Helping shape the future of health
Dr Andrew Murray, Cruden Leadership Fellow, Royal College of Physicians and Surgeons of Glasgow, Co-organiser of the Scottish Medical Leadership Conference, 21 September, Glasgow
The context
There is an innate paradox in healthcare: while the Scottish and UK NHS, and indeed many health care systems worldwide serve patients and populations well, ongoing improvement is always required; more of the same is rarely enough.
We have certainly come a long way. Global life expectancy for almost all of human history has hovered stubbornly between 20 and 30 years. In the last 200 years, life expectancy has accelerated significantly, increasing more in this time than the previous quarter of a million years, with global life expectancy at birth now standing at 71 years, whilst this figure is 81 years for the UK, and a world leading 84 in Japan[1].
Perhaps we do not celebrate enough the significant advances we make. Scotland helped bring the world antiseptic, anaesthesia, the Glasgow Coma Scale, antibiotics, CT and MRI scans as well as playing a leading role in medical education and training. Massive advances have occurred in health worldwide. There is a misunderstanding that things are becoming worse in health care systems. This is not true. They are getting better and will continue to get better. Fewer people are dying today than ever before due to violence, poor sanitation or hunger. People on average are better off economically and health wise than ever before. Fewer children under the age of five are dying, giving people the confidence to have smaller families, with fewer than 3% of Banglasdeshi children now not living to see their fifth birthday compared to almost 25% only 45 years ago[2].
Have we hit the ceiling - can we go no further? The truth is that things are changing at a faster rate than at any point in human history - this is ‘the age of acceleration’ coined by respected futurist Mark Stevenson[3].
The human touch will always be central to creating health and treating disease, but we are now assisted by the internet, incredible mobile phone technology, over half a million medications we can prescribe, information systems that can glean up to date knowledge on any given disease or treatment, mechanical systems and robots that can augment human capabilities, and new research focusing not only on new treatments, but on new processes and ways of doing things.
The challenges we face
We face new challenges in continuing this improvement. We are in some ways victims of our own success. Technology has afforded us globalisation, communication worldwide, and expectations of care and indeed medical education and standards are sky-high. Health needs themselves are greater with a higher percentage of older citizens with a heftier burden of chronic diseases. Type 2 diabetes costs the UK NHS over £1million per hour which is predicted to near double in the next 20 years - and this is at a time of austerity with the piggy bank empty.
With these demographic and chronic disease timebombs, doing what we are doing at present will not work. Increasing investment in health systems may be necessary, but is not by itself sufficient. Spend on the NHS has increased from under £500million in 1948 (£10billion in today’s value) to over £130billion currently - far outpacing GDP and total public expenditure[4]. The NHS is an intensely political issue and each election sees more money, and thousands of more nurses and doctors promised. Few believe this politics by numbers to be the answer, we need to build on previous success, invest wisely and do things differently. Wise, courageous leadership and collective action is required.
Inevitable next steps
Prevention and promoting health
The World Health Organisation define health as “a complete state of physical, mental and social well-being, not just the absence of disease or infirmity”. Significant amounts of premature mortality are partly due to an excess of risk factors for chronic diseases in Scotland, which include physical inactivity, unhealthy diet, smoking, and harmful use of alcohol.
Prevention is better than cure. NHS spend on preventative strategies totals less than 5%, despite Public Health England stating that physical inactivity alone kills 1 in 6 people, and costs the economy £7.4billion every year[5]. According to the Commonwealth fund, the UK NHS’s weakest dimension by far is ‘healthy lives’[6].
Together we can turn strategy into action, and the National Treatment Service into a true National HEALTH Service to reflect the stated aims of the Christie Commission[7], 2020 vision[8] and Five Year Forward View[9]
Creating health
Some studies have highlighted that less than 20% of health outcomes are determined by the quality of the health service. Better sanitation, adequate nutrition, and providing social cohesion are some of the factors that have helped us live happier, longer lives than our ancestors. We can use the assets approach highlighted by previous Chief Medical Officer for Scotland Sir Harry Burns in supporting factors that provide individuals and communities with a real sense of control of their destiny. We can do things with people, not do things to them.
Embracing technology and change
New things are coming including increasing use of technology to allow consultations by health professionals online, perhaps even virtual ward rounds as more patients are cared for at home. A fully electronic records system allows rapid sharing of information. The mobile phone will increasingly be used as a diagnostic tool, taking oxygen saturations, pulse and even processing bloods and ECG’s. Reliable monitoring and processing of tests will allow patients to be cared for at home more frequently, while technology will mean that people of 100 years old will have operations previously thought too complex or too invasive. Age will become less of a barrier to treatment.
Collaboration
An unswerving focus on our patients will bring increased collaboration and compassion. Health and social care will be fully integrated soon[10] and the interface between general practice and hospital care will blur. This logical pooling of efforts will lead to far closer work with sectors like education, transport, justice, finance and communications, looking to influence and shape the culture to make healthier behaviours normal, and systems to prevent health issues in people and populations more robust. These efforts will be measured to check that changes have led to improvements to inform further work.
