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Health and well-being

Health and well-being

Health is a world issue. Many of the most acute needs, and many potential global problems, lie in the poor nations. By 2020, four billion poor people will probably still be without adequate care, public hygiene or housing. Some two billion will have the basic needs met, but will be looking to more, and to medicine as a part of the package of public goods afforded by the state. Something over one billion will be reaping the fruits of the extraordinary potential latent in biological understanding, and their appetite to consumer ever-larger quantities of this will be accentuated by demographics.

The issues of development are reviewed elsewhere. Here, to emphasise the issues of change in heath care itself, rather than its finance or basic introduction, we focus on the industrial world.

Three forces seemed to be creating relevant change in these nations: demographic change, knowledge (coupled to technical capabilities) and consumer sophistication. These forces were confronted by three weighty sources of inertia: scarce resource, poor organisation and risk aversion amongst regulators, politicians and the general public. Risk aversion can, of course, expand to become the rejection of entire bodies of practice, notably if the technologies are seen to be threatening, the benefits dubious and the practitioners unreliable.

Figure 1: Six forces that must be resolved.

Beyond the industrial world, there are aspirant billions. Here, growing wealth, capabilities and integration with global opportunities will create a distinctive and often new set of demands. The basic science that is applicable to medicine in such regions is relatively poorly developed. However, first world technologies may be applied very rapid in these markedly less restrictive regulatory regimes. Indeed, the adequacy of control of dangerous technologies is everywhere a major issue, but of greatest concern where control is lest developed. Regulatory issues will become important in international affairs. So, too, will be the agreement and incentive to create of products destined to be used predominantly in low income areas.

Figure 2: Health share of state spending rises with income.

As Figure 2 suggests, demand for public health services has risen faster than state income. It is surprising, however, that demand for private medicine does not grow ahead of public provision. Indeed, two thirds of the differences between national male life expectancy can be explained by variations in public health spending, both in absolute terms and as a proportion of overall state expenditure. Private expenditure is negatively correlated with longevity, suggesting that we buy private care when public services are at their weakest.

Technical change will become increasing dramatic. Stems cells may give us new organs; but so may pigs. Genome scanning may tell us much about ourselves. It may define regimes which for the individual and for groups which will preserve health, use interventions precisely and manage defined sources of risk. The public good (and commercial rationality) may force regimes upon us as individuals and as members of vulnerable groups. The social and legal implications of this have yet to be explored.

The greatest benefits from the fundamental advances that are in train cannot yet be foreseen. The outcomes will, without doubt, be multi-faceted. The key applications may be found in managing the susceptibilities of populations or the specific needs of individuals. Insights will guide rational drug design. Statistical insight may support risk management and evidence-based policy formation. Applied genomics may lead to the creation of specifically 'genetic' mechanisms of intervention or to the better understanding of in vivo or in vitro regeneration.

One central truth of medical care is that early and appropriate intervention creates disproportionate gain, and usually costs relatively little. Technologies which alert us individually to the early indicators of disease - for example, to stage0 cancer - must have a disproportionate impact. Such techniques are often non-invasive, may be rendered routine for domestic use and may, for reasons associated with advances in population genomics, be focused upon susceptible sub-populations. There may be great potential in developing the potential for interaction between these capabilities, domestic IT and the integrated health system interfaces which we discuss in a subsequent section. Further, targeted diagnostics - which establish the genetic basic for or clonal lines within in a tumour, for example, or tools which can trigger apoptosis in cells displaying specified surface markers - may have very powerful and ramifying implications. Some of these technologies require the full thicket of regulatory delay to be negotiated, whilst others do not. Their arrival may be surprisingly swift.

There may be considerable synergies between technologies. Robotic surgery will need input from biology, of course, but it will need engineering, image processing, sensor systems and multi-layer semi-autonomous software at least as much. Information technology may monitor our physiological state so as to keep us balanced and poised as we age, or whilst we shift between the attractors of multipolar disabilities. Biological technologies may fend off the onset of age and keep us poised and functional, but tailored social processes and financial ingenuity may reduce stress upon us as we age and may offer us humane support. Information technology-mediated tasks - such as counselling the errant young or the wavering old - may give us a role in life. As a result of all of this, we shall almost certainly live longer. We may cost disproportionately more in doing so; yet we may also be gainfully employed for longer.

