By the end of the 20th century very significant improvements had been made in the effectiveness of healthcare; half of the added years of life were due to the second healthcare revolution.
The first healthcare revolution took place in the 19th century when public health measures such as the provision of clean clear water led to the first great leap in population health. In the second half of the 20th century, the second healthcare revolution took place. Mirroring the developments that created computers, aeroplanes, television and space flight, healthcare saw the introduction of hip replacement, transplantation and effective drug therapy for a wide range of conditions. The second healthcare revolution had a major impact on the health of populations, but at the end of the 20th century, the eight major problems still remained and these problems, set out in Table 1, show no signs of being diminished by the application of laboratory science or genome technology.
The five dimensions
Twenty-first century healthcare will have five dimensions which will be significantly different from 20th century healthcare. These dimensions, which together help in forming the 21st century paradigm, are:
- Knowledge-based healthcare
- Citizen-centred healthcare
- Web-enabled care
- Better value healthcare
- Sustainable healthcare.
The 20th century healthcare was based on bureaucracies—on hospitals, payers, insurance companies, primary care organisations and private providers. The 21st century healthcare system, however, will be based on knowledge-based systems of care. For example, it is possible to think of a National Epilepsy Service for India which would exist without any bureaucracy except that which was needed to run the web service, and this could be done by different organisations making a contribution. The National Epilepsy Service for India, England or Estonia would be an entity that would have:
- A community of practice of patients and professionals
- A dataset
- A clear depiction of patient pathways using the Map of Medicine software
- An evidence base updated annually.
These and other knowledge features will create 21st century healthcare systems. Obviously, bureaucracies are needed to employ people and manage money, but the priority is for systems of care which create networks of individuals and organisations and pathways for those patients to follow. This requires the knowledge of using the web applications.
The 20th century was the century of the clinician; the 21st century is the century of the patient, or the citizen who might become a patient. Many health services are now based on a paradigm which assumes that the patient or citizen is competent and should be fully involved, contrary to the 20th century assumption that patients were less intelligent and hence be given less information. The truth of the matter is that many patients are more intelligent than clinicians and that it is easier to help the public learn concepts, for example the appraisal of risk, than to help highly trained professionals unlearn the wrong concepts with which they were inculcated during their professional training. The involvement of citizens also emphasises the need to focus on healthcare and its outcomes.
IT is an old-fashioned term which is still reasonably useful, but with the advent of cloud computing, the concept of technology changes and the most important step that an organisation can take is to use the power of the Internet. The power of the Internet allows:
- every patient to have their own record
- images to be passed easily from one organisation to another
- Provide access to the up-to-date quality information to both patients and professionals Update the documents such as laboratory reports with up-to-date findings or evidence.
It is important not to go too far down the road of ‘technological determinism’, namely that change in technology inevitably drives social change, but neither is it important to ignore the contribution that technology can make to social change. As Manuel Castells emphasised, it is both knowledge and IT that citizens are using to transform society.
Better value healthcare
Every society on earth is faced with the possibility of funding more ‘cost-effective’ services than it can afford, either in terms of money or manpower. Where there is a finite budget, decisions have to be made on the basis of value, both by individual patients and by those who make decisions about groups of patients or populations, as shown in Figure 1.
The key concept in the 21st century is better value healthcare, identifying ways in which the resources invested can be used to maximise value.
This is particularly important when taking into account the constraints imposed by the 21st century’s greatest challenge—climate change.
In many countries, healthcare takes about 10 per cent of the gross national product, and in many countries a significant footprint is left by the health service with, in the UK, the NHS being the major public sector carbon footprint. There is also good evidence that in almost every healthcare system there is very significant waste. Making better use of the resources available, the same amount of care could be provided from a smaller carbon footprint or, if more money were available to put into healthcare, that money could be used to provide services without increasing the carbon footprint.
The eight major problems of healthcare:
- Poor quality care delivery
- Poor experience of patients
- Unknowing variations in policy and practice
- Failure to introduce high value interventions
- Uncritical adoption of low value interventions
- Failure to recognise uncertainty and ignorance
Sir J A Muir Gray, CBE is the Director for National Knowledge Service in UK. He is also Chief Knowledge Officer to the NHS.