1. The future of health care Richard Smith Editor, BMJ www.bmj.com/talks

2. The possible agenda Dangers and difficulties of looking to the future Why bother then? How best to think about the future? What is Foresight? Drivers of the future Three scenarios Pictures of the future of health care Two reports on the future of health care What does the future mean for now?

3. Dangers of predicting the future I never make predictions, especially about the future. Sam Goldwyn Mayer

4. Predictions of Lord Kelvin, president of the Royal Society, 1890-95 "Radio has no future" "Heavier than air flying machines are impossible" "X rays will prove to be a hoax”

5. Looking to the future: common mistakes Making predictions rather than attaching probabilities to possibilities Simply extrapolating current trends Thinking of only one future

6. Looking to the future: common mistakes People consistently overestimate the effect of short term change and underestimate the effect of long term change. Ian Morrison, former president of the Institute for the Future

7. Why bother with the future? "If you think that you can run an organisation in the next 10 years as you've run it in the past 10 years you're out of your mind." CEO, Coca Cola

8. Why bother with the future? “The future belongs to the unreasonable ones, the ones who look forward not backward, who are certain only of uncertainty, and who have the ability and the confidence to think completely differently. ” Charles Handy quoting Bernard Shaw

9. Why bother with the future? The point is not to predict the future but to prepare for it and to shape it

10. How best to think about the future? No answer to the question, but one way Think of the drivers of change Use the drivers to imagine different scenarios of the future Imagine perhaps three; each should be plausible but different Extrapolate back from those future scenarios to think about what to do now to prepare

11. What is Foresight? Foresight is a method of thinking about the future in order to think about what should be done now The British government has conducted two rounds: startingin1994 and 1999 The first round was concerned mainly with informing research policy; the second was much broader, including social impacts

12. The aims of Foresight To produce a report on how the future might look To provide material for central and local government and public and private organisations to prepare for the future To shape the future To get a whole lot of people thinking about the future

13. The methods of Foresight Decide on subjects Gather a group together-- diversity is important Ask them to think about the future, using whatever methods they want Oblige them to think along way ahead (2020 in the latest round)

14. The methods of Foresight Oblige them to be bold and creative (hard) Try and persuade them not to be too linear (hard) Oblige them to think about scientific, organisatiomal, political, and social implications Ask them to make recommendations on what should happen now to prepare for the future Disseminate with energy

15. The Foresight panels 1999 Healthcare Ageing population Crime prevention Manufacturing Built environment and transport Chemicals Defence, aerospace, and systems

16. The Foresight panels 1999 Energy and natural environment Financial services Food chain and crops for industry Information, communications, and media Materials Retail and consumer services Impact of e-commerce on future business models

17. Healthcare task forces Public and patients International influences on health and healthcare Older people Organisation and delivery of healthcare Information

18. Healthcare task forces Delivering the promise of the human genome Pharmaceuticals, biotechnology and medical devices Neuropsychiatric health Transplantation

19. Drivers of change in health care Internet Beginning of the information age Globalisation Cost containment Big ugly buyers Ageing of society Managerialism Increasing public accountability

20. Drivers of change in health care Rise of sophisticated consumers 24/7 society Science and technology -- particularly molecular biology and IT Ethical issues to the fore Changing boundaries between health and health care Environment

21. Examples of future scenarios for information and health

22. Three possible futures: titanium Information technology develops fast in a global market Governments have minimal control People have a huge choice of technologies and information sources People are suspicious of government sponsored services There are many “truths”

23. Three possible futures: iron A top down, regulated world People are overwhelmed by information so turn to trusted institutions--like the NHS Experts are important Information is standardised Public interest is more important than privacy

24. Three possible futures: wood People react against technology as against genetically modified foods Legislation restricts technological innovation Privacy is highly valued Internet access is a community not an individual resource There are no mobile phones

25. Pictures of the future of health care

26. Pictures? Asking people to draw pictures can free up their thinking as well as those who look at the drawings It’s the conversation around the drawings rather than the drawings that matters Having said that, here are two pictures of the future of health care that I carry in my mind. The first is from Tom Ferguson, an acute observer of the digital age, and the second from Uwe Reinhart, professor of economics at Princeton

28. Fee for service for the rich Marks and Spencer style managed care for the middle classes Safety net service for the poor

29. Two reports on the future of health care

30. Healthcare 2020 Foresight Healthcare Panel Department of Trade and Industry, London www.foresight.gov.uk

31. Selections from Healthcare 2020 42 recommendations Institutionalise thinking about the future--otherwise, as with genetics, the future may take longer to realise More “rolled back healthcare”-- more community and home based healthcare with IT support

32. Selections from Healthcare 2020 Chronic disease management will be a cornerstone of future healthcare Diagnosis needs to be made more rational--as the Cochrane Collaboration has done for treatment Patients and the public will come to the heart of healthcare--but how will this happen with the public?