There are known to be around five publication cycles between a key basic discovery and its embedding in practical potential, and around the same period to move from these statements of potential to something which enters the regulatory race. Equipment tends to move somewhat faster than this, ethical pharmaceuticals considerably slower. A 10-25 year lag between latent potential and actual practice seems generic and unlikely to change quickly. Explosive commercialisation may accelerate this - as characterised information technology uptake during the 1990s - but there will be pressure on regulatory regimes from both directions: to make them stronger, and to make the swifter. "Leakage" through regimes elsewhere must be anticipated as a rising force.

Technical change is predictable when it is the dominant force. More complex areas are, however, affected in relatively unpredictable ways. The introduction of anaesthetics had an initially foreseeable outcome. Today, however, better anaesthesia allows longer, more invasive surgery but also permits 'day' surgery for hitherto very serious interventions. As the level of mutual interaction between the disciplines grows, so the pace of change in practice may greatly exceed the speed with which any one component moves. We may find that practice changes even faster than technology. Completely new industries will be born in the next few decades, greater in economic scope and social impact than anything that we have seen since basic industrialisation.

New expectations and new kinds of contract with those providing health care will emerge. Health care, like education, is something which we usually need most when we are least able to earn. Most industrial populations expect the public purse to provide in adversity, yet the funding of this is improperly developed. The age bulge of many OECD countries present a novel and enormous problem. Japan, Austria, Italy and Germany are examples of nations which have made minimal provision for the direct costs of dependency. For example, the composite French, German, Italian pension bill will require 40% of their joint national income by 2050.

These figures and forces point to the need for very considerable change in the health industries of the OECD. There are two fundamental issues that have to be explored. First, the mechanisms of health delivery need to be re-considered. Second, the means by which these mechanisms are to operate (to self-optimise, to exhibit adaptive, locally-focused wisdom) also needs to be defined. These issues are considered in the second part of this paper.

The mechanisms of delivery.

Health, in common with other vast, semi-statal systems such as defence-aerospace, seems to have self-evident if rather general goals. Under these generalities, however, balances which have to be struck. Here, the criteria are far from self-evident. It is not at all clear what to do or how to do it; and there is little consensus as to the approach to be taken to these issues by the various interests that are involved.

The staff of health-providing organisations are generally high minded and highly motivated, and they may see the goals of their particular part of the system as paramount and self-evident. Each, for the best of reasons advocates their parochial goals. Much of the complexity of the modern health system has arisen from its roots in disconnected, problem-focused activities. To this must be added advocacy groups that act directly upon health provision, litigation and the threat of it and the generic political instability with which those spending a large fraction of state income must, perhaps inevitably, live.

Much of the complexity - and thus inefficiency - of contemporary health systems appears to stem from three related weaknesses.

However, not only is there no appetite for debate, but there is also no national-scale machinery or focus through which it might occur. Health policy is a highly researched field, and there are many dedicated think tanks and academics who work on these topics. Further, there are data to inform the field as there is in few others. However, society needs inclusive discourse rather than lucid, academic debate if it is to decide what options it has with regard to its health provision. Such a debate is wholly lacking in the established policy channels. Closed debate may arrive at conclusions which make every sense to the closed rationality which generated them. It seems logical to restrict bypass surgery for chronic smokers who are clinically obese, for example, but this perspective may prove utterly unacceptable to the general public.

We began by noting three drivers of change and three sources of inertia. Poor organisation (and forces which obscure direction, or prevent change) serve as one source of inertia. We have discussed some of the sources of these. Second, all health systems face scarce resource. This situation will get relatively worse as the OECD populations get older and as we all expect more. Other claims on state income will demand that our health services become more effective in delivery and, at least in transition, that we pay for more of our own needs from our savings. Health provision may well become less equal, at least in the medium, term. This sits ill with 'gray power' as a likely powerful political force in the decades to come.

Third, both legislators and the general public share an aversion to risk in the health sector. The reasons for this are understandable. Political careers are destroyed on technical issues which emerge from obscure corners. As an example, "Jennifer's Ear" had a major impact on the UK 1992 election. A sequence of problems associated with food came to a climax with BSE. The resulting distrust has cost a direct UKPDS10-20 bn of public money in new measures, compensation and disruption. The climate so created was, without doubt, instrumental in the subsequent UK reaction to GM crops. It remains the case, however, that large areas of medical testing is error-prone. Studies suggest that about a tenth of patients are being treated for the wrong disorder. Pathology assessments have a best-practice error rate of around 2.5% in the less straightforward areas. Assessment for Fragile X syndrome segregates about 30% of samples into a "can't know, don't know" category. As a rule of thumb, about 30% of medicines that are prescribed work, and about 30% do not. A further thirty percent are thrown away, and ten percent make the patient more ill.

