The King’s Fund, a UK health charity ran a scenario essay writing competition, and here is the link and of course congratulations to the winner: (winner, runner up and other scenarios, but not mine).
My scenario builds on the notion of service unbundling and draws on strong and weak signals of changes likely to impact health and social care perhaps to about 2035. My objective was to avoid a doctrinaire scenario which would ignore the forces at play. The UK’s NHS, as an example, is becoming organisationally tightly wound through a focus on the integration of care and the transfer to funding from hospitals to the community GP. On its own, that shouldn’t be a problem, but tightly wound systems lack the capacity to flex in response to shocks to the system, partly by narrowing service options (service integration would drive out competing alternatives). The counterargument to this is horizontal and/or vertical service integration in the form of increasing the hospital service mix (horizontal) and incorporating services usually provided by GPs, or community agencies (vertical), but these have the benefit of working locally, integration funding streams and enabling managers and clinicians to innovate in response to local priorities.
The scenario is written as a retrospective view from the year 2047.
UPDATE in the midst of the pandemic: We see the NHS struggling along a number of dimensions. The failure to use private laboratories for testing illustrates a doctrinaire approach to service structure. Weakened bed capacity, going way back to Tony Blair who drove out at lot of bedded capacity as the health economists advising the NHS at the time (you know who you are), saw the carrying costs of idle beds as an avoidable cost. Staffing projections neglect to take into account the whole country’s health care professional supply and demand (50% of pharmacists don’t work for the NHS as do few nutritionists and about 20% of nurses) so the system is not just undersupplied but demand poorly modelled. So we see shortages of expertise, and of capacity to manage surge demand for beds and testing. The diversion of money into primary care means hospitals who are the main actors in the pandemic in terms of service delivery, must grapple with covid patients as well as existing demand for care which leads to serious waiting lists and resource diversion.
When I wrote this scenario, I had argued these constraints were problems as early as 1990s, as serious problems for the underlying logic of NHS funding and policy making. However, governments when confronted with a crisis, often seek greater control thus tightening organisational arrangements and this is exacerbated in a policy environment like the UK where the benefits of such tightening is taken as received wisdom.
I believe this scenario is still relevant.
Between 2016 and 2035, the way that people worked had substantially changed by widespread digitisation of information. Smart machines and robots had moved from doing physical work to being central to much cognitive work and which led to fundamental restructuring of the economy. By 2035, taxation was changing from taxing people to taxing the work done by devices, cognologies, and robots.
The fault lines between reality and expectations were starkly evident during the 2020s, as public investment in health and social care struggled to cope with the rapidly changing world. People were becoming accustomed to flexible access to personalised services that came to them and expected the same from care provision. Rising displeasure at service decline led to middle-class flight to alternatives with rising use of private medical insurance, progressively fracturing the social contract that legitimated publicly-funded care. Indeed, by 2028, 38% of the population used private care, with over 55% amongst Millennials.
Fearful health and social executives and worried Ministers of Health had reacted to these stresses by pulling the system even more tightly together, to protect jobs and avoid the failure of publicly-funded institutions.
This fed further public displeasure by the dominant middle-aged Millennials who challenged the traditional approaches to health and social care. In the United Kingdom, for instance, this unrest led to the 2028 Referendum on their tax-funded healthcare system, leading to the replacement of this system with social insurers and personal Social and Health Care Savings Accounts.
The process of changes in health and social care around the world has become known as Unbundling. This brief historical retrospective outlines three of the key components of that unbundling.
The 1st Unbundling: of knowledge and clinical work
Professional knowledge was affected by digital technologies which had unbundled knowledge from the expert. This changed how expert knowledge was organised, used and accessed; research institutions and knowledge-based organisations were the first to feel the changes, with librarians being one of the first professions to face obsolescence. Rising under-employment, particularly in traditional male-dominated occupations was still being absorbed by the economy.
Routine cognitive work and access to information and services was increasingly provided by cognologies (intelligent technologies) or personal agents as they were called. Widely used across society, they were embedded in clinical workflow from diagnosis to autonomous minimally invasive surgery. By this time, jobs with “assistant” in the title had generally disappeared from the care system, despite having been seen as an innovative response to workforce shortages through the late 20-teens. These jobs had turned out to be uninteresting, and being highly fragmented, required time-consuming supervision.
