The future is not a place like the Isle of Wight awaiting our arrival; it is more like the Great Western Railway, something that we have to imagine, design and build. If we do not do it, other people will make the future, and it is becoming clearer what future healthcare will be like.
Designing the future does not require vision because, in the words of William Gibson, “the future is here, it is just not evenly distributed”. By looking about we can see many examples of leading edge work that just needs to be generalised. We do not need vision or dreams, although Pharoah’s dream is probably a perfectly apt theme for post-crunch healthcare – we have had seven or so years of plenty and we all know what comes after that.
Furthermore, post-crunch healthcare also arises at the appropriate moment for constant carbon healthcare, for healthcare in an era of sustainability. Even if money were to flow, health services would need to focus on the carbon consequences of their development and work towards not only a zero carbon gain but also a dramatic reduction in the amount of carbon used by healthcare. One hospital has made it clear it needs to double its electricity supply, using pre-crunch thinking, but that type of policy is unsustainable for both financial and carbon reasons. Even without the crunch, therefore, we would seek to change our focus away from effectiveness to value.
The last decades of the 20th century were dominated by the concepts of effectiveness and efficiency, following the publication of Archie Cochrane’s brilliant short monograph. Effectiveness will be taken for granted in the 21st century, as indeed will cost-effectiveness. In post-crunch healthcare the focus will be on value, on the health gain resulting from the benefits invested.
Archie Cochrane used the word “optimal” in the introduction to Effectiveness and Efficiency, but the term “optimality” was promoted about a decade later when Avedis Donabedian published his three volume blockbuster, now distilled into a single book, An Introduction to Quality Assurance, published in 2002 shortly after his death. In this book Donabedian describes optimality as:
“The balancing of improvements in health against the cost of such improvements. The definition implies there is a ‘best’ or ‘optimum relationship’ between costs and benefits of health care, a point below which more benefits could be obtained at costs that are low relative to benefits and above which additional benefits are obtained at costs too large relative to corresponding benefits.”
Effectiveness will be taken for granted, as too will be efficiency; the key question for post-crunch healthcare and sustainable healthcare is the value derived from the resources used.
Commissioners have to decide on how they derive most value from the correct allocation of resources, sometimes called allocative efficiency. We have arrived at the position where we spend, for example, £9.2 billion a year on mental health services, £4.6 billion a year on cardiovascular services, and £3.7 billion a year on musculoskeletal services – the process of accretion. Decisions about allocation will become much more explicit post-crunch, but the main impact will probably be on the services to which these resources have been allocated where the people who manage health services, principally clinicians, make bids to people who pay for services, working on the assumption that money would be available. Post-crunch, and in an era of sustainability, this would not be a wise planning assumption.
Those who pay for healthcare, the taxpayers and those who represent them, will increasingly receive requests for more resources for some high-value development with a questionable return, namely: “Is this development of higher value than something we are doing at present?”. They will be expecting a positive response to this answer, and furthermore expect the resources to be released by increasing investment in low value activities. This does not mean stopping “ineffective” interventions, or even those for which there is no evidence of benefit, but where there is uncertainty and lack of evidence, those who pay for healthcare will expect that activity either to stop or to be addressed explicitly, for example by highlighting the uncertainty in DUETs and by organising research to tackle the uncertainty. Just how far this will go remains unclear. Will the medical profession, for example, accept, or even campaign for, a 5% reduction in the salaries of its senior members so that more resources are available for interventions?
This approach has been taken in the private sector and, post-crunch, may be relevant in the public sector also, and it would, of course, have the environmental co-benefit of a reduction in the carbon footprint of the NHS as a whole.
As a corollary any moves made to reduce the carbon footprint of health services will improve the value derived from the resources allocated, resources which will be expressed in terms of Carbon.
Post-Crunch Low-Carbon Healthcare means, and needs, better value healthcare.