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The global health situation

Alex Knight - Tuesday, June 30, 2015

What happens when something important becomes increasingly urgent?


An analysis of the global health situation


The Foreword to Pride and Joy, which was kindly written by Dr Mike D Williams, starts with a sentence that asserts: 'Healthcare is a fundamental necessity of all societies'. If this is so, then why are there so many examples of poor quality care, untimely care and, in the extreme, examples of catastrophic failures in the delivery of care around the world? Also, why is almost every nation deeply concerned with the affordability of care? And why are so many staff within healthcare feeling disgruntled or dismayed? In my view and experience these are not trivial questions. Too many people’s lives – both patients and staff – depend on us finding the underlying cause of such a grotesque situation. This is not something to be pursued for its own sake but should be the first step in helping us to find a new way forward. 


Throughout Pride and Joy, Stevie uses scientific ‘effect-cause-effect’ thinking. This starts with developing an understanding of the way Linda’s hospital is currently operating and rather than trying to find isolated causes for each of the undesirable outcomes he seeks the common cause; the common cause which can explain why good people with good intent are struggling to find a way to simultaneously improve the quality of care, the timeliness of care and the affordability of care within Linda’s hospital. His search for a common cause comes from a belief in inherent simplicity. Stevie helps Linda and her team to understand that this common cause is in fact an unresolved dilemma; one that has been creeping up on them and growing for many years. He shows that when medical costs are rising faster than budgets, the multitude and seemingly diverse nature of the effects can be explained. The growing intensity of these undesirable effects become visible but, most importantly, Stevie shows how the disparate and increasingly desperate actions to tackle individual effects are futile. Attempts to resolve one part of the system simply exaggerate the negatives of another part. In this blog I will show how the same analysis and technique can help us gain a better understanding of what is happening at a global level.


Healthcare is a fundamental necessity of all societies


Let us return to the statement that "healthcare is a fundamental necessity of all societies" and see what we can deduce from this statement and what we see happening in reality.


One very clear fact is that for many nations the total expenditure on healthcare is rising year on year. Graph 1 shows the growth in healthcare spend per capita for a selection of countries between 2001 and 2011. For a country such as the USA, the total spend has risen from $1,500 billion to nearly $3,000 billion. 



Graph 1: healthcare spend per capita (US$) between 2001-2011 (Source: www.data.worldbank.org)


Even though we see continuous growth in expenditure on healthcare we all know that expenditure and affordability are very different. Healthcare is a top priority for many nations but has to compete with other expenditures.


Graph 2 shows healthcare spend as a percentage of GDP between 2001 and 2011, and in almost all instances you see the same gradual increase. However, it is worth noting that this increase in healthcare spend as a percentage of GDP has been happening where, in most countries, GDP has also been growing. In the USA, healthcare spend as a percentage of GDP was approaching 18% in 2011 and you can see other nations, such as the Netherlands and France, spending close to 12% of GDP on healthcare.



Graph 2: healthcare spend as a percentage of GDP between 2001-2011 (Source: www.data.worldbank.org)


With these figures it is easy for us to see why expenditure on healthcare for many nations, although a necessity, is increasingly seen as unaffordable. Even though in many instances the overall cake is growing in size, the proportion of the cake required to fund healthcare is growing even faster. This is why it is of such concern for a nation. Clearly, when times get tough the problem just becomes more and more acute.


In chapter five, page 64, of Pride and Joy, Stevie helps Linda’s team understand how this unaffordability is playing out in their hospital and the inevitable consequences of a deterioration in the quality of care, the timeliness of care and the growing disharmony among staff. In reality I have seen situations that are much worse than this, resulting in real conflicts between medics and managers living with this tension on a day-to-day basis. As the book progresses, Linda and her team, with some guidance from Stevie, take the road less travelled.


For any nation experiencing such a situation, it is totally understandable for them to increase their focus on preventative care and education around lifestyle choices to reduce the need for care. However, such changes are unlikely to deliver quick results and so there remains a clear need to scrutinise the productivity of the delivery of its health system.


This scrutiny often takes two routes: Firstly, it will become increasingly important for the pharma industry to help address the overall affordability issue rather than focusing on gaining a bigger portion of an increasingly unaffordable cake. Although drug costs are an obvious place for scrutiny, a closer examination reveals this expenditure is a relatively small percentage of the total spend on healthcare. So while such scrutiny is appropriate, on its own it is going to be insufficient to have a major impact on the overall affordability issue.


Secondly, the scrutiny will focus on the productivity of the front-line clinical staff who make up the vast proportion of total expenditure. In the UK (2011) over 1.4 million people worked for the National Health Service. You might conclude that there must be a cost saving opportunity here. Indeed there are many examples where the heart of cost saving initiatives has been to trim front-line staff. However, research in the UK[1], similar research around the world[2], and the common experience of clinical staff, validates that when front-line staff are increasingly pressurised, the quality and timeliness of care suffers and catastrophic incidents of care increase. It seems to be a fine line between saving money and saving lives. At these times, systems can shift from being predictable and stable, sustained by staff working harder to mask issues, to suddenly becoming unmanageable and chaotic. This transition is non-linear and all too often a health system will rapidly slip from a coping strategy into one of catastrophic failure.


For many countries there is now a situation where this fundamental necessity is being compromised more and more every day. Even the so-called wealthy or growing countries are not immunised from this. Healthcare remains stuck in an environment where a rapid and sustainable breakthrough in productivity is still necessary.


The head of a nation’s health system has a huge responsibility and faces the unenviable challenge of simultaneously improving the performance of the health system whilst at the same time ensuring there is absolutely no risk of further deterioration in the provision of healthcare. And yet, our analysis has revealed that simply trimming drug costs or front-line staff is not going to deliver the size of improvement needed within the timescales available. As a result, many countries are now experiencing something that is important to them becoming increasingly urgent. Also, the unprecedented increase in expenditure to date has not delivered a similar size of improvement in either improving quality of care and/or improving access to care. In many countries backlogs and waiting lists abound. Spending more money does not appear to be a guarantee of better quality and timely care.  


As a result, the challenge to increase productivity intensifies and it is now clear that any approach must simultaneously:


  • Improve the quality and timely access to care, and
  • Improve the affordability of care,
  • Without simply expecting staff to work harder, and
  • Achieve all of the above in an unprecedented timescale.


It is important we are explicit about these criteria as any proposed direction should not be judged simply by the size of the results relative to any other methodology, but the size of the results relative to the size of the problem. 



[1] Williams, M. D. (April 2011). Developing a System Resilience Approach to the Improvement of Patient Safety in NHS Hospitals.

[2] Gawande, A. (2010). The Checklist Manifesto. London: Profile Books

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