Ian Morrison

Across the globe doctors are miserable because they feel like hamsters on a treadmill. They must run faster just to stand still. In underdoctored Britain they must see ever more patients, fill in more forms, and sit on more committees just to keep the NHS afloat. In the government sponsored, single payer system in Canada; the mandatory insurance systems in Japan or continental Europe; or the managed care systems in the United States doctors feel that they have to see more patients to maintain their incomes. But systems that depend on everybody running faster are not sustainable. The answer must be to redesign health care.

Doctors are increasingly dissatisfied with the amount of time they can spend with patients. A recent survey by the Commonwealth Fund found that three quarters of doctors in the five countries studied believed that “spending more time with patients is a highly effective way to improve patient care.” Evidence from general practice in Britain shows that longer consultations are of higher quality, and patients want more time with doctors. Yet 62% of doctors in Britain, 43% in the United States, 42% in Canada, 38% in Australia, and 32% in the Commonwealth Fund study reported that “not having enough time with patients is a major problem.”1 The result of the wheel going faster is not only a reduction in the quality of care but also a reduction in professional satisfaction and an increase in burn out among doctors. Retirement seems the only way to get off the wheel.

Hamster health care has its origins in the increasing complexity of health care, the way it is paid for, and the rising expectations of patients. Whether in a formal fee for service system, salaried practice, or in systems where doctors are paid a certain amount for each patient each year, doctors have been brought under increasing pressure as they try to provide better care, and they are caught between stingy payers and patients with high expectations.

Perhaps the purest examples of hamster care are in Canada and Germany. In these countries there is a fixed budget for all services provided by doctors and a standardised schedule of fixed fees. Doctors try to earn their target income by providing more and more services. But as the number of services provided by all doctors rises and exceeds set total budgets, so the fee for each service goes down. Like frantic hamsters the doctors run ever faster – but to no avail. In Canada the decline in fees is reinforced by limits on total income. Once that income limit is reached there is no incentive to see patients and so physicians take what is euphemistically called “reduced activity days.” In other words, there is little incentive to keep practice doors open after a certain amount of income has been reached. After that point the doctor’s time has no value even though demand continues from patients who have free access to primary care.

Hamster health care is not unique to fee for service or single payer systems. For example, in the United States, most doctors participate in the traditional Medicare system (a discounted, fixed fee for service system) as well as several managed care plans, most of which are typically preferred provider organisations, that reimburse doctors through a system of discounted fees for services. Because the managed care insurance market has consolidated both nationally and regionally, the typical American doctor is receiving payment from a smaller number of more powerful managed care plans. Pressure from the powerful payers has meant falls in fees in real terms in most managed care markets. Even in large health maintenance organisations, such as Kaiser Permanente, where doctors are salaried, doctors complain of the hamster care problem. It is known within Kaiser as the “Kaiser reward” – the more efficient you are in seeing patients the more patients you get to see.

British doctors will recognise the Kaiser reward. Within the hospital system good performance can mean more patients but not proportionately more resources – and there is no increase in salary. Rising emergency admissions swamp the system, and harder work is accompanied by rising waiting lists. There is a sense of going backwards. In primary care doctors work harder but patients must often wait longer to see them, leading to growing dissatisfaction all round.

Many health economists see no problem with hamster care – after all, it is more service for less money. But a system that exhausts doctors and other healthcare professionals is not sustainable. In part it is the result of organising medical practice in a way that is ill suited to an information age and a world of sceptical, better informed patients who know about and want the best care.

Solutions to hamster health care will come from getting off the wheel, not running faster. Doctors need to redesign their work to meet their patients’ needs within the economic constraints, just as we have seen in the financial services and other service industries. That means using information technology creatively (particularly the internet) to communicate with patients and manage the process of patient care as part of a fundamental redesign of clinical practice. Kaiser Permanente is committing a billion dollars to this task in an effort to redesign the way it offers health care. The Institute of Medicine in the United States will soon produce a report on redesigning health care, and Britain’s Foresight report on health care contains many ideas including the creation of virtual cyber physicians and rolling back healthcare into the community. These groups are to be applauded for their efforts and thoughts, but globally we need experiments that redesign care to take advantage of new technology. To date we have just bolted these technologies onto hamster care, spinning the wheel ever faster.

Ian Morrison is an author, consultant and futurist based in Menlo Park, California. This article was published December 23, 2000 in the British Medical Journal.

Next week the leaders of British doctors will meet to consider the future of medicine. The BMA, the General Medical Council, the royal colleges, and the departments of health will all be represented. This is the first time that these groups have met at such a summit conference since the Christchurch conference of 1961. That conference led to the present system of postgraduate education. Next week’s meeting occurs against a background of falling morale and is a response to a request to doctors from Ken Calman, the chief medical officer of England. He asked us to look beyond the current turmoil in the NHS to consider the core values of medicine, and on p 1140 he sets out his vision of the future. One thing we know about the future is that it will be different from now. Doctors tired of change may long for a period of stability, but this will not happen.

