Stephen K. Klasko, M.D., M.B.A., President and CEO, Thomas Jefferson University and Jefferson Health, was an advisory board member of CPP's Health and Social Care Inquiry. In this guest article, Stephen highlights why we must pursue a vision of health which is supported by technology that widens access, increases quality and reduces costs.

As the out of country representative on CPP’s health and social care inquiry, I know just enough about the NHS to be dangerous, and while some of my insights may be anecdotal, some are universal issues across the continents. With that in mind, this essay seeks to add value from my areas of expertise, namely around population health, technology, augmented intelligence and educating the workforce. I want to acknowledge input from colleagues Peter Kopelman in the UK, Lauren Collins, Judd Hollander and David Nash at Jefferson, Gregory Shea at Wharton, Antonia Chen at Harvard, Brian Nester at LeHigh Valley Health, Steve Gabbe at Ohio State University, and Ignazio Marino, a transplant surgeon and the former mayor of Rome. Even among this dedicated group, the need to acknowledge budgeting for hospital facilities and to shore up the current workforce, competedwith solutions based on telehealth, secondary and tertiary prevention, and social determinants of health.

A universal trap

The NHS is the envy of many, a historic leader in bringing healthcare to all, and at the same time caught in the classic dilemma of legacy systems - stretched to rebuild ageing infrastructure with modern technology, while finding that even its own goals of access are unsustainable.

The NHS suffers from the same geometry problem that traps every country’s healthcare decisions, namely the iron triangle of cost, access and quality.[1]

As access has increased, cost has increased, and patient experience and quality may be compromised. The choices presented here are difficult. While social determinants of health are responsible for the majority of long-term healthcare improvement, the perception is that the financial and political costs of measurably affecting obesity, causes of diabetes and heart disease will exacerbate the short-term financial shortfalls in providing acute care. In much of the world, we have sunk costs in legacy infrastructure and workforce, while facing the need to reduce costs by a comprehensive prevention initiative based on improving physical, mental and social health.

Can we leapfrog to a future of nimbler, less expensive, better targeted, care, or will we continue to shore up our 20^th century history of hospital system-building, knowing that access for poorer people will continue to fall, and citizens with chronic illness will continue to confront a fragmented provision of care?

Bottom line: We cannot afford to get bogged down in the impasse between legacy infrastructure and community-based services. We must use the best of what we have to pursue a vision of health, supported by a technological platform that facilitates personal support regardless of location.

Answers

This is no idealistic dream: If we can see what will be clear in 20 years and do it now, we will create immediate help for unsolved issues in population health, and immediate savings for budgets. This is ‘future-thinking’.

Future thinking will save money today, take advantage of new helpful technology, and prepare a workforce to tackle complex care.

Here's how focusing on the future can save money:

1. Healthcare with no address

Often seen as just telehealth or retail medicine, the future of care outside the traditional hospital is actually a way to truly create integrated prevention on a platform of technology.

How does this save money? We too easily forget that prevention has deep layers. A quick look at the opportunities make clear how much new technology for monitoring and intervening can make integrated prevention an achievable transformation. While primary prevention may be funded through social services, housing and job programmes, secondary and tertiary prevention provide the opportunity for technology to reduce direct medical cost:

• Primary prevention is our lowest cost, highest value activity - vaccines, healthy food in schools, dental care for children, suicide prevention for teens and communal activities for seniors to ward off loneliness.
• Secondary prevention is deeply tied to seeing a new relationship with the patient as consumer. Giving patients greater control over their health records, developing positive psychology for self-care, using technology to text teens we know are at risk - these work to prevent hospital visits and crises.
• Tertiary prevention is surprisingly difficult in a hospital-based world. When a patient leaves the hospital, we have trouble prescribing food as medicine, monitoring by remote technology, and ensuring self-care. The result remains repeated readmissions, because we know how to handle someone in the hospital bed. But we can save money immediately if we know how to help someone in their own bed.

2. A workforce to address the crisis in complex care

Our 20th century history created great professional institutions with one flaw - the silos between disciplines means we do not have a workforce capable of complex care, helping a patient through mental health, physical health, and social health. Population health research tells us that 80% of a healthy life depends on non-medical factors.[2]^{, [3]}

And we can now show what the ancients argued, that physical health depends very directly on mental wellbeing. In fact, adverse childhood events will bring on physical illness. The trick is challenging our educational institutions to build a team-based workforce that appreciates and intervenes, often using simple tools of education and coaching.

