random notes on healthcare systems in Europe
Are healthcare systems designed, or do they just grow? Apparently, there have been moments in which people with some kind of mission do heavy movements - think UK’s National Health Service “from the cradle to the grave” redesign back in 1948 http://www.sciencemuseum.org.uk/broughttolife/techniques/nhs.aspx. But after that, just like after moving the family to a new home, it looks like things interact with the rest of our lives, pile up, deteriorate, or are at most minorly mantained or redesigned.
The result, in Europe (lots of adjacent countries), is that there’s a variety of national healthcare systems, each the result of their own national circumstances. They are very different (more or less money, more or less services, different ways to link payment with services, etc) and I’m sure we could learn from each other if we are to have meaningful conversations. A Swedish evaluation (I’m not linked to any of that, and my scientist trainers insisted that we should to try and look at the methods before believing in conclusions) looks at 35 such systems (http://www.healthpowerhouse.com/index.php?option=com_content&view=article&id=5&Itemid=2) and even dares to rank them (http://www.healthpowerhouse.com/files/Report-EHCI-2012.pdf). I haven’t read any of that in full, mind you: it’s just a window into the diversity of systems, probably with a view to answer the questions given by whoever paid for the evaluation, and not necessarily useful for us.
In any case, I’m personally interested in these systems’ failure modes. In Spain, we’re seeing how a system designed for a younger pyramid of people, mostly healthy and paying taxes, more or less worked for a number of decades, and seems to be rapidly deteriorating due to a number of factors:
Demography: more elderly people (I read somewhere that people over 65 years old spend a lot more than the younger ones, so an increase of 1% in the number of older people hits the common wallet disproportionately) and a smaller proportion of tax-payers (same effect).
Technology: more newer and more expensive medications and surgical procedures that are applied more often. This is a good thing (“hey, replace my hip so I can learn to play golf at 95 years old”), but it’s also more expensive. Also, it grows exponentially, while money grows linearly at best - or it used to, anyway. And that differential creates tension and pain: “sure I’m only going to have x-rays, and not that other fancy dynamic computarised image in full colour?”.
Management: healthcare systems are wicked. Two examples from a few years ago are: if you reduce waiting lists in surgery by having surgeons work also in the evenings, you increase waiting lists in the services in charge of post-surgery care, and the motivation; and if you pay them to work in the evening then they are less motivated (and more tired) to work in the morning. And management is part of that mess.
Economy: not just through demography, technology and management (factors which have been at work for a few decades now), but now as a result of the economic mess Europe is in right now. Those with their hands on the common purse’s strings use their best judgment to effect deep cuts - which are then hated by everybody else. As in “can’t you see that if we don’t prevent cancer we’ll have to cure cancer and that’s more expensive?”.
In short, at least in Spain, healthcare systems seem to be biting more than they can chew, changes are being pushed without much time for consultation (which would be messy at best), and it’s the weaker who pay for it more (too many examples). A clinician I know described the situation as one of disease in the healthcare system itself: it’s insufficient in the same way a heart can be insufficient, when it can pump blood forward, but less than is needed, so you get swallen legs (waiting lists), pain for lack of fresh blood (lack of resources), etc. If the aethiologic (causational) factors are still there, then the disease won’t go away, etc.
Even the World Health Organisation has been looking into it very recently. http://www.euro.who.int/en/what-we-do/event/oslo-conference-on-health-systems-and-the-economic-crisis Maybe they could use some help. #justsaying
Things could get magically better, but there could also be at least two basic failure scenarios: we muddle through with this economic/peak-everything crisis and we boil slowly and frog-like, or something faster (an economic crash, a war, a pandemic) gets in the way and we’re toast rapidly. Chronic vs Acute systemic failure. In an acute failure, we’d have to go all catastrophologic and think about reducing deaths (1), mostly the easily avoidable ones in the younger ones, using whatever it takes. With chronic failure, we can also include pain (2) and disability (3) - and look into wisely redesigning some subsystems for maximum effect. (The classic fourth priority, aesthetics (4) is either social pain/disability or luxury.)
What to do? What can we do as edgeryders. I’m completely lost here. The way Alberto puts it: “important problems, lots of opportunities, but little capacity”. But there are some ideas anyway:
There’s the idea to create a wikipedia for health-care systems. Maybe one project would be to describe our different healthcare systems using some kind of grid?
Some folks are working on “open data policy for health care”. We’d also need “open thinking on open data”.
Maybe the kind of thinking outlined in our pandemic booklet can be deepened for chronic scenarios? Needs x Jurisdiction?
Maybe we need to have better aims? What’s the worst pain that we should prioritise? Any good leverage point for systemic intervention?
Ok - this ends my “brain dump” at the moment. As I said, I’m as lost as anyone, and I feel I can’t even pose meaningful questions for us to answer. So, open space!