The future of healthcare

The world spends a lot of money on healthcare. But it’s not enough.

Between 1995 and 2016, global healthcare spending grew by 4% per year to reach US$8 trillion, 8.6% of the world economy.[1] This growth was driven by economic development and by governments prioritizing healthcare.

Healthcare spending is not evenly distributed:

• In 2016, 41.7% of total health spending was in the US
• The countries of sub-Saharan Africa collectively comprised 1%
• High-income countries spent US$5,252 per citizen
• Upper-middle-income countries spent $491
• Lower-middle-income countries spent $81
• Low-income countries spent just $40
• Low-income countries are home to 10% of the global population, but only 0.4% of global healthcare spending

This growth is expected to continue.
Healthcare spending is projected to continue to increase by 1.8% annually.

The disparities will continue too:

• 69.4% of this spending will be in countries currently considered high-income
• In 2050, low-income countries will comprise 15.7% of the global population, but still only 0.6% of spending on healthcare

But demand is increasing faster. That 4% annual increase in spending is just 2.7% per capita. The global population is increasing, and people are living longer. In 1950, average life expectancy at birth was 47. Today, it is 72. By 2050, it is projected to be 77, and by 2100, 82.[2]

A longer life doesn’t necessarily mean a healthier one. Conditions that used to be fatal can now be cured, but survivors often have complex needs. The burden of non-fatal disease and injury is rising, and a greater number of people suffer from multiple chronic conditions. Between 1990 and 2017, the global burden of disability increased by 52%.[3]

With economic development and prosperity comes a greater incidence of non-communicable diseases such as diabetes, heart disease and cancer — not only in rich countries but in the emerging economies of South-east Asia, Africa and Latin America too. The prevalence of obesity has nearly tripled worldwide since 1975.[4] In 2017, non-communicable diseases caused 73% of deaths and 80% of disability worldwide.

Our expectations of healthcare are increasing too. Patients are starting to see themselves as consumers: they have instant access to information via their smartphones and wearables, and they don’t understand why healthcare can’t be like that too. There is growing pressure on providers to modernize and embrace new technologies.

By 2050, there will be more than 1 billion people over 70. Who’s going to take care of us?

As the century progresses, the global population will become progressively older. In 2010, there were 350 million people older than 70, and 11.8 people of working age for each of them. By 2030, the ratio of workers to over-70s will have tumbled to 7.9, and by the end of the century, it will be just 3.4.[5]

The healthcare workforce is larger than at any time in history. In OECD countries, employment in health and social work has grown by 42% since 2000, to encompass one in ten jobs.[6]

But there is still a shortage. Today only half of all countries have enough healthcare workers to deliver quality services, and no country is on track to meet all of the World Health Organization’s health-related Sustainable Development Goals by 2030.[7] The ageing population and the rise in non-communicable diseases will generate demand for 40 million extra healthcare workers by 2030 — which would mean doubling the current workforce. Without action, the WHO warns that there will be a shortfall of 18 million healthcare workers, particularly in lower-income countries.[8]

We also face new threats, the magnitude of which is still unknown

Epidemics

At the time of writing, more than 2.5 million cases of COVID-19 have been reported to the World Health Organization and more than 180,000 people have lost their lives. Epidemics are able to move faster and further than in the past, due to globalization, greater connectivity and denser cities. “A new HIV, a new Ebola, a new plague, a new influenza pandemic are not mere probabilities … The only major uncertainty is when they, or something equally lethal, will arrive,” the WHO said in 2018.[14] COVID-19 was first reported to the WHO on 31 December 2019 from Wuhan, China; within eight weeks, it had reached six out of seven continents.

Climate change

Climate change threatens food supplies, increases the risk of exposure to extreme weather and wildfires, creates favourable conditions for the transmission of disease, and exacerbates the effects of air pollution. “The life of every child born today will be profoundly affected by climate change,” wrote The Lancet in 2019. “Without accelerated intervention, this new era will come to define the health of people at every stage of their lives.” [15]

Air pollution

Outdoor air pollution causes 4.2 premature deaths annually.[16] By 2060, it is projected to prematurely kill 6-9 million people worldwide each year, and cost 1% of global GDP as a result of sick days, medical bills and reduced agricultural output.[17]

Can technology fill the gap?

