By Sohail Inayatullah
Will health-bots monitor your caloric intake, warning you if you’ve eaten too much or not exercised enough?
Which medical model is likely to dominate – the democratic, the professional or the corporate? Can medicare continue or will globalization end Australia’s unique universal health care system?
How will the internet change how patients get information about their illnesses? Will doctors become knowledge navigators, helping patients decipher what is gold and what is crap? Will they be able to accommodate the dramatic rise in patients using alternative therapies such as chiropractic, acupuncture and meditation?
Will general practitioners even be needed as genomics and other dramatic technological advances repair defective genes? In twenty years, will general practitioners be seen as quaint practitioners of complementary medicine?
What will general practice look like in twenty years?
On February 11 and 12th, 2000 over 140 health professionals met for three days at the Brisbane Novotel to ponder these and other questions related to the health futures of Queensland and Australia. Professionals consisted of general practitioners and senior managers of the various health divisions in Queensland. Included also were directors of Queensland Department of Health, futurists, academics, pharmaceutical representatives and members of the community.
Participants were treated to a day and half of lectures on (1) systems approaches to international health, (2) impacts of the internet, the human genome project, ageing and complementary therapies on general practice (3) funding issues from the perspective of the Federal Government, (4) the role of state divisions in health care, (5) rural health care, and (6) perspectives from the hospitals.
The intent of these lectures, however, was not merely to provide the latest information but to help general practitioners and division chiefs develop a map of the future of the health care. To do this, along with plenary sessions there were eight small group sessions facilitators by futurists. In these groups the drivers of change were identified. From these drivers a systems map of how each subsection of the health system interacted with others (for example, how funding impacts who gets health care and through what delivery mechanism) was developed. This in turn was used to develop possible and probable scenarios. Once the alternatives were explored, participants articulated their preferred vision of the future. From this, a backast – a memory of the future – was developed so as to deduce which trends and events are likely to create the preferred future. The concluding session then asked participants to personally commit to action steps that reflected their preferred future. Considerations of the future were thus central to action steps today.
Drivers and Scenarios
As expected the drivers were: technology, funding issues and the costs of health care, globalisation, ageing of society, consumer demands, availability and distribution of resources, and expectations of the future.
Participants developed scenarios that can be divided into four distinct categories.
1. High-technology scenarios. They were called: digital doc, dr. robot, medi-net, IT and Star Trek. Of the five groups that reported this scenario, three considered these negative scenarios and two considered them positive. Features of this future included: 1. Germ line engineering (eliminating genetic defects for current and future generations), genomics (customized gene therapy), robodocs and smart cards and health-bots (interactive wearable computers that monitor one’s health). Generally, participants believed that the new technologies are likely to be patient-led. Doctors, while overwhelmed in this future, become far more holistic in their treatment, focusing on what technology does not give patients.
2. Corporatist scenarios. These were called: Big business ownership, corporatist, $ and corporate piracy. No group saw it as a preferred scenario although one or two individuals in various groups did find it preferable. Generally, loss of control was feared, and, even while there were some gains for consumers (lower cost and seamless service) gps believed that overall the quality of health delivery would decline in this future since cost considerations would become primary and managerialism would take over as the dominate organizational mode. However, one group did argue that instead of other corporations taking over gps, they foresaw a “future where gps develop a national corporation which has equity in, and market control over, services such as radiology, pharmaceuticals, nursing homes and private hospitals. Gps would then lead the money instead of follow the money as the do now”.
3. Worst case scenarios. These were largely around the axis of power. They were called: Drone, Mots (More of the Same), Big Brother and Capitation. In each case, doctors lost their autonomy and felt disempowered. For example, in the Big Brother scenario, “technological developments play into the hands of centralists by both increasing specialist monopolies and also eroding the meaningful relationships that are at the core of the GP Ethic”. Clinical governance creates a hegemonic culture wherein gps lose their maneuverability in creating the futures they desire.
4. Network/multi-door. This future consisted of a more diverse but strongly connected system. The titles given were: back to values, quality and network, multi-door, division cooperative, consumer ownership, GP ownership and medi-network. The central point in these networks/multiple doors was that doctors remained the gatekeepers with divisions or associations playing a systems coordinating role. For example, some of the roles the divisions played were: “advocacy with local services, research interpretation (separating the gold from the crap on the web), brokerage role through virtual amalgamations)” as well as a funding role. All these were considered positive. In this future, community members felt part of the system, indeed, this scenario was gp and community/patient-led.
5. Preferred Scenario
The preferred scenario had a range of titles. These included: multi-door (flexible, multiple integrated systems, doctors as gatekeepers and knowledge navigator), futuretopia (wisdom, consultation with the community, regional governing systems, empowerment of patients, focus on quality of life), Community Care (community instead of hospital focus, gp as gatekeeper, use of smart bots, practices staff and family friendly), Nimbin (partnership between gps and the community, reduced alienation, alternative and allied care, shared ownership and reduced isolation) and the Happy Health Centre (multi-door, part of lively gp network, and highly efficient).
In general, gps wanted new information and communication technologies to make the system more seamless (for administrative purposes) and so that they can have a higher degree of connection with other gps.
They desired the system to be far more community focused and power to be decentralized
What This Means
For Queensland health divisions, this is a clear mandate for them to take a more significant and decisive role in shaping the future of general practice. It also a clear indicator that doctors want a far more integrated and seamless system that is fundamentally based on the community health model – interactive horizontal relationship and not vertical integration is the desired vision of the future.
It also means that doctors, as long as they are the gatekeepers (deciding issues of quality, scientific evidence, etc), are open to alternative forms of health care, to alternative medicine.
Finally, for large pharmaceuticals this means that as they attempt to gain entry and leverage to local health divisions and gps, they must do so in the context of the community model, they must become a local community business, and not an external player.
For this Australian government, as globalization pressures the State to reduce universal care, they need to understand that doctors will resist this. Any changes in the health care system must begin with serious consultation with general practitioners, the divisions and community members. Vertical pressures from globalisation must as well live with the desire for localist community models of care, if they are to ensure that efficiency does not merely mean that the accountant instead the doctor runs the practice.