What are the three big themes currently driving change in health systems in the developed world?

Mark Britnell (MB): The three I consistently see are: firstly, the shortage and crisis in our healthcare workforce globally, forcing most organisations to think about the balance between short-term financial control and medium-to-long term health and prosperity

Second is undoubtedly the issue of ageing populations, and what developed economies are trying to do to address this - generally as societies, and specifically in terms of healthcare. Although people choose different words to describe it, the quest for integration between health and human services / social care is front and centre of every conversation on this topic.

Thirdly, the fiscal sustainability of health services. In practice, the developed world has a fair range in terms of expenditure – I was in the Netherlands yesterday, where they spend 12% of GDP on healthcare, but still find cost pressures - but it’s not as serious as compared to the NHS in England, which is certainly approaching the point at which there will need to be serious decisions about funding to ensure sustainability.

Whether I’m talking to academic health science centres, governments, or groups of primary care federations, they all express the same concerns.

The stand out one of these, the most important, is the ageing society issue – it really points to a reduced workforce and tax base, meaning less to spend on healthcare, which in turn creates greater financial pressure, and as people grow older they get more comorbid, which causes cost escalation and price pressure.

What are the three big themes currently driving change in health systems in the developing world?

MB: Clearly the developing world faces massive issues in non-communicable diseases and in trying to conquer TB, AIDS, and maternal and infant mortality. We take all of these as read.

Beyond these, because of the sustainable development goals (which all countries signed up to achieve by 2030), the number one issue is universal healthcare: it is driving huge change in expectations. Last week, I was in India with federal union health leaders, and Prime Minister Modi’s promised that his government will deliver this for a low-income population of nearly 500 million.

The second issue is how to do this. What we now find is a big debate on what are the most appropriate models and financing to deliver universal healthcare – not the same point as agreeing to do universal healthcare. How far should these countries replicate a largely 20th century ‘western’ infrastructure? Or should they leapfrog to a more digitally enabled system, supported by primary care practitioners?

Third is the levels of public trust in the political class and national governments. These sentiments are expressed in a variety of ways. Most acutely, they’re seen as a lack of general trust in some developing countries about their ability to spend public money wisely on healthcare. India are debating this now – how far are the public there ready to pay extra tax on goods and services to let the state be the healthcare payor?

So there are big, live arguments there about whether to use insurance and public expenditure.

I think it’s great that these governments are having to commit to universal healthcare, and it’s in turn forcing conversations about good governance, transparency and trust. Normally in developed democratic societies, you assume that you’ll start with good public governance, but here universal healthcare is having big impacts on these discussions.

If there are limits to the growth potential of healthcare as a percentage of the GDP of the world’s economies, will the biggest change come from patient behaviours, digital opportunities such as AI, changing the healthcare workforce, economic incentives, or something else?

MB: That’s a good question. I’d probably take issue with the premise of the question about limits of wealth that we can dedicate to healthcare. When I started as a management trainee in the English NHS 30 years ago, people were saying that healthcare spending of 10% of GDP in US would bankrupt the country or threaten its national security.

What we’ve learned about the global economy, broadly speaking, is that it has massively expended in wealth creation, so I think we’re nowhere near limits of expenditure in terms of healthcare.

Even if you don't believe or agree with that, think of US healthcare spending at 18% of GDP, Swiss at 12-13%: there’s a long way for others to go to commit a greater proportion of their economic wealth on healthcare

But this is clearly a big and pressing issue. Healthcare spending in the developed world for the past 60 years has outstripped economic growth by about 2%, and I personally think that's great as it shows we're civilised and want to spend more on better healthcare and quality of lives

But fiscal pressures are everywhere, and some global research we did a few years ago suggests that when patients reach level 4 activation, their consumption and cost of care drop by between 8 and 21%. No health system in the world is likely to be financially sustainable unless it gets vigorous on patient activation. There is the possibility of a substantial prize there.

Linked to that is the exploitation of digital and artificial intelligence (AI) capability, and I think healthcare in the developed world has been slow to realise its potential. I see this as a senior partner of KPMG and in other industries. Health is a low and slow adopter of digital and AI.

