What will the future of healthcare in the Nordics look like? To get an expert's perspective from the outside, we talked to Charles Alessi, the Chief Clinical Officer for Healthcare Information and Management Systems Society (HIMSS) International.
The Nordic Window to the World
- An outside-in perspective on data structures, precision health and the Nordic potential
Aside from working as a general practitioner in South West London for over 30 years, Charles Alessi now serves as the Chief Clinical Officer for Healthcare Information and Management Systems Society (HIMSS) International. HIMSS is a not-for-profit organisation working to improve healthcare in quality, safety, and cost-effectiveness through information technology and management systems. Additionally, he is a senior adviser to Public Health England, a government agency set up to protect and improve the nation’s health and to address inequalities. His interests today lie in ageing, dementia and helping patients with two or more chronic conditions (multimorbidity), as well as how digital health and behavioural science can assist people in making better decisions. The Copenhagen Institute for Futures Studies interviewed Charles to get his perspective on what the future of healthcare might look like.
From your perspective, what are the most significant challenges in healthcare today? It’s very clear that the systems we have at the moment are not sustainable.
First, we practice medicine by body part rather than looking at an individual holistically. We don’t appreciate that nonhealth determinants are as important as they are. Therefore, we continue to focus on biomedical models which only provides 20% of value to the individual while ignoring the 80%. Secondly, our systems are set up in a way that not only values but also benefits organisations that provide care rather than organisations that prevent the need for people to receive care. Essentially, we reward illness and we don’t reward the prevention of illness.
How could the incentive and reward structures of systems be changed to promote the prevention of illness?
Systemically, there are two things that need to change. One that is absolutely fundamental is defining new financial metrics that drive the system. As long as we continue to reward organisations for providing solutions to illness, we cannot expect those organisations to concentrate on prevention. It’s not because people working there are malicious or because they are not trying to do the right thing, but because their organisations are set up to treat diseases. The second thing is that we need to assist organisations in making this transition. We need to both reward organisations for delivering good care, but we also need to start the introduction of new metrics which prevent illness in the first place. We cannot expect systems that are already struggling with coping with multi-morbidity, the burden of non-communicable diseases (NCDs) and cardio-metabolic disorders to also be able to cope with prevention. If we don’t sort the financial metrics out, this will remain an aspiration.
On that note, in the Nordics, about 9.8% of GDP is spent on reactive treatment of diseases whereas only about 0.3% is spent on prevention. The Nordic Health movement should be built on the principle that Nordic governments in the future should spend half of the health budgets on treatment and half on prevention in what is called the 5/5 Aspiration. Based on your experience and knowledge, how can we start to make this shift happen?
First off, let me say that I agree that it is essential that you reallocate funding so it is spent equally on treatment and prevention, but you have to be careful how you do it. If you do it by taking money away from the health system and putting it into a new system, you’re more likely to get pushback from the health system that won’t have enough money to deliver care. Additionally, it is probably not the most efficient way to do it. I think the best way to do it is to leave the money where it is and change the financial metrics that drive the existing health system and give them the challenge. Health systems are pretty effective at following the money, so let’s use that!
During the Nordic Health 2030 workshop series, it was also pointed out that healthcare systems have been trying to make the shift for a long time now…
I agree we have been on the path to try and make a change the last 30 years, and we still haven’t made it. However, I would suggest that we continue on that path with an addition. That addition is something called precision health. It is the flipside of precision medicine and focuses on predicting, preventing, and curing disease precisely. I think that is our only hope. If you manage to do that, there will be two things you will achieve. First, by empowering people, you will get more activated populations, and evidence shows that an activated individual is less likely to express symptoms. The second is that if you manage to increase traction around risk-reducing behaviour preventing disease means that individuals will be healthier longer as well as more productive and contribute more to society. Precision medicine, in the beginning, would decrease costs but because of specialisation we may not see the reductions in cost that we had hoped for. Therefore, the answer is precision health, which combines both preventive as well as predictive health.
What does precision health mean for individuals? How can it activate them to better care for themselves? Could you give some examples of how they could experience health in the future?
If we look towards behaviour, there is no reason why we can’t introduce gamification in the process and establish direct communication with the individual which doesn’t need to be mediated via the medical system. For example, if someone stopped smoking, they would get some points they could cash at the supermarket shopping for groceries. In addition, it could also help alleviate some of the inequalities between people from lower socioeconomic groups through financial incentives to buy healthier foods. And the point here is on incentivising and not forbidding! In the 21st century it is not the clinician’s place to tell individuals how to live their lives. Instead, the clinician is there to ensure you are aware of the fact that if you do something today in a certain way, it could have consequences down the line. The decision is ultimately down to the individual and should always remain their choice.
