I was in the Netherlands last week and met a small group of people trying to think courageously about the future of health. It was invigorating to see such bravery, often in the face of resistance from 'the system'.
The Netherlands has the best health care system in Europe, according to the Euro Health Consumer Index. Its citizens have to take out health insurance. The Dutch government oversees the quality of, and ensures access to, care, but does not directly manage the system. The country spends about 12% of its GDP on health care.
Despite its top ranking, citizens and leaders are worried about the rising cost of care. Like all OECD countries, the Netherlands has an aging population and a growing proportion of its citizens are obese (although the growth is not as large as in other countries). Both, of course, drive up the demand for care. While pharmaceutical costs have been contained by some drugs coming off patent, the price of other health technologies continues to rise – and steeply. Rising costs translate into higher premiums and co-payments, and, understandably, citizens’ disquiet is aimed at insurance companies whom they blame for charging more and providing less.
One of the group was from an insurance company and it was interesting to hear how they don’t seem to have many options on containing costs. The care they’re paying for is getting more expensive so premiums and co-payments have to rise. There is a clear sense they want to shift to paying for health, rather than sickness, but there are no clear models to follow, especially when it comes to clear and sustainable return on investment.
We discussed how we value health solely from a medical lens. Was a diagnosis made? Yes. Was treatment administered? Yes. Fine, here’s a cheque. Yet nowhere in that transaction was it clear that the treatment was what the patient wanted. Indeed, at no point did we ask the patient if he or she wanted something else as well as, if not instead of, the treatment. We only offer what the medical industry thinks people should have.
One of the group runs an elderly care facility and many people spend their last days there. He asked one elderly couple what they wanted. They said a double bed. They’d slept side-by-side for decades and now, in their final moments together, they were divided into a single bed and armchair. He arranged for a double bed but met resistance from the health care system. He replied that it was not only what they wanted but it was what they valued; besides, none of the drugs he had to offer had been tested in the over 80s so no one is sure they work. He knew, however, that the double bed did work – because his patients said so.
This almost-maverick approach was echoed by another member of the group who is helping nine general practitioners to completely change how they care. They’ve decided to reject medicine’s tick-box approach and spend more time with their patients. When they do home visits, for instance, they make sure they understand their patients’ day-to-day issues. One patient, for instance, was struggling to focus on her medication as she was struggling with her knitting. These nine general practitioners are thinking about how they help with these things before they deal with medical problems. They believe that it’s only when they engage people as people can they engage them as patients.
The younger GPs in the nine are worried they’ll be chastised by the system (especially the health care regulators managing the tick-boxes) but the older ones have said they’ll protect them. The older ones believe they can make the case for a completely different approach to care, one that is no longer taught in medical school and yet is fundamental to primary care. This initiative highlighted two recurring themes of the evening – the need for stories and the need for bravery.
We need stories because so much of what people actually want – and value – is hard to reduce to quantifiable metrics. The double bed, for instance, was about the need for intimacy. How does the International System of Units suggest that we measure intimacy? And yet it’s what the patient valued. We need to find ways to value non-quantifiable things if we’re to develop a true system of care, and stories seem like a good way to start.
On bravery, the group was clear that few health care leaders genuinely understood the need to try something new, despite their rhetoric. They felt so-called leaders talk about the need to monetise health rather than sickness and yet few were willing to give it a go. Interestingly, as we talked about what was stopping us from being the change we wanted to see, one member of the group admitted that she often held her tongue through fear that her ideas would look idealistic or naïve.
Towards the end of the evening the youngest member of the group said he felt he was too inexperienced to have a strong voice, which led me to rant about over-valuing experience. I’m stunned that anyone under 40 listens to baby boomers, a cohort that was resolutely awake at the wheel as populations aged, health care prices rose, and the future became unsustainable. It seems clear to me that we have little to learn from them, except perhaps how to shirk intergenerational responsibility and then slink off with a healthy pension. The one baby boomer in the group agreed.
I ended the evening with two clear feelings. Firstly, I was grateful that six complete strangers were willing to share their thoughts, hopes and fears in order to participate in a deeper discussion about the future of health. Secondly, I was left all the more resolute that the key to change is to link these brave people with other brave people, as is happening through the Creating Health Collaborative.
When I got home I suggested to the group they create their own Collaborative, and they’re going to give it a go. If you’re thinking your country needs a forum for fresh, courageous thinking (via doing), drop me a line.