Competition?

Competition is touted as a solution for all the ills that afflict healthcare, not withstanding the evidence from a market that is not deficient in competition, the US, that more competition does not equate to better healthcare. One of the great thinkers, Muir Gray, has written two recent blog posts, here and here, which outline a pragmatic framework which could be used to foster improved healthcare. Strongly recommended reading.

A vision of the future? Bilingual healthcare workers

From the inestimable Muir Gray, (thanks Tony), one possible approach to the problems facing us. Remember Einsteins definition of insanity, doing the same thing over and over and expecting different results. I think that summarizes healthcare. The model we have is designed, or rather evolved from the post war period to deal with a different set of problems. Acute self limited, or fatal illness. Coincident with the rise in healthcare technology, probably the early 50's with the development of ICUs following polio epidemics, the healthcare-industrial complex has in part generated problems and expectations that we are no longer equipped to handle. The paradigm of how care is delivered has to change radically. There is a very interesting book published in the 80's looking at how complex societies fail. The thesis and it applies equally well to complex systems is that a system evolves to deal with a complex problem, problems become more complex, hence the system becomes more complex and eventually a point of diminishing returns is reached where the inputs (think regulation, accreditation, legislation etc) consume more resources and the system collapses.
Gray provides one possible approach to this challenge. Basically the bilingualism to which he refers is that healthcare workers must be versed in not only the ability to provide clinical care to their patients,

"They need to know how to:

• Develop systems
• Build networks of clinicians and patients
• Design pathways
• Manage knowledge
• Harness the internet’s potential
• Engage patients
• Create and manage programme budgets
• Develop the right culture"

He describes this as population medicine. It is highly recommended. 

Wow, Oh Wow

That was Muir Grays Twitter post on seeing this weeks BMJ. Apart from the papers referenced below (Reducing Variation March 24th), there are a number of other papers worth checking out. A report from the Netherlands again finds a marked variation in utilization of medical interventions. An editorial on variation in the NHS; a look at how to redevelop care for long term conditions, and a lot more.

Why such emphasis on variation? Surely the areas with low utilization will balance out the high users for a zero sum game. This is unlikely to be the case, there is mounting evidence, mainly from the US, but also from other countries, that outcomes are not affected by the amount of care given above a certain amount. Therefore there are huge opportunities for reducing waste, saving money, and a lot more good stuff.