The benefits of precision medicine were substantial by this time, enabling earlier diagnosis and simpler and less invasive treatments. Theranostics, the merging of diagnosis and therapy, unbundled the linear care pathway and the associated clinical and support work. This also led to the unbundling of specialist clinical services, laboratory testing and imaging from monopoly supply by hospitals. Indeed, the last hospital was planned in 2025, but by the time it opened in 2033, was deemed obsolete.
The 2nd Unbundling: of financing and payment
The unbearable and unsustainable rise in health and social care costs necessitated better ways to align individual behaviours and preferences with long term health and well-being. Behavioural science had shown that people did not always act in their own best interests; this meant the care system needed people to have ‘skin in the game’, best done by monetising highly salient personal risks.
Existing social insurance systems which used co-payments were more progressive in this direction, while countries with tax-funded systems were forced to reassess the use of co-payments, and financial incentives. The Millennials, having replaced the baby-boomers as the primary demographic group, were prepared to trade-off equity for more direct access to care. It also became politically difficult to advance equity as a goal against the evidence of poorer health outcomes as comparisons with peer countries drove performance improvements.
The use of medical/social savings accounts was one way that gave individuals control of their own money and building on consumerist behaviour, this directly led to improved service quality and incentivised provider performance as they could no longer hide behind the protecting veil of public funding. The social insurers were able to leverage significant reforms through novel payment systems, and influence individual health behaviours through value-based (or evidence-based) insurance not possible under a taxation system.
The 3rd Unbundling: of organisations
With people used to having their preferences met through personalised arrangements, care was organised around flexible patterns of provision able to respond easily to new models of care. This replaced the “tightly coupled” organisational approach known in the early part of the 21st century as “integration”, which we know led to constrained patient pathways, and limited patient choices unable to evolve with social, clinical and technological changes.
The big-data tipping point is reckoned to have occurred around 2025. Because the various technologies and cognologies had become ambient in care environments they were invisible to patients, informal carers, and care professionals alike; this enabled the genesis of smaller and more diverse working environments.
By 2032, medical consultants were no-longer hospital-based, having become clinical care social organisations, with their cheaper, smaller, portable, networked and intelligent clinical resources. Other care professionals had followed suit. These clinical groupings accessed additional clinical expertise on as-needed basis (known as the “Hollywood” work model); this way of organising clinical expertise helped downsize and reshape the provision of care and met patient expectations for a plurality of care experiences.
It takes time to shift from the reliance on monopoly supply of care from hospitals in those countries that continued to pursue a state monopoly role in care provision. However, most repurposed themselves quite quickly as focused factories, while the more research-oriented specialised in accelerating the translation of research into daily use, helped along by the new research discovery tools and the deepening impact of systems biology which was making clinical trials obsolete.
What Cognology Says
This Unbundling arose as a product of the evolution of social attitudes, informed by the emerging technological possibilities of the day. The period from 2016 to 2025 was a critical time for all countries, exacerbated by shortages in the workforce coupled with economic difficulties and political instability.
Today, in 2047, we are well removed from those stresses that caused such great anxiety. We must marvel, though, at the courage of those who were prepared to build what today is a leaner, simpler and more plural system, removed from politicised finance and management decisions.
It is hard to imagine our familiar home-based theranostic pods emerging had this trajectory of events not happened. As our Gen-Zeds enter middle age, they will, in their turn, reshape today’s system.
Plus ça change, plus c’est la même chose.
27 December 2047
Note on the Scenario
This scenario is informed by strong and weak signals, including:
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Cook D, Thompson JE, Habermann EB, Visscher SL, Dearani JA, Roger VL, et al. From ‘Solution Shop’ Model to ‘Focused Factory’ in hospital surgery: increasing care value and predictability. Health Affairs. 2014 May 1;33(5):746–55.
Cullis P. The personalized medicine revolution: how diagnosing and treating disease are about to change forever. Greystone Books, 2015.
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Europe’s robots to become ‘electronic persons’ under draft plan. Reuters. www.reuters.com/article/us-europe-robotics-lawmaking-idUSKCN0Z72AY
First 3D-printed drug just unveiled: welcome to the future of medicine. https://futurism.com/first-3d-printed-drug-just-unveiled-welcome-future-medicine/
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With Samsung’s ‘Bio-Processor,’ wearable health tech is about to get weird. Motherboard. http://motherboard.vice.com/read/with-samsungs-bio-processor-wearable-health-tech-is-about-to-get-weird