The goal of integrating mental, physical and social health is not idealism. It can save money right now. For example, ‘hotspotting’ super users[4] and then assigning teams to help each individual, will immediately bring down the cost of caring for the 5% who account for 50% of the health care bill.[5]

In most cases, super-users will have mental and social problems the team can address, and simply guiding a patient will prevent expensive hospital visits. At Thomas Jefferson University, we have been teaching inter-disciplinary teams of students to intervene with super-users – where simple home visits and coaching can bring greater relief while ending the use of expensive services. Our data is pending for publication, but it shows significant declines in costs attributable to super-users, while increasing the sense of self-efficacy for clinicians and students involved. For example, Jefferson students taught a patient how to change a colostomy, ending her history of routine weekly trips to the emergency department.[6]

This future can be written today - with people, technology and bold thinking. It can save money. And it will tackle political hot-button issues like loneliness, teen suicide, queues for surgeries, and health disparities between wealthy and poorer regions.

3. Disruption

In the early 2000s, I had the opportunity to work with Apple as they disrupted an industry that was moving from a computer ecosystem to a mobile, digital lifestyle. Healthcare has an opportunity to go through a similar once in a lifetime shift from a business-to-business (B2B) model to a business-to-consumer (B2C) model, one in which the educated patient is the boss. That shift in paradigm must now be debated – what should we expect from a national health service based on what is affordable for the longer term given the daily advances in technology (in a context of an aging population)?

A transformative approach, ‘healthcare with no address’ entails telehealth, hospitals at home, micro-hospitals, joint replacements as outpatients, and rehab at home, for example. At Jefferson through a combination of telehealth, urgent care, and internet scheduling, we are able to get 70% of our non-trauma, non-ambulance patients out of the emergency room. From the NHS perspective, that means moving from a model of throughput for overcrowded emergency rooms to a model in which technology and artificial intelligence (AI) keep a good percentage of patients out of the emergency room and into less expensive and more convenient settings.

What about the disruptors, such as genomics and augmented intelligence? I believe:

• By 2020, 25% of hospitals and physicians could be providing real time genomic based decision support at the time of writing.
• By 2022, 20% of the population will be relying on virtual health assistants for wellness and management.
• By 2025, 35% of all care in the UK will be delivered virtually, and ten years from now, the majority of interactions will be virtual or remote and the majority of them will involve AI or machine cognition applications.

What happens to the hospital beds? How does that affect payment models? Healthcare workforce? How do you prepare for those disruptors?[7]

4. Social determinants and place

As it relates to social determinants and the issue of healthcare in place, the key will be to ‘think globally and act locally’. There is no way that these incredibly complex social issues can be handled using a ‘one size fits all’ approach.

The creation of pilot programs in diverse communities where the social and academic entities in that area are incentivized to work together rather than being funded separately, will yield important solutions as to what moves the bar and what does not. It will require a level of collaboration among social and academic entities that does not usually exist. No one entity can solve a community’s problems, but too often government funding becomes a competitive game. Rather the funding should be dependent on social agencies and healthcare entities actually collaborating to solve social and inequity issues, moving from individual funding to ‘group funding’ will help drive that behavior.

More resources should be spent to educate the population towards wellness and living a healthy life in healthy places. How you incentivise individuals and populations toward wellness is a universal problem. If you are going to really look at healthcare in place or ‘healthcare with no address’, then dollars for food as medicine, environment, smoking cessation, alcohol and drug overuse have to be as plentiful as dollars for hospital beds and new technologies.

5. Political pressure and perceptions

Although the NHS still enjoys wide support from the population, it has been under significant pressure and challenges that can jeopardize that positive view. NHS budget constraints could negatively affect the way the population perceives the system. Engaging the population is essential to face social healthcare determinants and therefore it is fundamental that the population keeps believing and supporting the NHS and its principles. Prevention is a long-term gain, but not always politically expedient.

The education of consumers will pay huge dividends for the NHS in the long run. Effective healthcare systems have learned that shifting more purchasing power and decision making to patients has reduced unnecessary procedures and overall costs per population. The B2C model only works with an educated patient base.

6. Data and population health

We know more about social determinants of health – jobs, education, housing – than we know how to target interventions that reshape the provision of direct medical care to end health inequalities. In part, this is due to the difficulty in measuring and implementing a complex-systems approach simultaneously at the national and local levels. A systems dashboard is critical.

The study of single independent determinants may not be considered completely reliable, so it should be mandatory that policymakers focus their attention towards a complex-systems approach, which will allow the full evaluation of the intricate relationships between single determinants, while obtaining the big picture on how the ‘system as a whole’ works. This would allow public health professionals and politicians to plan the right interventions to tackle disparities and inequalities at local and national level.

7. Infrastructure

The NHS could use the reported decline in infrastructure as an opportunity, freeing itself not just in a technological sense but also in a definitional sense. How can it best use technology to free itself to redesign diagnostic and care delivery? The Secretary of State for Health and Social Care, Matt Hancock, has made it his mandate for the UK to become more tech enabled. Creating IT based-systems on ‘wearables’, apps, etc. will allow patients to make decisions that affect their own healthcare. In Leeds Teaching Hospitals, for example, the teaching and innovation lab is using design technology and virtual reality technology to affect mental health and primary care improvement.

