Developed world can’t have it all or health will hit the buffers

Mind the gap: health services in trouble if we continue to expect too much. PA/Carl Court

Health services are under constant scrutiny and rarely out of the news. But discussions about how and even whether they can continue are likely to exercise the whole developed world in the near future.

Irrespective of whether funding and services are provided by the state, the private sector or by charities, a perfect storm of issues is brewing that could be catastrophic unless they are addressed.

In the UK and across Europe, populations are reasonably stable, average incomes are well above basic levels, and population health (in terms of basic needs such as housing and nutrition) is relatively good. Deaths from infectious diseases are also low and life expectancy is high, although the negative impacts of affluence (so-called “lifestyle diseases”, such as obesity and diabetes) are growing.

More money, more problems

But the population demography in health terms is changing. There is more emphasis on older people, and conditions such as dementia are increasing; more long-term conditions and co-morbidities (when people also suffer other health issues at the same time, including mental health problems) and rising hospital admissions are all increasing the strains on health services everywhere.

Finances are also being tested. Most health systems (both state and private) depend on the insurance principle: the ratio between the number of people who pay premiums and the number who claim. That ratio is changing as older people pay less and claim more, which means higher costs for everyone else.

Medical technology is accelerating; medical science has become steadily more capable over the years, with a growing ability to diagnose and treat more conditions like cancer. It is also better at providing (very expensive) treatments for extremely rare conditions such as Gaucher’s Disease as well as conditions such as baldness and erectile dysfunction, which only became diseases when they became treatable.

Still we want more

Rising expectations are also fuelled by politicians and the healthcare “industry”: politicians win elections by promising more services rather than fewer, and commercial companies survive by marketing their services to generate business.

We now expect more in terms of what services may be available, as well as where and when they’re delivered. Results are expected to be virtually guaranteed, and we’re increasingly concerned with improving our “patient experience” too.

Comparisons are regularly drawn between the delivery of health services and commercial ones such as banks or restaurants; John Lewis and Amazon-style comparison sites and others have been name-checked.

Bigger and better

The way in which rising expectations are driving demand exactly mimics the developed world’s wider consumerist philosophies: economies depend on growth which requires increasing demand, driven in turn by the public’s hunger for more goods and services, delivered more quickly, more cheaply, and with greater choice. Just as next year’s smart phone has to be better than this year’s, so next year’s antidepressants have to be more effective, with fewer side effects, than those available now.

However, since health care is enormously emotive, and usually largely funded by third parties, the question, “can I afford it?” is rarely asked, either by individuals (for whom health is beyond financial measure) or by “the system”, for whom the penalties (electoral defeat for politicians, and lost business for suppliers) outweigh most hypothetical future problems. As a result, efforts to manage expectations downwards have been few and have generally failed to make much progress.

Experiments in prioritising need, such as those in Oregon and New Zealand have had little impact, so the only serious control mechanism to have been generally invoked is that of increasing efficiency. While there’s always room to improve, the pressures are such that efficiency savings will no longer suffice, and Society will have to start challenging what services are provided, not just how.

Genuine rising need, growing expectations, and medical technology’s ability to provide more are creating a tsunami of rising costs, which becomes the perfect storm once we include Society’s increasing risk aversion and reduced investment.

We’re spoilt

So can we avert it? Assuming the human propensity for short-term fixes can be overcome - possibly an assumption too far - reducing public expectations would help: understanding that healthcare resources are limited, and that some things are more important to treat than others.

How to do this is harder to prescribe; raising awareness of the real cost of services may help, even if these aren’t actually charged. The UK “GP budget holding” experiment in the 1990s (and now the new GP Clinical Commissioning Groups) was partly intended to increase cost awareness for professionals at least. But the way funding is organised means there’s little alignment between effort and reward.

Actual charging for some services to augment free healthcare services (co-payment), is used in countries such as France and New Zealand to demonstrate the link between usage and costs, but wouldn’t go down well in the UK.

Creating “tiers” of services has been partially implemented in countries such as Canada, where everyone is guaranteed basic services, but more luxurious products have to paid for separately - for example, basic cataract surgery is free, but the fancier lens implants aren’t.

The obvious variables that could be adjusted are the availability of services, or their price. Changing the third variable - demand - would require our societies to bring back a more collective “communitarianism” in which politicians were braver in telling it like it is, and our expectations were more in tune with reality.