The last decade has seen a resurgence in health R&D, particularly in medical technology. Healthcare is second only to IT in research, with worldwide R&D spending reaching US$177bn in 2019.

The last ten years have seen strong growth in patents too. In the world’s top science and technology clusters, medtech is now the most frequent field of patenting. But this likely underestimates the actual level of innovation, notes the World Intellectual Property Organization, as health-related R&D is taking place in many other fields, including artificial intelligence.[11] Regulatory agencies such as the US Food and Drug Administration have approved record numbers of novel medical devices over the last five years, heralding an era of breakthroughs in material science, digital health and other technologies,[12] while venture capital is flooding into health start-ups.

New tools will diagnose problems, cure diseases, improve efficiency and disrupt business models. Genetics, stem cell research and 3D printing will enable more personalized treatments, while automation, data analytics and AI will underpin everything from robotic surgery and diagnosis-by-algorithm to patient monitoring and caregiver support. Wearables will prevent illness by flagging risk factors and nudging us towards healthier lifestyles.

Healthcare is one of the biggest targets for the big four tech companies, with Alphabet, Apple, Amazon and Microsoft all investing heavily in R&D, acquisitions and collaborations. Google has shown that its AI can detect diseases such as lung or breast cancer and acute kidney injury earlier and with greater accuracy than traditional methods. In a study with more than 400,000 participants, researchers at Stanford University found the Apple Watch reliably identified heart rate irregularities that were confirmed to be atrial fibrillation, a leading cause of stroke and hospitalization.

“With new technology and service models, we’re increasingly able to provide a lot of care outside hospital,” says Mike Lovas, design director at Healthcare Human Factors in Toronto, a consultancy within Canada’s largest academic hospital network, UHN. “We’re looking at how we can help people be healthy or enable them to manage their conditions at home, setting up systems to monitor and keep them stable.”

In collaboration with cardiologist Dr Heather Ross, Lovas’ team helped design Medly, an app that monitors patients at risk of heart failure, the single most common reason for hospital admissions in Canada. Every morning, patients check in with their weight, blood pressure and symptoms, and receive feedback from Medly’s cloud-based algorithm — perhaps a warning about their salt intake or to increase their medication.

If they need more attention, a nurse will be alerted. The system has not removed the need for human intervention, but it has changed the number and types of role. “Over time, we’ve made the system smarter and we’ve increased the patient-to-nurse ratio — we now have 400 patients to one registered nurse. We don’t need a physician to field every clinical question.”

Lovas is now design director of the Smart Cancer Care initiative at Princess Margaret Cancer Centre, one of the world’s largest, which aims to reimagine the future of cancer care. Since the start of the COVID-19 pandemic, they have successfully virtualized around 75% of clinic visits. “We’re now exploring how we can deepen virtual care, so that it’s not just phone or video. We’re looking at nurse-led virtual clinics, asynchronous messaging, remote symptom tracking, and automated follow-up visits — the patient submits lab results, symptoms scores and questions, and the clinician reviews. If everything is okay and the patient doesn’t want to see the doctor, they just schedule the next follow-up in 6-12 months.”

What about the people?

Technology will support the healthcare workforce of the future, but it will not replace them.

Health is one of the least automatable sectors — according to management consultant McKinsey, only 36% of activities can be automated, predominantly data collection and processing.[19] Clinicians will still be needed to care for people, to interpret and contextualize sensitive information and to explain the choices available.

But as workplaces, today’s hospitals leave a lot to be desired, says Mike Lovas at Healthcare Human Factors. “Different types of work happen in a hospital — consulting with patients, doing physical examinations, preparing medication, communicating with colleagues, providing education — all with different demands. But hospitals typically have limited function. There’s a case room with a bed and a computer, and there’s the hallway. Clinicians flip fluidly between different contexts, but they often just do the work wherever they can find space. Hospitals, especially older ones, are not optimally designed for the variety of work that takes place there.”

Not having the right kinds of spaces means activities take longer, and increases the likelihood of mistakes. “When somebody’s carying out a high-risk task, like administering certain medications, they absolutely cannot be distracted,” says Lovas. “The physical design of spaces can go a long way in supporting patient safety, specifically in the way that we allow clinicians to focus on critical tasks.”

