Richard Smith: Zero based healthcare

Richard SmithYou may have heard of zero based budgeting where an organisation starts from the assumption that nothing that was in last year’s budget will automatically be in next year’s and instead starts with a blank sheet. It’s a good way to think what is really essential and what adds most value. My friend, Ian Morrison, a futurologist, has thought what zero based healthcare might look like.

“You start,” he writes, “with spending your first health dollar on clean water and condoms, then add lady health workers (as they do in Pakistan, where local women, not nurses, are empowered to give basic prenatal care, dramatically reducing infant mortality), then add immunisation and hydration therapy for infants, then capitated primary care (as they do in Chile), then free generic drugs (as in South Africa), then basic surgical services. All this could probably be done for less than £1000 per capita, even in the United States.”

So there would be no hospitals, although you’d need some sort of protection from the weather to provide primary care and surgical services. A school building might do for the primary care and a tent for the surgery, making it more likely that services would cover the country. And I suggest that you don’t have doctors delivering care, rather you have one or two of them overseeing the many people who do deliver care, people trained to do particular tasks well. In order to get maximum value both the primary care and the surgical services would be built around evidence based packages of care. (I’m nervous about even a few doctors—because once you have them they immediately want to start building hospitals and doing elaborate procedures.)

The obvious reasons for avoiding hospitals and doctors is that both are expensive, and once you have them they get ever busier until like the US you are spending 17% of your gross domestic product on healthcare with the prospect of it soon being 20% and ultimately everybody either working in a hospital or being a patient.

Ian’s list seems mostly admirable to me, but, of course, there will immediately be problems. Clean water must be the first priority, but supplying clean water can be very difficult. I think of Dhaka, where it seems to be impossible to supply clean piped water to a city full of dense slums, that grows everyday, and is awash with rivers and lakes that flood when the monsoon comes. As a result the Cholera Hospital is always busy and twice a year has epidemics with a thousand admissions a day.

Food doesn’t feature in Ian’s list, but clearly adequate, nutritious food is more essential for health than drugs or hospitals. Food dense with calories, sugar, salt, and fat is also bad, and I think that Ian’s list should have included more public health measures like high taxes on tobacco and alcohol, bans on smoking in public places, and bans on marketing unhealthy products. It’s these public health measures that really make a difference to health. He might also have included things like social justice, good housing, and healthy urban design.

Condoms are a must. If we don’t limit population growth we’re all doomed. We’re probably all doomed anyway, but condoms may delay doom for a while. Condoms also protect from sexually transmitted infections, but sadly the religious tend not to like them. Hostility to them is one thing that brings Catholics and Muslims together.

Lady (a very unBMJ word) health workers are a good investment as are many community or lay health workers—because they are where the people are, understand the people, and can carry out simple cost effective interventions—like immunisation—very well. “Ladies” (or women as the BMJ calls them, and I prefer) may be right because they can gain access to pregnant women and newborns, life stages when simple interventions can have maximum benefit. To reduce maternal mortality we’ll also need people to do caesarean sections, and such operations should be top of the list of “basic surgical services.” Obstetricians are not required. Fixing fractures, cleaning wounds, and removing cataracts will also be included in basic surgical services. There will be no cancer surgery. We’re increasingly understanding that “cancer is us.”

Immunisations (but not all of them) and oral rehydration treatment also produce huge value. Primary care will need to be capitated so that the health workers are paid for looking after people, preferably keeping them healthy, rather than “doing stuff.” Perhaps we might even follow the Chinese emperors and pay the health workers only when people are well.

Some generic drugs—antimalarials, painkillers, morphine, selected antibiotics, and antihypertensives—do lots of good, but we must be very selective in the ones we allow and never let drugs replace non-drug interventions. So perhaps we’ll have bed nets rather than antimalarials. We’ll allow no drugs for mental health. End of life care is not on Ian’s list, but I’d like to see it prominent in what primary care offers. (Perhaps that’s wrong. Humans and human like creatures have managed to die for two million years without healthcare, probably, I suspect, in a way that is much better than dying in an intensive care unit.)

Sadly most poor countries do the opposite of what Ian proposes and start their healthcare systems with a medical school and hospital. But you can see what fun it would be to be a health dictator. Do you agree with Ian’s list and my comments, or would you do something very different?

Ian’s list comes from Leading Change in Health Care: Building a Viable System for Today and Tomorrow by Ian Morrison published by Health Forum Inc. I was asked to provide a quote for promoting the book and wrote: “Ian has a gift for pithy phrases that are both shockingly true and funny. I quote him more often than I quote Winston Churchill, Oscar Wilde, Mark Twain, and Mickey Mouse combined.” I am not on a commission.

Richard Smith was the editor of the BMJ until 2004 and is director of the United Health Group’s chronic disease initiative.

  • I like this idea. I'm sure you're right that what you'd end up with, if you did everything sensibly, would look rather different to what we have now, and be all the better for it.

    Perhaps the way to go about it would be on the basis of rigorous cost effectiveness analysis. You could start with a great big long list of health interventions: clean water, immunisations, cryotherapy for veruccas, open heart surgery, etc etc. You then calculate the cost effectiveness of each one. Then start with the cheapest, and keep adding things to the list until you've spent your health budget.

    That way, fantastically cost effective interventions such as immunisations would be added pretty near the start, and interventions of dubious cost effectiveness, such as routine mammography screening, would fall by the wayside.

    There are only 2 problems with this. First, I doubt you could get everyone to agree on the criteria for evaluating cost effectiveness. For example, how do you calculate the cost effectiveness of condoms? If you think of the standard method of cost per QALY, it ain't going to work: using condoms prevents a whole lifetime's worth of QALYs in the person you've just stopped being born. But that doesn't mean they're not essential for, as you so nicely put it, delaying our doom.

    Second, the idea is way too radical to have any chance that politicians would ever go for it. As I argued recently in another context (free beer for all!), any sufficiently radical idea will automatically be rejected by our political classes, no matter how good it is:

  • India is a very good – or bad – example of what happens when you go down the wrong track ie high-tech specialist healthcare. It's very difficult to turn back the clock…

  • Tracey

    You describe an incredibly anti-human, anti-woman health system.

    For example, why do you start with condoms? You mention limiting population growth but there are other more effective ways to limit population growth besides the distribution of condoms. Clearly, you are building the health system of the Utopian society in which every one who does not wish to be pregnant is very happy to use a condom every time they have sex–meanwhile, everyone is dying of vaccine preventable illnesses.  Condoms are the cheap fall back when health systems have ineffective delivery systems or ordering systems for more sophisticated forms of family planning. Also, no obstetricians for deliveries or c-sections, this might be possible but as someone who is a multiple veteran of trips to the delivery room, my favorite person in the entire healthcare system is the anesthesiologist. If these things exist, why cannot they be made available?

    It is human nature, our gut survival instinct that drives people to seek the best possible healthcare services that they can afford.  Come to Indonesia or Bangladesh and you will understand why those who have the ability to pay will travel to the places where high quality health care services are available. Go to Bhutan and you will find a healthcare system that pays for its cardiac cases to seek treatment abroad–recognizing the importance of providing services that cannot be produced locally. “The cancer is us” but who wants to die of cancer that could be removed or treated? Not me. Why should the poor suffer?

    So, I disagree with you and with Ian but thank you for making me think about how I would design the ideal health care system. It would emphasize prevention and low cost solutions but would be set up to meet the needs of more than just pregnant women and children under the age of five–so that adult health issues would be included. There would definitely be choice and there would definitely be more than condoms.