There are good examples, such as Clalit in Israel: for 40 years, they’ve pursued a robust population health management platform, in tandem with big data and analytical capability. Clalit are now getting into cognitive assistance and AI.

Israel and its four HMOs get comparable health outcomes for 7.3% of GDP, at 20-25% less cost than comparable countries. It’s a sign of what their PM Benjamin Netenyahu calls “a tech-savvy, start-up nation”. Others are doing this well, be it Mexico, with their medical telephonic care service; Tonic in Bangladesh; or parts of US: if you look at the innovators, you see channel switch from face-to-face to face-to-phone/screen/web.

In healthcare generally, we are in the foothills of understanding and appreciating opportunities, let along maximising them.

In the area of workforce, digital enablement of healthcare could improve productivity by 10%. The truism here that there’s no healthcare without the workforce is widely understood but not deeply appreciated, because every health system in the world praises its staff as angels and gods - but actually when it comes to the consistent adoption of HR best practice, healthcare is lagging behind other industries which have realised that there’s a global war for talent.

That said, there’s an interesting paradox: as the world becomes more tech enabled and healthcare more super-specialist, our training programmes are not allowing practitioners to work at the top of their game. Too much of their valuable time is wasted or not optimised. There is a lot of role confusion, and what follows from that is poor utilisation of skills and excess cost built in to training and regulation.

In practice, this means the typical healthcare workforce shape in a developed world economy is like a conifer tree with a broader mid-section. What technology enables you to do, with better targeted training and better deployment of scarce clinical workforce resources, is get staff to practice at top of their game but to also have a very broad base, so more like an English oak tree with a broader base.

It’s not as much about the traditional workforce entrants and more about bringing in people from local communities. Not people whom we’d call less skilled (a pejorative term), but older people with long-term, conditions (LTCs) need frequent reassurance and good care, which could be delivered by new entrants supported by AI and telehealth.

And I don't believe most developed world healthcare has switched its staffing to meet those patient’s specific skill needs. I'm familiar with changes in other industries: they look across 5-10-minute intervals at what staff are doing with their time, and from that analysis they re-profile what staff need to do supported by other humans with different skills and with technology. In healthcare, this is a nascent endeavour, but it will speed up exponentially over the next ten years.

On the subject of economic and other incentives, we come back to cultural expectations. The paradox of healthcare globally broadly speaking, is that as Lampedusa wrote in ‘The Leopard’, “everything needs to change for everything to stay the same”.

In developed world healthcare systems, the dominant models of care have not really changed for 100 years, yet the explosion in progress and the global race in genomics tells me that we’re probably only 10 years from its widespread adoption and introduction into most developed world health systems. When that comes to be true, genomics will make the conversation between the individual and the state/funder profoundly different in regard to rights and responsibilities that citizens/patients and funders/governments have to each other.

If the individual’s genetic code can be understood for less than $1000 (which will probably be with us within the next 3 years), my belief is that (as NHS Genomics say), it'll be better suited for systems with universal healthcare to adopt genetic medicine, as the risk pool will be broad, large and stable.

But when we start to better understand our genetic profile, there will have to be a bigger conversation about wellbeing, health and health promotion. If we look at the expenditure patterns of developed healthcare systems, the phrase that ‘prevention better than cure’ is not at all borne out.

Society will have to have a serious ‘right and responsibilities’ conversation on our roles in keeping ourselves as individuals and citizens and taxpayers or customers on as good a health status as we can for as long as possible.

This interview was conducted by Andy Cowper and is the first part of a series on the Future of Healthcare.

Mark Britnell is KPMG’s Global Healthcare Practice Chairman, and one of the foremost global experts on healthcare systems. He has a pioneering and inspiring global vision for health in both the developed and developing world, having led healthcare organisations at local, regional, national and global levels – provider and payer, public and private. As KPMG’s healthcare leader he has worked in over 75 countries on more than 350 occasions, overseeing 45 KPMG country health practices operating in across six continents.