Currently, medical and political corridors – nationally, internationally, but also locally – are filled with talk regarding sustainability of health systems. Individuals, communities and societies all wish to ensure that we have the best of access to appropriate and effective treatments, care locations and clinicians … while ensuring equity of access without inappropriate healthcare rationing.
How will we manage to accomplish this?
Modern medicine is vastly expensive and would be unaffordable to society without complex systems of healthcare delivery, funding and coordination. Unfortunately, despite this heavy regulation, the cost of healthcare will continue to increase, a result of changing population demands and expectations, as much as increasing cost of improved treatments, technology and salaries.
Western societies in recent decades have committed increasing proportions of GDP to healthcare, but, as the US illustrates, without necessarily delivering better quality of care or health outcomes.
NZ government, via Vote Health, funds a predominantly public-delivered health system accessible to all residents; however not necessarily all services to all people. NZ Vote Health has increased funding from 7% of GDP in 1990 to 10% of GDP in 2010, amounting to some $14.8 billion in 2013/14. Whilst our proportion of GDP spend on health is currently greater than OECD average, our total dollar spend is somewhat less than the OECD average in view of lower NZ income per capita.
In recent years, this increased funding has been in line with increased demand for health services. However, the Government has clearly signalled that future annual funding changes, starting with the 2013/14 financial year, will now be less than anticipated demand, a ‘falling uplift’ of the national healthcare spend.
Where is the need greatest?
For medicine to improve health and wellbeing of our community as a whole, we need to have a clear understanding
of the needs and challenges confronting our population and prioritise our efforts accordingly.
Despite relatively recent success of modern medicine in effectively treating many of the diseases of ‘western society’ such as cardiovascular disease, hypertension and diabetes, our whole population has not benefitted equally. Significant disparities of health outcomes persist within our population. These endure through individuals’ lives as a result of ‘social determinants’ of health experienced early in life, such as poverty and limited educational attainment.
Our Mäori and Pacific populations are particularly disadvantaged by social inequity and carry a major cost – on average, a loss of some seven years in total life expectancy compared to our Päkehä population. It is imperative that major efforts are now being undertaken within health and other agencies to address disparities of health outcomes by specifically focusing on these early social determinants.
Prominent recent examples of this include targeting high levels of childhood immunisation, government initiatives for housing insulation for low-income earners, and the current call from the Children’s Commissioner to urgently address childhood poverty. Hawke’s Bay DHB now has an explicit intention to focus on health disparities, exemplified by the appointment of our Director of Population Health to the local position of Equity Champion.
Additionally, whilst our total population is projected to rise slowly over the next 20 years or so, Hawke’s Bay, and New Zealand in general, will experience unprecedented changes in the age profile of our populations.
At present almost half of Hawke’s Bay births occur in families within the lowest quintile of social deprivation in our society; many of these births are to Mäori and Pacific families. The proportion of lowest quintile births is expected to rise further. Without effective means of addressing social determinants of health within these sectors of our community, disparities of health outcomes for the duration of these children’s lives are to be expected … generating a significant healthcare cost.
Meantime, Hawke’s Bay’s population will grow exclusively in the over-65 age group. Our population over-65 years of age will increase from 15% of our total population in 2011 to 25% in 2021, with greater proportional increase in those over 80 years of age. This increasingly elderly population will increasingly challenge current models of healthcare provision and should cause us to re-focus on how best to provide healthcare for our entire population for the duration of their lives.
Ageing our population
We have successfully ‘aged’ our population with modern medical practice. This improved population health and longevity is a result of healthier lifestyles on average, together with widespread use of effective treatments and systems of service delivery. Improved life expectancy has occurred specifically by reduction in ‘premature mortality’, that is, by prevention of an early death for many of our population.
Medicine does not extend the ultimate age a human may attain, but does allow more of us to achieve our individual potential lifespan. However, successful population ageing carries a significant cost to many individuals and society in general. These costs are now the major driver of the increasing cost of modern healthcare. Understanding the specific challenges an aged population poses and planning accordingly is now at the heart of sustainable healthcare for our entire population.
Dying at older ages is much more costly in dollar terms to society than dying younger. Much of this cost is for ‘care and support’ rather than for increased medical treatment, but the cost is still borne by our health dollar.
