Erewhon Healthcare – The Best in the World

Erewhon has a population of 5 million people. It is a population with an age distribution typical of most developed countries with about 15% of the population over the age of 65, and the population is ageing. Most live in cities, with two big cities each with a medical school, and city living is increasing and there are some thriving towns and some depressed industrial areas and large sparsely populated rural areas.

The economy of Erewhon is improving slowly but taking into account the impact that population ageing has on health and social care; it is wise to work on the assumption that there will be no real increase in resources available for health and social care.  The population of Erewhon is covered by a payment system that is based on combination of tax and insurance but the responsibility for health services is discharged to 10 geographical areas each with a budget taking into account age and deprivation. They have the responsibility for resource allocation; the responsibility for health service provision is based primarily on programmes and systems. Each of the populations, served by the Health Boards called A-J, happen to have a hospital, largely for historical reasons, with two of them being larger teaching hospitals and there are ten Mental Health Services and about 50 general practice teams in each.

Ten Key Value Questions in Choosing Healthcare

For decades to come need and demand will increase faster than the resources available. Society will need to maximise value from the resources it allocates for public services including healthcare and to do this ten questions need to be addressed

Question 1: How much money should we spend on healthcare?

Question 2: Is the money allocated for the infrastructure that supports clinical care at a level which will maximise value?

Question 3: Have we distributed the money for clinical care to different parts of the country by a method that recognises both variation in need and maximises value for the whole population?

These questions are primarily the responsibility of the Cabinet and the Secretary of State for Health. Then comes the role of the Commissioners. They will want they resources they allocate to be used in ways that have a positive answer to questions 5-10 but they hold those to whom they have allocated resources to do this. The answer to Question 4 is, however the primary responsibility of commissioners. It is important to note that specialist commissioners produce some of the answers to question 5 but do so with regard to the effect their decision this has on the distribution of resources to the different and the thirty sub groups of the population outlined in Appendix 1

Question 4: Has money been allocated to different patient groups in a way that is not only equitable but also maximises value for the whole population?

Question 5: Are all the interventions being offered likely to confer a good balance of benefit and harm, at affordable cost, for this group of patients?

Question 6: Are the patients most likely to benefit, and least likely to be harmed from the interventions, clearly defined?

Question 7: Is effectiveness being maximised?

Question 8: Are clinical risks being minimised?

Question 9: Can costs be cut without increasing harm or reducing effectiveness

Question 10: Could each patient’s experience be improved?

This game focuses on Question 4 which is not only a responsibility of commissioners. They have to make decisions about the allocation of resources between programmes, for example between respiratory disease and cancer. Clinicians will be responsible for the allocation of resources within programmes, for example between asthma, COPD and sleep apnoea within the respiratory programme budget and, with patient involvement making decisions within each system , and the STAR tool is a related game designed specifically for this purpose (2)

Attitude

There is a negative, over pessimistic view of old age and older people. This derives partly from a failure to understand how many of the problems of old age are preventable and are not due to the ageing process. Poverty, for example, leads many people to withdraw from society but it is not a consequence of ageing. It is a consequence of social inequality and injustice. Some individuals can retain a positive attitude in the face of the these negative pressures but this requires resilience and a definitely decision to think positively about one’s position, capabilities and potential.

Disease Prevention

For most people, old age is feared because it is associated with disability and disease, and it is true that the prevalence of disease increases decade by decade.   However, the ageing process is not the principal cause of disabling disease, and many of the disabling diseases of old age are preventable.

It is true that disease occurs more commonly as we grow older. With every year that passes the probability that a person will develop or be diagnosed as having a disease increases but this does not prove that ageing causes disease. The reason for this increase is the ridiculously simple explanation is that every year that passes means that the person has been exposed for yet another year  to the risk factors that cause disease.  It is usually the length of exposure to risk, both environmental risk and lifestyle risk, that causes the increase in disease not the ageing process.

Fitness

The Actual Rate of Decline is faster than the Best Possible Rate of Decline, that is the rate of decline due solely to the ageing process and the difference  between the two is the Fitness Gap. Both the point at which physical decline starts, and the rate at which it proceeds is for the first few decades determined by loss of fitness, and loss of fitness is determined by social factors, namely by the decisions people make about their life and the pressures which influence them decreases

Fitness has four aspects, all beginning with the letter S, and what we call the fifth S,  namely the pSychological benefits of exercise