33. Selections from Healthcare 2020 Improving health through innovations in social policy rather than through high tech Putting health at the centre not the edge of politics Regeneration medicine will become a major component of healthcare--use of stem cells, xenotransplantation, tissue engineering, induced regeneration, modulation of the ageing process

34. Selections from Healthcare 2020 Physical and engineering sciences will become much more important –whole systems engineering –mimicry of sensor/effector pathways –image analysis –predictive modeling of biological behaviour –clinical decision support

35. Selections from Healthcare 2020 We have done badly with neuropsychiatric illness, but it will become steadily higher profile with rising prevalence and a sharp increase in diagnostic and therapeutic possibilities Dementia may eventually strike 85% of the population A greater emphasis is needed on prevention

36. Selections from Healthcare 2020 Beyond electronic patient records to “health biographies” Cyberphysicians Moving from information to knowledge

37. Information and health: technological developments “Think for itself hardware” and self- generating software by 2020 Wearable computers; “intelligent clothing” Personal agents-- “digital butlers”; smart sensing Electronic circuitry can be connected to nerves and tissues

38. Cyberphysicians: “the problem” Healthcare is a “knowledge based business” but information is poorly delivered Doctors now suffer from the “information paradox”--drowning in information but cannot find the information they need Patient information is often neither evidence based nor easily accessible

39. Cyberphysicians The number and form of “infomediaries”--knowledge brokers will proliferate All the information available to professional will be available to patients Cyberphysicians will look after people’s health, detecting changes through sensors, prompting preventive activities and treatments

40. Infomediaries: doc.coms People will be able to use doc.coms to: Ask questions Interact with others with similar interests Use software that will help with health risks Use decision support systems Consult with professionals Access their own health records Buy health related products

41. Health records: “the problem” Current health records are: Paper based Disorganised Often illegible Lost Scattered Poorly linked

42. Health records Health records might be Electronic, lifelong, perhaps recording all food and drink consumption, exercise, etc Accessible from anywhere Linked to other records, like social care Multimedia Collect information from sensors in the body or home Data mined But beware Big Brother

43. Crossing the quality chasm A new health system for the 21st century Institute of Medicine, 2001

44. Report’s opening quote Knowing is not enough; we must apply Willing is not enough; we must do Goethe

45. IOM report: the problem Between the health care we have and the care we could have lies not just a gap, but a chasm A system full of underuse, inappropriate use, and overuse of care Unable to deliver today’s science and technology; will be even worse with innovations in the pipeline

46. IOM report: the problem A fragmented system characterised by unnecessary duplication, long waits, and delays Poor information systems; disorganised knowledge “Brownian motion” rather than organisational redesign

47. IOM report: the problem A system designed for episodic care when most disease is chronic Health care providers operate in silos

48. IOM report: moving forward Commit to a national statement of purpose for the health care system Six aims –safety, avoid injuries –effective, evidence based –patient centred, patient values guide decisions –timely, reduce waiting and delay –efficient, avoid waste –equitable, care doesn’t vary by gender, ethnicity, etc

49. IOM report: 10 rules for redesigning health care 1. Care based on continuous healing relationships--care whenever its needed, not just through face to face visits 2. Customisation based on patient needs and values 3. The patient as the source of control 4. Shared knowledge and free flow of information

50. IOM report: 10 rules for redesigning health care 5.Evidence based decision making 6. Safety as a system property 7. The need for transparency--all information available, including the system’s performance on safety, evidence based practice, and patient satisfaction 8. Anticipation of needs

51. IOM report: 10 rules for redesigning health care 9. Continuous decrease in waste 10. Cooperation among clinicians

52. IOM report: getting started Concentrate on the conditions that account for most health care (cancer, heart disease, mental health) Produce plans that will lead to substantial improvements--like England’s national service frameworks A fund for innovation

53. IOM report: six challenges for health care organisations 1. Design seamless, coordinated care 2. Make effective use of IT, including automating patient records 3. Manage knowledge so that it is delivered into patient care

54. IOM report: getting evidence into health care delivery Ongoing analysis and synthesis of medical evidence Delineation of guidelines Identification of best practices in design of care processes Better dissemination to professionals and public Decision support tools Goals for improvement Measures of quality for priority conditions

55. IOM report: six challenges for health care organisations 4. Coordinate care across patient conditions, services, and settings over time 5. Advance the effectiveness of teams 6. Incorporate measurement of care processes and outcomes into daily practice

56. What will survive as the world changes completely: 1. Clear ethical values 2. Being clear about our mission 3. Putting patients first 4. Constantly trying to improve 5. Basing what we do on evidence 6. Leadership 7. Learning

57. Conclusions Patients will have the same access to knowledge as professionals Self care or “rolled back care” will become steadily more important Professionals and patients will become much more equal partners Evidence will become steadily more important

58. Conclusions Health care systems will increasingly be concerned with chronic not acute disease Health will increasingly be at the centre not the edge of politics There is a chasm between what health care could do and what it does do Some things--ethics, learning, leadership--will continue to be important whatever happens

59. Conclusions The future is highly unpredictable Nevertheless, it is important to think about the future; those who do prosper A good way to think about the future is to imagine different futures, usually called scenarios Two reports, one American and one British, have had similar thoughts about the future