer term. Furthermore, an irreversible procedure that does have surgical risks attached to it does not make it an attractive option for everyone. 
 
Takeaways
"We know about the escalation of the diabetes burden. We know that established therapies, diets and lifestyles could effectively reduce the burden of diabetes. And yet the burden shows no signs of slowing. IF patient data from the Wandsworth Medical Centre are indicative of the situation more generally, we should seriously consider the way doctors communicate with patients. Doing 'more of the same' is not the answer. We need to find new innovative solutions to engage, interact and motivate as many people as possible," says Dr. Hussain.

 

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What does the nephew of the 41st American President and the cousin of the 43rd have in common with an Indian doctor?

They're both passionate about using new technologies to provide high quality healthcare at affordable cost.

Bush and Shetty
Jonathan Bush, a relative of two former American Presidents, is the co-author of Where Does it Hurt? which calls for a healthcare revolution to give patients more choices, and affordable quality care.

A former Army medic and ambulance driver, Bush is the cofounder and CEO of athenahealth, one of the fastest growing American cloud-based service companies, which handles electronic medical records, billing, and patient communications for more than 50,000 US health providers.

Dr Devi Shetty is a brilliant heart surgeon, and veteran of more than 30,000 operations. However, his growing international reputation rests less on his medical skill, and more on his business brain. He wants to do for healthcare what Henry Ford did for the motorcar: "make quality healthcare affordable."

Shetty is the founder and chairman of Narayana Health, and by thinking differently to traditional healthcare providers, he's built, India's largest private hospital group comprised of 23 hospitals in 14 Indian cities.
 
Shetty practices what Bush preaches
Bush suggests that the only way America will provide convenient quality healthcare at affordable cost, is if doctors do what they're trained to do, others perform routine services for less: for example, nurse-intensivists relieve surgeons from ICUs, and most importantly, if healthcare entrepreneurs are encouraged to tap into the transformative power of the marketplace.

For the past 15 years Shetty has been practicing what Bush is now preaching.  Narayana Health provides high quality healthcare, with compassion at affordable cost on a large scale. For instance in 2013, its 1,000-bed specialist heart hospital in Bangalore alone, performed a staggering 6,000 operations, half of them on children. By contrast, in the same year, Great Ormond Street Hospital in London performed less than 600.

In addition to hospitals, Shetty has developed a telemedicine practice, which reaches 100 facilities throughout India and more than 50 in Africa. Narayana Health is also India’s largest kidney-care provider. Shetty has started a micro-insurance program backed by the government that enables three million farmers to have health coverage for as little as US$2 in annual premiums. Over the next five years, Shetty plans to grow Narayana Health four times its present size and become a 30,000-bed hospital chain.
 
Healthcare change will come from developing nations
Bush says, the only way to build a flourishing health marketplace that everyone wants and can afford is for Americans to demand more from their health providers, and accept greater responsibility for their own health.

This will not happen, and Shetty explains why.
 
Shetty argues that the greatest advances in healthcare will not come from wealthy nations like the US and UK, but from developing nations. Rapidly changing technologies provide opportunities for developing nations to leapfrog wealthy nations, which are encumbered by entrenched and aging technologies.
 
Hospitals in developing countries with few advanced procedures can quickly leapfrog world-class hospitals such as those in the US and the UK, says Shetty. Instead of slowly replacing aging technologies, they can quickly implement innovative operational designs, and state-of-the-art technologies, which gives them a competitive advantage.  
 
Narayana Health City Cayman
This is what Shetty has done in the Cayman Islands. Backed by Ascension, the largest private health network in the US, and the Cayman government, which has designated a 200-acre site for the development of Narayana Health City Cayman.
 
 The first phase, which opened in February 2014, is a 104-bed tertiary hospital, which provides surgeries for less than half the average US price, with quality outcomes that match or exceed the very best US hospitals.  Narayana Health City Cayman is expected to develop into a 2000-5000-bed conglomeration of JCI accredited multiple super speciality hospitals in a single campus providing affordable healthcare to thousands.
 