Actuarial assessments of sources of risk and public acceptance of these are almost complete unrelated. Pesticide residues are substantially less dangerous than the natural toxins present in insect or pathogen-affected crops. Most herbs, spices and natural stimulants - and much cooked food, such as charred toast or grilled meat - would fail an elementary toxicological screen. Cigarette smoking, sun-bathing and alcohol use are demonstrable individual and public menaces, yet these have become socially sanctioned. Pervasive, ill-understood risks concern us greatly. Our food is adulterated, manipulated by unknown influences and it is not 'natural'. That most of our diet is new to the species over the last 500 years (and virtually all of it novel in the past 5000) does not deflect from this irrational search for the wholesome. (A diet 'natural' to H. sapiens would major on fallen fruit, carrion and insects: perhaps a new line for the supermarkets?)

What, then, are the proper mechanisms of delivery of health systems in which the population as a whole can place their trust? (Note, please, that the means of keeping these systems up to date and adaptive are discussed in the subsequent section. )

At least five streams of choice and activity have to interact within any such a system. They need to do so in appropriate time frames, which will always be much longer than media enthusiasm or political vicissitude.

Each of these steps involves substantial change, considerable work and political risk. For example, empowering the 'customer' will weaken other stakeholders. It will take time and resource, probably starting at school and continued through a network of advisors and counselling, network-trawling and self-education. It will entail some health centres growing in unplanned ways and others going bust. It will increase litigation and enhance pressure on doctors. It will also allow a re-introduction of 'wisdom' into medicine, establishing a partnership between the reasonable, creating powerful mechanisms for others to become reasonable.

It is worth noting that the customers are already creating such changes, whether it be through support groups or agitation, self-education or internet help forums. Advocacy is now a major profession, and the advocates target everything from the research industries to the policy process. The successes of the AIDS-focused interests have produced alliances around age, disability, care provision and 'whole person' medicine. These groups are now afforded the trust hitherto directed at the doctor as authority figure, and some of them do not merit the transfer. Indeed, the level of charlatan claims is astonishingly high when compared to the age when medicine could do, in essence, little but support and hope.

Managing the mechanisms.

It is not impossible to see how any one of the four issues suggested in the preceding chapter could be put into place. The level of effort is considerable and the details of implementation would turn many systems on their heads. At issue is, however, the way in which such complex, loosely-coupled systems can maintain themselves.

The central insight seems to be that day-to-day operations (and the oversight of this) have a time frame with is completely distinct from the machinery of adaptation. Consider Figure 3, which is adapted from the Nuffield report 'Genetics and Health'.

Figure 3: Loosely coupled domains.

The connections which are shown are clearly a small subset of the true influences that are at work. If such a system is to acquire a direction, a 'brain', then it needs short- and long-term corrective features.

There is no shortage of immediate drivers. Politicians respond to the media, the media to the events of the moment. Five year plans - to reduce coronary hear disease, for example - will lead health managers to order more arterial bypass operations -but not to spend resources trying to reduce the root causes of CHD, such as smoking. Political time frames set criteria which lead to resources being wasted. However, politicians react to the pressures upon them and do so without any long-term framework upon which they rely. They cannot be expect to invent a complex, technically-satisfactory, self-correcting, evolving long term view on health, any more than they can invent a future for any other expert topic to which they are outsiders. This is a gradual process in which the professionals in the activity - health, law, defence - need to be involved.

However, we have placed an expectation of instant expertise upon politicians. They are to invent the future of every sector which they touch, often doing so in very short periods of time. There is no alternative available, and the voices that demand action are both loud and focused on the electorate. Pressure groups want it yesterday. Science pours in possibilities and potential expenses. Individual parts of the health delivery system find a voice and complain when they feel affronted or alarmed.

For all that these are the voices of an open society, however, they are neither systematic not, in truth, much help in adapting the system to become fit for purpose. They create something closer to Brownian motion than a flow. What is needed are two distinct structures:

This could be taken as a recipe for democratic power without the politician. Such a happy state is, however, unlikely either to appeal nor to occur.

The custodians of the 'strategic' process need to be responsible to politicians both for the construction of the processes that will be followed and for their happy outcome. Politicians will be needed to overcome the inevitable power struggles that develop when silo walls are merged and local independence increased.

The regulatory process is, in many ways, very similar to the regulation which occurs today over complex industries, and political accountability is well-understood in these. The cross-cutting nature of the task requires political salesmanship, needs translation into terms that the public can follow and requires media management and the related portfolio of skills.

