Dwayne Crombie's speech to the Bupa Health Foundation
Dr Dwayne Crombie, Managing Director Bupa Health Insurance, says while we have a great health system in Australian, it's time to look at prevention and innovative reforms to make sure it stays that way.
The Future of Healthcare
By Dr Dwayne Crombie, Managing Director Health Insurance
In thinking about the future of healthcare, I thought I might return to those things I trained in before I passed to the dark side of “health insurance”, namely public health.
On one level, we do very well in Australia, typically we come in the top three for life expectancy with an Australian male child born in 2010 actually topping the world rankings at 80.1 (Lancet, 2017). The health system here compares favorably to our natural peers as evidenced by the recent Commonwealth Fund Survey.
And we don’t even spend that much being a fraction under the OECD average percentage (and that is helped by the static state health spending in Europe post GFC). But there is widespread evidence that our health system (like most western countries) is not fit for our future challenges.
Our system is way too hospital centric and was designed for a different time and place.
In reminding ourselves that any system exists to serve our community, not serve itself, I thought I might highlight three vignettes about current and future challenges.
The first is about our children. Often infant mortality is used as a crude measure of ‘health in a country’, ours is okay at best, we just make it inside the top 20 but do better than our traditional peers (UK, USA, Canada & NZ).
However, at a more granular level, we now know a lot about how important the first 1000 days really are (from the time of conception). From conception to the age of two, babies grow at an astonishing rate and adapt constantly and with considerable plasticity in their key systems.
When I trained, we thought DNA explained pretty much everything with the odd dose of nurture.
Now we know that the interplay between the environment we face can have a considerable impact on how our genes are expressed – through the newish science of epigenetics. With really strong evidence that the what and how we are exposed to our environment at the start of life affects our propensity to many conditions later in life. Indeed we know these experiences can be passed on epigenetically from mothers and grandmothers in particular. (Telomeres provide a weathervane on how things are going)
As well as that we know that how our brains wire up (synaptic pruning) is also a key factor along with the complex interaction with our microbiome including gut microbiota.
At a practical level, social and emotional bonding and attention has a profoundly positive impact, so one challenge is how can we improve resilience in those babies and families who are disadvantaged and whether we can undo some of negative impacts earlier in life (much less expensive than fixing the downstream problems) by much more proactive interventions with families.
Typically the healthcare system is good on the physical stuff but not as effective at galvanizing or focusing on social and emotional support.
Obesity and being overweight is a much more recent challenge to humanity. It is a leading cause of ill health and a rapidly increasing factor in all cause mortality. 35% of adult Australians are overweight and 30% are obese, making some 2/3’s of the adult population. We manage 600 million visits to fast food outlets annually! Even more alarmingly the Deakin Research Centre on Obesity (WHO Collaborative) found rates of up to 38% for obese or overweight children in grade 4 in rural Victoria and it is in children and young people where the battle is being lost (compare this with a 7% rate when I was a child).
Now, at one level of healthcare sustainability, one could keep building bigger and bigger hospitals with more doctors to keep up with more and more stenting, more amputations or even being more proactive with lots more invasive and non-invasive bariatric (obesity) surgery.
Looking back at photos of the 1970’s, it is not just the hair and clothes you notice, but how thin everyone is. The editor of the Harvard Public Health Magazine went so far as to suggest we need a 1970’s protest movement to undo the powerful convergence of the food industry, food availability, the substitution of fat by even more energy dense carbohydrates from the flawed focus around low fat only. Indeed there may be plenty to learn from that other great crusade in public health – reducing tobacco use on how we might solve a challenge like this, but this is much more multi-dimensional.
The major near term public health goal is to try and slow down the current trends, especially in children and young adults, where it may be easier to undo. Getting the science right and updating the key public messages is in train, but the science is complex because epigenetics and the microbiota may underlie many of the changes.
How do we mobilize communities? How do we find common ground with industry that at least moves in the right direction and how do we try to align economic incentives with health ones, using regulation only as necessary?
We are entering what some call the Anthropocene era. As a species we have been around for about 250,000 years but our impact on the planet is now so profound that we are reshaping all other species (flora, fauna) and the entire biosphere, regardless of how nature is independently changing.
Our success as a species has especially relied upon our development of language and an amazing adaptive ability to share culture socially, by creating knowledge and expertise to share and pass on. Nowhere is this clearer than in human brain development, where the capacity to adapt through learning, plasticity and undoubtedly epigenetics is an evolved characteristic.
When the previous US surgeon general as asked, what was the most challenging disease of the 21st century? He answered that it is social isolation.
How ironic, as Thomas Friedman pointed out in his recent book. We are the most technologically connected generation in human history and yet more people feel isolated than ever. Connections that seem to matter most, and are in most short supply today, are the human to human ones.
Isolation and weak social connects are known risk factors for many diseases. They increase the risk of heart disease by 30%, as well as substantially increasing your chance of being admitted to hospital and your risk of dying.
They also weaken communities and their resilience and ability to adapt. How we should respond from a system level is less clear. If a biochemical marker raised your risk by 30%, we’d be taking it very seriously and probably looking for a miracle drug for it. We won’t get our young people to give up their smart phones but how we help them with their loneliness?
Isolation and loneliness are not just the result of poor social skills or lack of social support. An unusual sensitivity to social cues, especially ambiguous cues, may be a significant factor.
Working with soldiers who feel isolated on deployment has shown that effective interventions focus on how one perceives social cues and then helps them reorient how they interact with others.
With older people the causes may be slightly different, it is often to do with “your world dying before you do”, as one older person put it. Therefore structured and routinized social support is proving more successful. Similarly, with middle age men who tend to let their friendships lapse.
In summary, if you ponder how we might address these three big issues it is not hard to see that strategies and programmes to proactively manage them up front do NOT occupy much of the time or resources of the traditional health system.
All require an ‘investment’ mindset with long lead times to show change (10+ years). All require complex behavioural, cultural and social change, there isn’t a magic bullet to fix them.
As a Kiwi, we have successfully applied an investment mindset to workers compensation, the same philosophy is now being applied to disadvantaged families and children by the Ministry of Social Development. It has support all the way up to our current PM, who as an ex Treasurer buys into this investment mindset.
I am inclined to think that the current health system is struggling to provide the kind of joined up leadership to strategically address any of these issues, given many require a clearly desired outcome and a much broader and shared community coalition, much akin to a ‘protest movement’. This may sound naïve but the pressure to solve these challenges upstream will increase dramatically.
The challenge inside the healthcare system especially around more integrated care is to find ways to continuously adapt and innovate that DON’T require Big Bang changes or major political reform.
As was pointed out at the recent CEDA forum, hoping for constitutional change to the split federal responsibility for health and the funding silos, is like hoping for the Tooth Fairy to wave her magic wand.
The clear implication is that we will have to rely upon incremental disruption. As with other sectors, this will principally come from: changing consumer expectation (as slow as that might be in healthcare), technology including digital and genomics, workforce roles, robotics and automation, partnerships - especially diverse and novel ones and reforming incentives for non inpatient care. Our fundamental task is to re-think how we better solve patient and consumer problems, needs and care.