What should a liberal health service look like in 2016? A recent study may offer a partial answer. The study, which examined the effect of palliative care on patients with incurable cancer found, perhaps unsurprisingly, improvements in patients’ quality of life and reduced instances of depression. Those patients who had been assigned palliative care were also less likely to opt for expensive, aggressive end-of-life treatments, yet actually lived a third longer. This is a staggering result, both improving outcomes and saving money. Similarly, hospice care may cost 35% less, or save $2,300 per patient, and is linked to greater wellbeing for patients and their family.
A liberal health service would give such services far greater prominence and would be inclusive of similar examples of lateral thinking.
The slow medicine movement emerged in response to these ideas and advocates avoiding unnecessary and costly treatments to focus on nurturing patients. Proponents argue a vast number of expensive and wasteful procedures are carried out without good reason; one study found 11% of healthcare interventions have no good evidence to support them, just the desire to do s omething . Another study found nearly 90% of patients undergoing percutaneous coronary intervention wrongly thought it would reduce their chance of a heart attack, and half of cardiologists would perform one even if they thought it had no benefit. An estimated one in seven NHS treatments are unnecessary. The NHS should respond by encouraging the spread of programmes like Choosing Wisely, which could improve patient wellbeing and save up to £2 billion per year.
Hogeweyk, a Dutch model village and nursing home, offers another example a liberal health service could enthusiastically adopt. Nursing homes are often clinical and unwelcoming, but Hogewey is designed to be familiar and comfortable. Residents from Indonesia have warmer apartments and are served their own traditional cuisine, while in the apartments of residents who were upper-class or wealthy, carers dress and act as if they were domestic servants. Residents engage in a variety of social activities and move freely around shops in the village. Hogewey costs no more than a British nursing home, yet residents eat better, live longer, require less medication and demonstrate greater wellbeing. A liberal health service would support the expansion of similar dementia villages in Britain.
A liberal health service would respond to the ideas of the slow medicine movement by encouraging a healthcare system that didn’t just work in hospitals but within the community, embracing the principle of subsidiarity. This is made vastly more achievable by the tech revolution; smartphones and the miniaturization of diagnostic tools mean ever more procedures can take place outside the hospital. Australia’s Hospitals in the Home has taken advantage of the development of portable x-rays and blood tests to provide hospital treatments in patients’ homes, improving outcomes and reducing complications. In the USA, patients order their own blood tests and get the results online, making it cheaper and more convenient.
Technology could also move healthcare out of hospitals by enabling a range of co-production initiatives, substituting the traditional healthcare model for a grassroots network allowing people to share resources and shape their own care. RUILS provides adult social care, and allows users to pool their direct payments and personal budgets to increase purchasing power. Service users can vote on how the service is run and sit on the board. SUN is a scheme which brings people with emotional and behavioural problems together for both crisis support and social activities, viewing the community as the doctor. SUN has reduced planned and unplanned hospital visits (725 to 596 and 414 to 286 respectively), hospital bed use (330 days to 162) and A&E attendance (down 30%). The USA’s Chronic Disease Self-Management programme is built around peer support, lead by those with experience of suffering chronic diseases and allows patients to self-manage symptoms within the community. A trial found wide-ranging improvements in symptoms and mood and savings of four dollars for every one invested. More GPs should be encouraged to utilise social prescribing, as has successfully been implemented in Bradford, to ensure greater attention and take-up for good value co-production programmes.
Greater integration of some of the innovative developments in technology and the Internet of Things could also unleash a more patient-centric healthcare system. Google has designed a contact lens to monitor the glucose level of diabetics without the need for invasive finger-pricking. The readouts can be displayed on a smartphone or streamed directly to the patient’s clinician. Proteus manufacture a pill with sensors to monitor the patient and share data with an app. Verily has created a tremor spoon for patients with Parkinson’s, with sensors that monitor the condition. Propellor Health is developing smart inhalers for asthma sufferers, to detect the surroundings, time and air quality associated with attacks.
Conventional, top-down methods of evaluating and delivering healthcare are cumbersome and unresponsive. Many conventional tools to rank hospitals and empower patients do nothing if not the opposite. Bottom-up initiatives, growing out of the experiences of real patients, offer far more promise. PatientsLikeMe connects patients suffering similar illnesses so they can share their experiences of symptoms and treatments. Jourvie is an app designed by anorexia sufferers to help others with the same condition. Ginger.io monitors the patterns of behaviour of people suffering from mental illness to track their mood, and offers clinical support when it believes they are vulnerable. Babylon is a subscription service that allows patients to order prescriptions, text a doctor or make video consultations. Users rate their experience, and poorly rated doctors are removed from the system. For the cost of a Spotify account Babylon lets patients be far more proactive in monitoring their health, reducing unnecessary hospital visits and diagnosing serious problems earlier. This is likely to bring long-term savings, and the government should play a role in subsidising access to similar services for the less well-off in society. GPs could be encouraged to prescribe subsidised access to patients identified as most at risk, or to persistent, high-cost users of GP services.
This is what a future liberal health service should look like; preventative and interventionist healthcare delivered in homes and communities by a combination of new technology and old-fashioned human contact