The clear focus must be on our patients, with the assets of the 160,000 NHS Scotland staff, social care colleagues, territorial and special health boards, along with leading organisations like medical royal colleges, universities, medical education groups, regulators and trade unions fully utilised in collaborating to achieve lasting change and real improvement.
Leadership and medical education
Everyone working within health and social care will come to recognise themselves as a leader. To embed this culture of ‘collective leadership’[11] and effective leadership behaviours, will require programs and support at undergraduate and postgraduate levels, and during continuous professional development.
Engaging staff at all levels and developing these non-technical skills will be increasingly prioritised driving a continuous focus on improving quality, collaborative working and resilience. Hierarchies will be flattened considerably with an aim of generating wins for the patient and the systems, and allowing good ideas to flourish.
Technological leaps and different working and social patterns mean health professional education is changing. World class educational content and the ability to participate in educational events can be achieved from your own PC, whilst quality content can be syndicated and used globally. The boom in mobile device-led learning and podcasts means the commute and any spare minute can be used to accumulate knowledge. Non-technical skills will be further prioritised.
What else is possible?
What is inevitable is that life expectancy will improve worldwide, and in Scotland, but its extent and efforts at assessing quality of life are harder to be sure of.
Already technology has advanced sufficiently to allow robots to perform surgery directed by a human hand in another continent. Prosthetics can even improve human function, Paralympic performance may sometimes exceed Olympic achievement. The price of genetic testing will, according to Moore’s law inevitably drop close to zero[12], making it practical and perhaps even sensible for all to have full genome sequencing. If I knew I had a significantly increased risk of stroke, it would likely positively influence what I eat and the lifestyle choices I make. Patients may be able to make their own medication at home using a 3D printer[13]. This is the tip of the iceberg - and ethical considerations are overtaking what is technologically possible.
Health and the economy have proven to be the issues that matter most in parliamentary elections in Scotland and the UK. Closer collaboration is required between our politicians on health. Frank Dunn[14] points out that successive governments have driven major improvements in smoking rates for example, but politicians have also frequently presented the public with conflicting and confusing information. We need a consensus and collaborative approach to health from our politicians and medical leaders, although operations performed by robots may be easier to achieve.
Conclusion
A near tripling of average life expectancy worldwide is the greatest achievement of human civilisation in the last 200 years. But good is the enemy of better. Hoping that the problems we face will go away does not give our patients the best opportunity to live happier and longer, and may consign our children to a darker economic future. Providing the best healthcare for our patients will continue to challenge and reward in equal measure.
Many of these topics will be up for debate at the Scottish Medical Leadership Conference which takes place on 21 September in Glasgow. This FMLM regional event, in collaboration with the Scottish Academy of Medical Royal Colleges and Faculties, is hosted by the Royal College of Physicians and Surgeons of Glasgow, and features leading speakers including Mr Peter Lees, Lord Smith of Kelvin, CMO for Scotland Dr Catherine Calderwood. There is the opportunity to network, present posters, take part in discussion sessions, and workshops which include: social media for medics, health and finance in Scotland, paired learning, and FMLM's Leadership and management standards for medical professionals. I hope to see you there.
You can also watch Dr Andrew Murray's 'Toughts on the future of health' in video format.
[1] The World Health Organisation. Life expectancy: Global Health Observatory Data. World Health Organisation. 2015. Accessible at http://www.who.int/gho/mortality_burden_disease/life_tables/en/
[2] Hans Rosling. The Banglasdesh Miracle. Gapminder. 2007. Accessible at http://www.gapminder.org/videos/gapmindervideos/gapcast-5-bangladesh-miracle/
[3] Mark Stevenson. An Optimists Tour of the Future. Profile Books, 2013
[4] Diabetes UK. The Cost of Diabetes. Diabetes UK, 2014. Accessible at https://www.diabetes.org.uk/Documents/Diabetes%20UK%20Cost%20of%20Diabetes%20Report.pdf
[5] Varney J, Brennan M, Aaltonen G. Everybody Active Every Day. Public Health England. 2014. Accessible at https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/353384/Everybody_Active__Every_Day_evidence_based_approach_CONSULTATION_VERSION.pdf
[6] Davis K, Stremikis K, Schoen C, Squires D. Mirror, Mirror on the Wall, 2014 Update: How the U.S Health Care System Compares Internationally. The Commonwealth Fund, June 2014
[7] Christie C. Commission on the Future Delivery of Public Services. The Christie Commission. 2011. Accessible at http://www.gov.scot/resource/doc/352649/0118638.pdf
[8] The Scottish Government. A Routemap to the 2020 Vision for Health and Social Care. The Scottish Government. 2011. Accessible at http://www.gov.scot/Resource/0042/00423188.pdf
[9] Stevens S. Five Year Forward View. NHS England. 2014
[10] Lamb N, 2010-2015 Government Policy: Health and Social Care Integration. Department of Health. 2013
[11] West M. Developing Collective Leadership for Healthcare. The Kings Fund. 2014
[12] Mark Stevenson. An Optimists Tour of the Future. Profile Books, 2013
[13] Idem
[14] Dunn F. Take Politics out of Healthcare. The Herald. 2015