Takeaway
Americans will have access to high quality healthcare at affordable cost, but it won’t happen in the way that Bush anticipates. Grand Cayman is only a 30minute flight from Miami.
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It's a travesty!

Health professionals don't effectively use mHealth strategies to proactively engage and support people living with diabetes. This failure destroys the lives of millions and unnecessarily increases healthcare costs by billions. This is a travesty.

Health information online
In the UK and US the majority of people living with diabetes and pre-diabetes have smartphones, which they use on a daily basis to send and receive information, purchase goods, bank, educate and socialize. Notwithstanding, 80% of health professionals still provide information for the management of diabetes in paper pamphlets, and the majority of diabetes care information on websites is digitalised paper pamphlets. Such communications strategies, cost millions, and fail to slow the progression of the condition.

Epidemic
Here's evidence, which suggests that current healthcare communications strategies are failing. Recent UK data released by the NHS show that people diagnosed with diabetes has increased significantly over the past decade. Today, 6% of UK adults are registered as diabetic, and an estimated 0.85 million people have diabetes without knowing it. In 2013 there were 163,000 new diagnoses: the biggest annual increase since 2008.

A 2014 study reported in the British Medical Journal revealed that the prevalence of pre-diabetes in England has tripled in eight years, from 11.6% in 2003 to 35.3% in 2011, which puts immense pressure on NHS finances. It's projected that by 2025, five million people will have diabetes in the UK.

The situation in the US is similar. Results of a 2014 study published in the Journal of the American Medical Association, show that there was a significant increase in diabetes between 2001 and 2009, and warns of a growing epidemic that could strain the American health-care system.
 
Diabetes UK report
Governments and charities are good at describing the burden of diabetes, but poor at introducing and promoting effective mHealth strategies to reduce the burden. In a 2014 Diabetes UK report, Barbara Young, the charity's CEO says, "The NHS is spending an eye watering amount on diabetes (£10 billion annually), but the money isn't being used effectively." Those who are diagnosed late or don't receive timely care can suffer complications such as kidney and nerve damage, which costs the NHS billions.

The Report emphasises the importance of better education on how to manage diabetes, and stresses that a staggering 80% of the £10 billion the NHS spends on diabetes goes on treating complications, which may have been prevented if patients had received more effective information about the condition.

If nothing changes, the Report suggests, by 2035 diabetes will cost the NHS £17billion a year, and thousands of diabetics will suffer unnecessary complications.

Online managed care systems
Where's the leadership to help change the situation?  There's evidence to suggest that when mHealth strategies are used in the management of diabetes, they slow the progression of the condition, propel self-management, and significantly reduce the costs of care.

For example, Professor Shahid Ali, a UK practicing GP and Head of Digital Health, University of Salford, has developed and implemented a mHealth system, which enhances the quality of diabetes care, while substantially reducing costs and increasing the efficiency of health professionals. 
 
In the US, Welldoc a successful technology company, founded in 2005 by an endocrinologist, provides  a mHealth solution for people living with diabetes, which coordinates diabetes care, propels self-management and achieves long-term adherence.
 
Professor Gordon Moore from Harvard University Medical School has developed a managed care system that embeds the clinical, behavioural and motivational aspects of diabetes care into any handheld device. It's like, Moore says, "having your doctor in your pocket".
 
Notwithstanding, governments and agencies responsible for enhancing the quality of care for people living with diabetes are failing to bring such tried-and-tested mHealth solutions to their attention.
 
Takeaways
According to Diabetes UK's, we, "know what needs to happen":
  • "More focus on ensuring that people know about diabetes
  • Provision and promotion of effective self-management
  • Integrated care planned around the needs of the individual
  • Effective promotion of lifestyle change."
But, how many more people living with diabetes have to endue unnecessary progression of their condition, and devastating complications, which cost health systems billions, before health professionals abandon their costly and ineffective communications systems and embrace cheaper and more effective mHealth strategies?  
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