Give us the freedom to innovate

Bruno Holthof is well-placed to have an opinion about the future of the Belgian health care. A medical doctor by training, Dr Holthof spent 15 years at consulting firm McKinsey&Company giving strategic advice to hospitals and pharmaceutical companies around the world. Since 2004 he is back in Belgium running the country’s largest hospital network. Comprising 3 general hospitals and 6 specialized hospitals, ZNA is also a top ten European health care provider. In this interview, Bruno offers his vision on the future of health care from a Belgian perspective.

Changing demographics and disease patterns

Let’s start by talking about the coming changes in the demand for health care, because that will have a dramatic impact on the way we need to organize our health care system. The main trend in this regard is the changing demography and the associated changes in disease patterns. We keep talking about the ‘graying’ of the population but in fact today we’re experiencing the ‘whitening’ of the population. What I mean is that we see a tremendous growth in the age categories 75+ and 85+. These people tend to have multiple organ malfunctioning. This means that we’ll need to treat these patients using a multidisciplinary approach and expand our geriatrics divisions. Furthermore, we will see a significant increase in dementia and hence we will need to increase our capacity for managing this condition, not only in institutional settings but also via home care and day care centers. All this is going to happen—we can predict this with confidence—and Antwerp will be hit fastest in Flanders.
Another key trend is the increasing birth rate, especially among immigrant families. This has implications for our pediatrics and maternity divisions. We also expect a further reduction in the maternity stay—from 4-5 days to 2- 3 days. Once we get to 3 days we’ll need to organize the entire process differently, probably by shifting to a single room model as opposed to moving the patient from a delivery room to a residential room.

Organizing around the needs of the patient

The advances in technology and medicine are making it possible to reduce stays for a whole range of conditions. Hence the hotel capacity of hospitals will need to be reduced and day care expanded. Such evolutions require a constant change in infrastructure, technology and organization. Children for example, are increasingly treated in day clinics. To better organize ourselves around the needs of the child we have been expanding our pediatric day clinic. The basic idea is to make sure that the flow through the day clinic is child friendly all the way and happens as smoothly and quickly as possible. At our hospital we’ve organized it as an adventurous journey from Green land to Sun land. The journey starts in Green land, a play area, where the child and the parents are welcomed and registered. The first diagnostic tests are done there. Then they move one to the next ‘country’ where they get their operating clothes and place their baggage in a locker. Afterwards it continues on foot or in a bed to the operating theatre. At the end of the journey the child arrives in Sun land where it is rewarded with an ice cream. At every stage we’re using playful methods to explain what is going on and the child can make choices too at several points in the process. It is a nice example of care being organized around the needs of the child and the parents.

Patients certainly are becoming more vocal and we need to adapt to this evolution. Also with regard to dementia for example, we are developing clear charters to make sure that we treat patients and their families with respect. It is important that we do not only focus on the medical side but also on, for example patient’s hair care and manicure because people with dementia tend to lose the ability to take care of themselves. It all has to do with respect.

Customized care

Customizing treatment to an individual’s needs and characteristics will also become increasingly important. Medicine has become much more complex and specialized; and it is constantly evolving and becoming more technology-intensive. In oncology, for example, we know that the effectiveness of certain types of chemotherapy is related to an individual patient’s genetic profile. As a result, therapy needs to be customized to the needs of the individual. Also in radiation therapy it is possible to do much more targeted and precise work, using sophisticated—and very expensive—equipment. In the coming years this trend toward more personalized care will only continue, not only on the basis of medical indicators but also on the basis of patient choice. It is true that many patients are becoming more vocal but in many cases they really have to be. For an increasing number of conditions—for example, prostate cancer, hip replacements, obesity, etc—there are several ways to treat it, hence it is essential that the patient is involved in the decision making.

Quality and the measurement of outcomes

The measurement of health care outcomes is becoming hugely important. At ZNA we’re making investments with the specific intent to start measuring outcome indicators. In 2011 we begin systematically measuring outcomes. Obviously you need to be very careful in the way you do this, especially in the way you correct for risk profiles. For example, an excellent maternity department could score really poorly if you just compared perinatal mortality rates in absolute terms. That’s because a reputable department will likely attract the most difficult cases.

Information Technology is enabling a more decentralized but connected health care system

Our ambition is to become a paperless hospital. We’re far from there, but we are investing with that intent. We will be setup with different form factors: mobile laptops, tablet PCs, smart phones, screens in rooms and operating theatres, etc. All our hospitals are already linked with a fiber network in preparation for the coming boom in data traffic. I expect a tremendous evolution in technology in the coming years. Imaging, for example, is becoming amazingly complex and this will certainly create a huge load on our network. For example, we recently streamed a live heart operation to a cardiology conference in Boston. These technologies enable much closer cooperation among different stakeholders and lines of care. For example, the multidisciplinary consult in oncology today requires people to come together physically. We’re currently exploring an advanced communication platform that will allow the caregivers to come together via video conferencing while they have access to all data and images from a common interface.

The key implication of all this technology is that we’ll need fewer large hospitals. In Flanders there was a trend to build large hospitals of 1000+ beds in a single location. In the future that won’t be necessary anymore. A degree of concentration is obviously still necessary to manage expensive medical equipment—patients need to come to the specialized infrastructure. But at the level of expertise you don’t need that concentration anymore. In the coming years a specialist will be able to deploy his or her expertise much more widely, even beyond borders. This is why I’m a proponent of smaller hospitals that are designed around the needs of the patients. Patients prefer smaller hospitals too. The future of health care will be more technological, more dispersed and more collaborative across the different lines of care. Our investment program is based on that vision.

An obsolete financing system is an obstacle to innovation

Innovation is critically important if we are to keep improving the quality and outcomes of health care—and keeping it affordable. The main obstacle to innovation, however, is our financing system. Our financing system is based on the retrospective payment of medical interventions and the duration of hospital stays. To illustrate, today in 2011 we still don’t know how much we will be paid for a hip replacement performed in 2006. Not only does that make financial planning very difficult but this type of system also often is a disincentive for investing in new technology and methods. Take obesity as an example. We know that we can’t just focus on surgery; equally important are psychological support and dieting to help patients reduce weight. But we don’t get financed for all that extra care. This is absurd. The financing should be linked to weight reduction outcomes; not just surgical intervention. As a hospital we should be funded on the basis of results, which would be a tremendous incentive to innovate, to invest in new technologies and methods.

Unfortunately there is lethargy in the system. You will always have stakeholders who resist change. That’s why I suspect that change will also have to come from patients. Patients are beginning to organize themselves via social networks – that’s a good thing. For example, we are seeing patients beginning to put political pressure on the way palliative care is funded. At present the government will only refund residential palliative care which has led to the closing of several day-care palliative initiatives – the only ones that survive are run by volunteers. But lobbying by patient groups should make an impact.

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