Past attempts to reform the UK health sector have produced much change, but limited reform. The guiding principle - that there should be no 'new architecture' save a market clearing mechanism - has proven flawed. Market mechanisms should allow real choices and experiments, real successes and real failures. They require symmetry of information. If patients were able to desert consultants with poor track records, then these would go broke. In practice, the patients cannot know, cannot anyway exercise choice and are usually lucky to get to the head of a queue. It remains in the profession's hands as to what happens to the pertinent information. Hospitals are not allowed to fail, staff are not paid by results or geography. An air of 1950s uniformity and mass production hangs over the entire enterprise.

Re-design that takes account of asymmetries, of political limits, or the practical pace of change therefore needs something other than self-assembly. It requires a feat of design of re-design and of continual experiment. What this might look like in detail awaits the appropriate assessment. The features spelled out in this note are, however, inalienable parts of this whole. Their most important parts comprise:

Figure 4: The very general architecture of a renewed system?

This - or a related - structure will not arise without political will. It is easy to distinguish the two phases that are entailed in this. Initially, it will be necessary to set up the structures and allow these to shake down in largely conventional ways. Second, as the various parts of the system begin to make calls on each other and present their perspectives to a common set of filters and asset allocation mechanisms, so the change in operational logic would role itself out. Local and pragmatic accommodations, particularly in the 'client focused' area of the figure, would lead to substantial pluralism in the system. The managerial demands of all of this would be - will be - substantial.

We have focused heavily on issues of public debate. The interface between the individual, rather than the public, with the system as a whole is increasingly seen as unsatisfactory. The role of the GP, for example, has changed out of all measure. At the same time, the primary point of presentation is as likely to be a psychiatric worker or a carer as a GP, a policeman as a paramedic. Whilst the system needs to assess the patient-client and assign to them the flow of services that are deemed necessary, as central figure who offers continuity, personal contact, a whole-person perspective will remain deeply important. That they are assisted by expert systems and informed by remote sensors does not remove the need for human wisdom, it enhances it. A families continue to fragment and as a secular, consumerist population abandons faith in anything that does not deliver tangible benefits, so the need for effective, personalised counsel becomes more acute when the familiar breaks down.

Above, we noted the limits to certainty and the need to accept a degree of best endeavour (and therefore, of risk.) As figure 5 suggests, however, there is an enormous domain of counselling and of 'seeing them through' which is also an art form, not a science. The 'certain' are is expanding, but not nearly as fast as the lay public imagines, and with each new source of precision comes an equivalent element of uncertainty. Further, as we shall see in a moment, the counselling aspect may well grow disproportionately in the years ahead. Whilst not a strictly 'medical' issue, it certainly impinges upon health maintenance and upon the resources of health providers.

Figure 5: Certainty is a small part of the full area of need.

Chronic support consumes a large fraction of the welfare budget in the OECD. Medical advances - such as the alleviation of psychosis and depression, or the substantial arrest of degenerative disorders - may well materialise in the next two decades. However, it seems likely that demographics will more than compensate for any such advantages. Social containment of these issues - in-house socialisation via broadband IT, the role of remote shopping for the elderly, security and physiological monitoring, perhaps limited robotics - will all have a role to play in managing the problem. Overall, however, the world will be substantially more complex than it is today: perhaps as different as the US in 1940 from the US today. The least able will find this a hard world in which to 'navigate' or about which to feel much confidence. Better interfaces with the complexities, ways of finding held and assigning trust to this may well prove as important as direct health care in reducing stress and generating self-sufficiency.

The 'discourse' around health and related choices will need to speed up if we are to proceed on the back of consensus. We are creating artificial urban worlds, from which the traces of natural verities are being erased. The new structures (the new forests, the new fields) have their rules, but they are perceptible only to the educated. Answers to the question 'why?' that are cast in these terms will sound as a re-statement of the problem, not a solution. Further, if the complexity is seen as threatening, then technical answers are seen, de facto, as coming from the enemy. It is, therefore, necessary to educate our citizens in how their world 'works'.

Further, it is necessary to embody this understanding in media and entertainment, popular discussion shows and humour if it is truly to be taken on board. A powerful force that can create such acceptance are the special interest groups. The speciality press, too, offers a backstop against which the mainstream press test opinions when a technical issue is raised. Creating public debate systemically - rather than around panics and villainy - may be a new tranche of activity that the public sector has to undertake.

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