In order to empower people and make this shift a reality, the Nordic Health 2030 workshop participants concluded that a data sharing infrastructure is crucial. What do you think is required for creating an effective data sharing infrastructure?
As a starting point, we need to understand what we’re collecting and to try and collect it in approximately the same way throughout. To be working with the collected data we need to set up a system which enables that data to be correlated across multiple data types. That same system needs to be able to process payments based on the levels of success in terms of achieving whatever outcome has been determined. The third thing you need is to set up an interoperability layer in which all data is put that is completely transparent both to the individual and to everybody else. This transparency can also help dramatically improve performance of systems through competition. We have to encourage that.
Working for both HIMSS and Public Health England gives you a broad view of international developments in healthcare and with that in mind, what is the potential for the Nordics in general from an outside-in perspective?
The Nordics are in such a wonderful place because they started on this journey of looking at general population health and making interventions many years ago. The main advantage you have is a different one and it is much more fundamental. The Nordics trust each other in general. Trust in government and in your systems is significantly higher than in a lot of other countries. Trust is at the basis of the relationship. You can have the world’s best IT systems and the world’s best infrastructure, but if you have a breakdown of trust between an individual and an organisation it’s not going to get you very far. Another significant advantage is the strong coherence as a group of countries going back to prehistoric times. The Nordics also have an educated population and the potential to activate that population in getting more involved in their health as well as care.
Do you think there is potential in greater collaboration across borders in the Nordics?
I think the opportunity the Nordics have is enormous. It’s about time you provided a window to the world to show that it is possible for an individual to move from one jurisdiction to another and have the same sorts of processes in place, which I think is within your capability.
Who do you think should be involved in making this happen?
Clearly the population needs to be there, which is a challenge in itself, but it is crucial that a very strong citizen voice is present in the development of these processes. On top of that, our colleagues from the healthcare sector also need to be included, as it is them that need to go through this transition. It’s a very big ask we’re making of them, so they have to be a part of the discussion. Lastly, without governments, the likelihood of anything happening decreases. While the Nordics have a reputation for conducting successful public-private partnerships, I am not entirely sure if it is the best way to go. It really depends on what level of trust the citizens have in their governments. To be honest, in my view, it doesn’t matter who provides the service, as long as they provide consistent, transparent, and high-quality care. For example, for pharma companies, I think this is a wonderful opportunity to rescue a business model that clearly is under significant pressure. That doesn’t mean they need to take control of an ecosystem, but there are ways they can contribute and remain a vibrant and important player.
What do you think the biggest challenges are in making the transition?
I’m most worried the providers of traditional services, as they are the ones going through the most significant change. People who are caring, be they physicians, nurses or whoever need to be comfortable in the digital age. There’s a lot we should be doing in terms of digital immersion for these individuals to assist them in their digital journey. The training for physicians isn’t quite what it could be, they are asked to fill the gaps, treat disease and now they’re being asked to manage non-communicable disease risk factors all within a very tight consultation. We also have to manage physician burnout better by ensuring we get the right training for clinicians. Currently, we’re still training physicians for the 20th century and it’s 2019!
There is a heated debate around ethical issues in relation to health data. What is your perspective on this matter?
Ethics are important especially in that people are not discriminated because of the choices they make. The other ethical issue we face is the issue of consent. We need to rethink consent, as we have used consent in a binary fashion to death. So-called blanket consent is what we tended to use up until now, but in the world of precision health, we have got to be thinking far more in a dynamic consent situation. Here, consent is something which is associated with the interchange of information. In addition to how the system treats individuals, it is crucial how this new form of healthcare is deployed. Everyone worries about ethics and consent when it comes to healthcare data. Nobody cares about ethics when it comes to everything else that we do. Even though it is harvested freely by all other organisations from the place you buy your books and your clothes to the supermarket. I think ethical issues related to health data are in the hands of the citizen. If the citizen is willing to share data with an organisation by giving consent that they trust not to sell their data indiscriminately, I don’t know what the ethical issues are. Ethical issues only arise if somebody is not aware of what is happening. People are fixated around who owns data, it doesn’t matter who owns the data, what matters is how it’s used. If people are not given a choice, however, and it’s perceived that people will be told what to do, I think you’re going to have revolution in the streets.