The NHS needs to invest in a ‘Silicon Valley for health’ in a similar way that Cambridge, Massachusetts has become a ‘biopharma cluster’. In reality many believe the NHS has done just the opposite, for example creating barriers to entry for new startups to work with the NHS because of the many regulations set up before you can contract with the NHS.

a) Public-private partnerships

The potential in partnering with the private sector as it relates to disruptive technologies cannot be overestimated. Creating data interoperability and an app store approach where the barriers to complementing legacy electronic health records (EHRs) are paramount. It is not just the technical capability to exchange data that matters but also the ease with which it is exchanged and understood by patients and providers. High levels of interoperability allow integrated care delivery to complex patients by multiple social and healthcare organizations collaborating digitally. In every other transformed industry, data and ‘getting rid of the middle layers’ has increased efficiency and experience and decreased cost.

The concept of ‘healthcare with no address’ enabled by AI, telehealth, and on-line templates that can be reviewed asynchronously by the doctor, may obviate the need for a doctor to see a patient in the traditional sense, thereby disrupting the cost, access and quality curve while reducing the increased need for specialists that can see a patient.

b) Post-acute care

NHS is suffering from a post-acute care breakdown, particularly as it relates to skilled nursing, inpatient and outpatient rehab and homecare services. There is little to no incentive to create alternative post-acute care assets or settings because the NHS pays a ‘daily rate’ to hospitals for bedding the patient. Why create a new post-acute setting or infrastructure to care for these patients, when the daily payment will surely be less than the daily rate hospitals are already receiving?

While there is a clinical imperative that exists, the economics of the payment system seem to be retarding a business breakthrough. Financially fragile, socially isolated seniors are a burgeoning problem for both the US and the UK. The UK seems to have relatively little infrastructure in this regard and it could take decades to build. Perhaps the UK is ripe for private post-acute providers to come in and offer a cost-effective solution that would:

• Provide better care/outcomes
• Un-clog hospitals
• Reduce unnecessary payments by the NHS to hospitals that are simply using some of their assets as hotel beds.

Conclusion and recommendations

The most exciting prospect for public investment is to stimulate new cycles of innovation. Technology is rapidly becoming available to redefine ‘place’. Dilemmas as great as public healthcare require the best ideas from all walks of life, from architects and designers, to community advocates, to cultural leaders, to tech entrepreneurs, to teachers, and most especially to real people who are trying to live healthy lives.

That spirit of innovation must be a core value for our educational institutions as well. In the age of augmented intelligence, we do not need to select and train physicians to be robots - we will have robots to memorize what we once asked doctors to remember. Our clinicians must be the human beings in the room, even if that room is virtual. Our universities must break down professional silos and build teams.

It's time to argue that in the UK we have the creativity and discipline to make health care an exciting, meaningful endeavour where integration and equity can be achieved.

Summary of recommendations

1. Prevention only works when it is integrated - when primary, secondary and tertiary prevention allow a healthcare system to respond to people where and when they need help.
2. As far as ‘place’ is concerned, the NHS should invest heavily in education activities on healthy living, which would promote a new culture of healthy place. This shift will require a change in culture - from acute care to integrated prevention.
3. Social and cultural determinants are a crucial issue, and the impact of immigration, Brexit and the millennial generation should be taken into account.
4. Education and innovation are the key words, especially considering the many new ways to administer health.
5. The education of consumers will pay huge dividends for the NHS in the long run. Effective healthcare systems have learned that shifting more purchasing power and decision making to patients has reduced unnecessary procedures and overall costs per population. In order for the NHS to reverse the cycle of increased costs for less efficient care, we need to move from a B2B model to a B2C model—from a model where the physician and administrator is the boss to one in which the patient is the boss.
6. More than new legislation, the NHS needs a new culture. Traditionally, the NHS has concentrated on taking care of patients with active disease and allowing them a quick return to work, to reduce the economic impact on the society as a whole. Population health and prevention is an investment for the future.
7. Innovation and technology are global. Jefferson is working with a group out of California on an interoperability model that will create a marketplace of IT applications across various legacy electronic health records. We are also working with a digital footprint technology around patients with serious medical illnesses. These kinds of innovations may be exportable to the UK system.
8. The ‘right to healthcare for all’ which has been the basis for the NHS since its inception is a noble goal. As healthcare delivery has become more complex, that ideal requires a very different approach. In the US, we talk about having ‘Star Wars medicine grafted onto a Fred Flintstone healthcare delivery system’. The importance of decreasing layers of complexity, having NHS healthcare enter the digital and consumer revolution, and giving more power to educated patients cannot start soon enough.

All views, thoughts and opinions expressed in this article belong solely to the author.