Clinicians can do the most good interacting with patients, but much of their time is often taken up with tasks elsewhere, or in moving between locations, especially in older facilities built for a different age. A 2018 survey used wearables and a sensor network to monitor contact time in a US intensive care ward, and found that nurses spent just 33% of their time in patient rooms, and physicians 15%.[20] So designers of new hospitals seek to devise more efficient, connected layouts. “We’re looking to reduce the amount of steps that someone has to take to do their job, and increase visibility so one person can monitor multiple activities,” says Jason Schroer, principal and director of health at HKS in Houston, Texas.

This could extend to grouping services more logically, reflecting the way they are likely to be accessed, says Vivien Mak, director at P&T in Hong Kong. “If you’re an outpatient coming back for a follow-up, you might have to go through five departments to see a doctor, have an x-ray, or a blood sample taken, pay for your medicine and collect it, and these might be in different buildings. If all of these facilities could be combined or put on a platform that is multidisciplinary in terms of care, then the patient can come to a one-stop service centre.”

Part of the problem is that healthcare estates have typically been developed piecemeal over many decades. “There have probably been quite a number of changes and additions, but they weren’t done according to a masterplan,” says Mak. “New blocks were built wherever was available, and the allocation of functions may not relate to the original block that well.” For both new-builds and redevelopments, she says, a common approach is to group facilities for outpatients, in-patients and “hot zone” functions such as operating theatres and intensive care units (ICU), and allow more sustainable expansion. “It’s becoming very important to plan for the future of these zones, and how they connect with each other.”

It’s rarely possible to shut down a whole hospital once it’s running, so reforming the masterplan is a long-term endeavour. Mak is involved in two such projects at public hospitals in Hong Kong. “You need to devise a grand plan for the hospital to be redeveloped phase by phase over the coming decades. You need to identify, where you can, some space for decanting and then decide which block goes first.”

Better logistics can also free up staff time. Hospitals are complex networks of supply chains for items that must be delivered without delay or contamination. Gunnar Linder, regional director at WSP in Sweden, says a central equipment store — shared between different operating theatres with just-in-time delivery — frees up clinical space, cuts walking distances and reduces overall equipment requirements.

In Hong Kong, there is also a move to separate elderly and acute care. Older people with complex conditions requiring long-term care will be looked after in specialized infirmary units, freeing up acute wards. “When you design an acute hospital for all services, you have to facilitate circulation and connections with operating theatres and ICUs. But most infirmary care patients don’t require those services, so it’s more efficient to look after them in another setting.”

Standardizing room and floor layouts could help to design out errors, she adds. This way, staff know automatically where to find the things they need: “No matter which floor staff move to, the logic is the same.” This applies to workflows too: “Say you always go through a certain procedure — you always greet the patient here, then move onto a certain function and so on — we devise a diagram that can be repeated across the hospital.”

Any workplace design requires the input of the users, but time-pressed nurses are not logistics specialists. Linder’s team has built a database of previous designs, “so they don’t have to start from scratch. We can map those rooms to maybe 90% accuracy at the beginning and then use their time and energy to take it from there.”

Lovas warns that “change fatigue” is very real in healthcare: “Frontline staff are used to old technology and siloed systems, they’re full-on in terms of workload, and especially in academic hospital settings, they’re constantly asked to do new things for different research studies. So there’s a huge hurdle to be overcome to introduce new systems, technology or models of care.”

Notes [1] Spending data from The Lancet, Vol. 393, No. 10187, April 2019 [2,5,9,10] Population data: UNdata. World Population Prospects, 2019, based on working age of 20-69 [3] The Lancet, Global Burden of Disease Study 2017 [4,16,25,27] WHO [6] Health at a Glance 2019, OECD [7,15] The Lancet [8] WHO, 20 September 2016 [11] Global Innovation Index 2019, WIPO [12] FDA, January 2019 [13] healthweather.us [14] WHO/IHM [17] The Economic Consequences of Climate Change, OECD, 2015 [18] The Lancet Countdown, 2019; CarbonBrief [19] A Future That Works, MGI, 2017 [20] The American Journal of Medicine, Volume 131, Issue 8