For an individual, living to an increasingly older age carries an increasing risk of disability and dependency towards the end of life. For those over age 90, more than half on average will be significantly disabled or dependent 12 months prior to death. Interestingly, those from poorer socio-economic or educational backgrounds are more likely than average to be dependent at this age, clearly indicating the power and lifetime persistence of effects of social determinants of health experienced at a very early age.
In Hawke’s Bay Hospital, acute bed occupancy over the past ten years has increased only for people over the age of 80 years; however, this increase is almost double the occupancy increase anticipated by population growth alone for this age group. This statistic is alarming and requires careful consideration. Unchecked, this escalating demand from our ageing population will in time progressively compromise hospital capacity.
In ageing our population we have possibly contributed to infirmity of our older population. Frailty is the concept of ‘lessened reserve’. The older individual has increased vulnerability to insult, needs greater time to recover, and faces the likelihood of onset of dependency … an indicator of potential futility of medical intervention and foreshadowing impending, though not necessarily imminent, mortality.
Frailty does now account for an increasing proportion of acute hospitalisation. Other factors contributing to excessive hospitalisation of our oldest are likely to include demand arising from our culture of ignorance of mortality, in which unrealistic acute models of care are applied to frailty.
Frailty can and does occur in absence of significant pre-existing disease or disability. For each of us, frailty is inevitable if we live long enough. It is therefore increasingly common in older people and, recognising it, we are able to understand the likelihood of irreversible cascade towards the end of life.
This recognition should allow a different approach to the afflictions suffered at this stage of life. Knowing that many of our acute treatments will afford little if any prospect of cure, we can instead focus on care and support necessary to maintain quality as opposed to quantity of remaining life.
Older people are highly likely to be aware of limitations of both medicine towards the end of their life and interventions they would choose to undergo. Many wish for comfort rather than life-prolonging measures, but unless these wishes are readily accessible, unwanted and unwarranted acute intervention can and does occur.
If we as clinicians and community understand better the limitations of our current acute and interventional approach to the care of our frailest population, we can consider the merits of providing such care in locations apart from an acute hospital. This shared care model is embraced in the concept of ‘primary-secondary integration’, whereby primary care aims to manage people as far as possible in locations closer to home, supported by hospital-based resources (secondary services). HBDHB is now progressing this approach.
Good quality and appropriate care can be ensured in these locations only with sufficient resourcing and with community endorsement of the merits of this approach. Central to this ‘de-escalation’ of intervention at a clinical level, however, is the need for shared understanding – between the individual, their attending clinicians and their families – of the goals of any treatment. Only in this way can unrealistic individual expectations be modified. Changing societal expectations, however, requires conversations to be led by health leaders; conversations that must frame health around the assured clinical outcome of mortality.
This rationalising (as opposed to rationing) of health resource – by providing care towards the end of life that is appropriate to need and likely benefit – has potential to mitigate some of the healthcare costs incurred by an ageing population.
Armed with better understanding not only of effectiveness of treatments, but also of limitations of intervention, particularly towards the end of life, we as a society need to reorient our expectations as to what a fully effective health system should deliver.
A possible framework for a new approach may include:
- Specific targeting of the social determinants of health to reduce life-long health disparities from the earliest of ages;
- A focus in midlife on healthy lifestyle (lack of mid-life fitness is also a strong predictor of disability and dependency towards the end of life);
- Population-wide use of effective treatments for acute and chronic disease; and,
- Towards the end of life, an explicit change of focus, understanding limitations of intervention, to a supportive rather than curative model of care.
Health sustainability requires more than just wise spending of our limited health dollar. In medicine we need to treat the treatable at all times to give our entire population the benefit of a healthy life for as long as possible.
However, we must also be more open with our population about limitations of our treatments, and allow us all to understand the ultimate inevitability of death. When this becomes foreseeable, a more supportive role for the duration of their life should be allowed.
Frailty and dependency in an increasingly older population clearly signals that an aggressive approach to treatment has unlikely benefit. Given the scale of such frailty, a more enlightened care approach towards the end of life might free significant health dollars to be invested earlier in the lives of our population.
Tim Frendin is a physician and clinical director for older persons’ health at Hawke’s Bay District Health Board. The opinions expressed in this article are personal and should not be taken as representing the view of HBDHB.