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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We Care

As the European population ages and the prevalence of chronic disease rises, it is becoming increasingly clear that we can’t deliver higher-quality, more affordable healthcare without aligning payment incentives and improving coordination across the many providers who care for a given patient. New capabilities and healthcare models are required, which results in challenges and opportunities for our medical community, as well as our patient-clients.

The impact of the ageing population

New projections for 2010–2060, published by the European Office for Statistics, state that the number of elderly persons will rapidly increase, with the 80+ population group doubling in size by 2050. From 2015 on, deaths are projected to outnumber births in the EU27 and almost three times as many people will be 80 years or older in 2060. In Belgium (population 10 million) there are more than 1,8 million people older than 65 and 0,5 million people over 80. Eighty percent of people over 65 have a chronic disease and in the 75+ age group 85% has more than three chronic diseases.
These demographics trends will also be accompanied by a rapid growth in the number of persons with physical disabilities – about 21% of the 50+ population has severe vision/hearing/dexterity problems. Diabetes is now talked of as the epidemic of the 21st century, and parallels the worldwide explosion of heart disease.
The ageing of the European population and the associated rise in chronic conditions will lead to a growing number of older people living alone and in need of care. Simultaneously there will be astonishing but expensive advances in diagnosing and treating diseases, in a very personalized manner.
In light of these trends it is clear that the problem of care and assistance will become increasingly important both from a social and an economic perspective.

Healthcare models need to change

These trends pose a double challenge to existing healthcare delivery models. Firstly, there is a growing mismatch between traditional services and new needs – health services for example were originally designed to deal with acute rather than chronic disease. Secondly, rising demand for healthcare services is placing tremendous pressure on healthcare budgets. In response, the healthcare model will need to change dramatically. According to the Institute for Healthcare Improvement, “many healthcare systems around the world will become unsustainable by 2015. The only way to avoid this critical situation is to implement radical changes”.

New economic opportunities

The required changes will also create new economic opportunities. There are 85 million consumers in Europe over 65 years old today and this is expected to grow to 150 Million by 2050. Their combined wealth and revenues are estimated to be over €3000 billion. Clearly there is a tremendous opportunity to help empower elderly people to stay active and live independently. There also will be significant opportunities in the use of innovative approaches to improve care and make it more efficient. For example, the telecare market is expected to exceed €5 billion by 2015 in Europe alone.

Healthcare is already expanding in scope

Some significant changes are already in progress. Healthcare – traditionally focused on institutional care and on curing diseases (diagnosis, treatment) – is expanding in scope in at least two ways. The site of care is expanding its boundaries by going outside the hospital and the clinical setting and moving towards the patient’s home. And care is enlarging its scope beyond the patient domains to also encompass the support of people with special needs such as the elderly and the disabled.

Beyond the institution

Healthcare is extending its “institutional” role and is becoming personal, ubiquitous and mobile. Informal caregivers (patient’s family, friends, volunteers) are complementing the tasks of the medical professionals, but they are also under increasing pressure and need more tools. All citizens are becoming users of these new healthcare services and will be motivated and empowered to manage their own health. Currently we are witnessing a new wave of change: healthcare is pursuing a prevention objective, by focusing on health conditions through fitness, weight management and a generally healthier lifestyle. The social behavior and lifestyles, as well as the identity of the individual elder person, will change. Their requirements and consumer behavior will change both in quantitative and qualitative terms. A patient-client will become a consumer.

New capabilities required: care coordination and outcomes measurement

The new care delivery models demand capabilities for care service coordination and an ability to track quality outcomes that were not previously required in healthcare. This should apply to all services, also home-based services. Accreditation of services needs to be approached in a much broader way and should be stakeholder driven. The financial model needs to be reorganized; financial flows should be reallocated and become more outcome-driven. What matters are healthcare results and comfort levels; not the volume of medical interventions. The government should also investigate and rethink their financing role in building infrastructure where cost calculation should be based on life cycle costing and alternative financing should be explored. To support the move to team-based models of care, healthcare systems must accommodate the information and workflow requirements of the many stakeholders and organizations involved directly or indirectly in patient care. Social dimensions should also be taken into account. The coordination of information between all actors involved is crucial. In coordinated care the healthcare delivery system provides a continuum of evidence-based, quality driven healthcare services in a cost effective manner. Coordinated care requires a change in care culture, education, infrastructure, and in the relationships between patients, clinical staff, and caregivers. It calls for the creation of “accountable care cultures” that work together in coordinated, collaborative ways to drive better disease prevention, personalized treatment and positive outcomes. Technology can support this transformation by delivering vital information and tools that meet clinician and patient needs. Healthcare will address new user groups other than the traditional patients: the elderly and people with special needs such as persons with disabilities. By taking into account the ageing of the population, this new and additional “assisting” role of healthcare will become increasingly important. Ambient Assisted Living refers to intelligent systems of assistance for a better, healthier and safer life in the preferred living environment and covers concepts, products and services that interlink and improve new technologies and the social environment. It aims at enhancing the quality of life (the physical, mental and social well-being) for everyone (with a focus on elderly persons) in all stages of their life.
Quality of Life will have a new, extended meaning where physical, psychological and social aspects are taken into account all together and the “way the patient perceives his/her overall health status” will become of paramount importance. Perception will be more dominant in the evaluation and acceptance of the services.
Hospitals – which play a significant role in the health system – should increasingly try to differentiate and complement their offerings. One-day interventions will increase and care hotels will be the place where patient recover and rehabilitate before going home. We need to design for users; the solutions need to be user- and demand-driven. Care initiatives should:

  • Respect patients’ values, preferences and expressed needs
  • Coordinate and integrate care across boundaries of the system
  • Provide the validated information, communication, and education that people need and want
  • Guarantee physical comfort, emotional support, and the involvement of family and friends; the social component.

The user-as-producer transforms the relations between consumers and markets and among citizens themselves. Furthermore, it is opening up the possibility of reconfiguring the production process around the user. In many sectors there is a gradual incorporation of users into the process of production. All the stakeholders (patients and their families, medical professionals, policy makers, health organisations, industry, institutions, insurance companies, the overall community) need to find a way to cooperate in a common effort to create solutions for a new economy and added value for the patient.

Healthcare is an ecosystem – not a factory

The efficiency and effectiveness of healthcare services are certainly becoming a major priority. More integration of information is needed, as well as integration of the logistical processes through the whole value chain and core trajectory. But we need to be careful in comparing healthcare management approaches with those used in industry. While some processes (e.g. some logistical processes) are reasonably universal and hence can be standardized, care processes don’t always lend themselves to such standardization. Care processes are very often unpredictable and unplanned. We could best describe the healthcare model as an eco system. The intelligence is in the total care-system itself. There is chemistry to the way care functions; it a complex, adaptive system—and many aspects of care are distinctly artisanal in character. All actors in the healthcare delivery process should take that paradigm into account. The opportunity for creating new solutions and the needed delivery models should be part of such an ecosystem, where catalyst intelligence binds the demand and delivery elements. Health technology assessment and multi-sector innovative approaches will be needed to bring value added care towards customers and to create new business opportunities. As such, it is in this context that the idea of “we care” gains multiple dimensions—we care for people with our brains, hands and heart. Unfortunately the implementation of new approaches in healthcare is hampered by various challenges and restraints; they deal with technological issues and lack of standardization but also – and in some case preponderantly – with political, legal, financing and cultural issues.

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