We must applaud this gathering of the clans of British medicine because all the evidence suggests that groups that look to the future do much better than those that look mostly to the past, hankering for a golden age that probably never existed. The simple fact that these groups, which often disagree in public and in private, are trying to speak with one voice is also important (p 1144). It will be important for the clans to consider how the world will change around them, and this editorial looks at changes that are likely to come in medicine, not only in Britain but in all countries. The clans should remember, too, that the common mistake that people make when looking forward is to overestimate the future importance of short term changes and to underestimate the effect of long term change. That is why it will be wise to look beyond the current turmoil in the NHS and not get bogged down in current grievances.

Medicine everywhere is in the midst of profound structural change. No health service is stable, and five key driving forces will continue to transform the practice of medicine well into the next century.

The power of big ugly buyers is the first driving force. Globally, governments, private payers, and individual patients are placing new demands on medical care. The payers in the health care system are demanding cost effectiveness from doctors. Whether they be purchasers in the British NHS or health care coalitions and large employers in the United States, power is shifting – to purchasers. And those purchasers want much better evidence of effectiveness than is currently available for many medical interventions. “Evidence based medicine” is a phrase that is currently familiar to only a few doctors, but all will know it by the millennium.

The rise of sophisticated consumers is the second driving force. No longer patient, these sophisticated consumers and their agents are challenging the unique authority of doctors and insisting on a greater role in clinical decision making. Patients cannot be treated as passive fodder for medical practice. Increasingly patients are as educated as their doctors. Doctors who have treated patients with AIDS have seen this most clearly, but it is spreading across medicine. The doctor-patient relationship, which many see as being at the heart of medicine, will change fundamentally.

New technology is a driving force that has long had an impact on medicine, and the clans will have a session on this force at their meeting. Molecular biology and information technology, both singly and in combination, will transform medicine in the next century. Total exposition of the human genome will raise new insights into disease and may allow effective treatments where none currently exist. The exposition will also allow new methods of diagnosis and deepen our understanding of disease processes: we will be able to predict disease patterns for individual patients. But perhaps more powerful still be the application of computers and communications to the practice of medicine and the coordination of care. Medicine is an information based activity, yet medical practice has lagged behind industry by decades (some say centuries) in the appropriate use of information technology. Reuters, which has already wired together the world’s financial community, has now taken the strategic decision to wire together doctors and hospitals. The most significant transformations will come from the combination of powerful hand held computers – so called PDAs (personal digital assistants) – wireless communications, and large databases on patients. Together these tools will support the mobile nature of medicine and provide a platform for new approaches to clinical practice in the hospital, the clinic, and the home.

Shifts in the boundaries of health and medicine will be the fourth driving force. Health results from a combination of social, economic, and psychological as well as purely biological phenomena. Most doctors now understand this and so increasingly do politicians; this enhances their reluctance to invest heavily in health services when they have only a small effect on health. As science clarifies our understanding of the complex relation between health and the environment of patients, doctors will be drawn into the web of systems around the patients that determine their state of health. New medical disciplines will emerge such as population health informatics, and old disciplines, such as occupational health, will be transformed.

The ethics of controlling human biology will be the final driving force. The mix of new technologies, cost pressures, and sophisticated consumers is a powerful and potentially toxic one. Death and dying will become a major focus of societal debate in the next century as the baby boomers confront their mortality. The legitimacy of rationing – by both public and private payers – on behalf of the patients they serve will come under enormous scrutiny. Debates on the ethics of rationing will not be solved easily by technical analyses; the battles may be ugly, political, and confounded by issues such as race and poverty. Profound questions will be asked about the rights of people to control and shape their own biology and the biology of the unborn. Deep seated beliefs about life, disease, personality, and death will be challenged by the new biology.

It thus makes sense for the British medical clans to concentrate on discussing the core values of medicine. Willard Gaylin, the president of the Hastings Centre, has written: “The most unfortunate thing about the shuttered process [of American health care reform] is that a remarkable opportunity has been missed. What could have been a wide open, far ranging public debate about the deeper issues of health care, our attitudes toward life and death, the goals of medicine, the meaning of “health,” suffering versus survival, who shall live and who shall die (and who shall decide) has been supplanted by relatively narrow quibbles over policy.” Exactly the same could be written about the debate over health care reforms in Britain and most other countries.

Doctors in most countries currently feel beleaguered. But they shouldn’t fear the future. Doctors will be at the centre of the new health system, but not as autocrats. Their dominance as care givers will be eroded by new tools, technology, and systems of care. But doctors have to have a central leadership role in care teams, policymaking, planning, and management. They will increasingly work in teams rather than individually, and they need to understand better how to be effective team players. If doctors do not take up the challenge of leadership in health care but instead retreat to form a selfish artisans’ union they will be letting down the patients and the society they swore to serve.

Ian Morrison is an author, consultant and futurist based in Menlo Park, California. This article was published October 29, 1994 in the British Medical Journal.