Writing exclusively for International Investment, Dr Sneh Khemka explains why primary care should be championed and how covid-19 has shown it's time to disrupt the manner of delivery.
When it comes to food, complicated dishes that use unusual ingredients, fussy culinary techniques and serving strategies reflecting Picasso might secure Michelin stars and book deals for celebrity chefs, but they aren't what most of us want to cook (or eat) on a daily basis. Instead, the zeitgeist of our time when it comes to home fare is to move away from over-elaborate recipes and concentrate on simple, high quality, seasonal food that satisfies our palate, pocket and nutritional needs.
In the same way, cutting-edge drugs, surgical break-throughs and the latest specialised medical equipment might garner the majority of attention-grabbing media headlines when it comes to health care, but it's really the quality of the basic underlying system that makes a tangible difference to improving and maintaining long-term wellness. It may be more mundane and less discussed, but primary care really matters.
Now consider that more than 60% of primary care can be done without physically touching the patient. Taking a good history, getting some vital sign readings and/or conducting a virtual examination can be exactly what is needed for an effective consultation."
Changing the story
It seems unjustified that there's a whole narrative around primary care being seen as the poor cousin of medicine, and yet it's a storyline that persists. Up to just two decades ago in the UK, training as a GP was, erroneously, seen as second rate choice and, in places like India and China, the consumer clamour is for the hospital specialist superstars, rather than the bread and butter primary care physicians.
By the same token, primary care is sometimes seen as an unwanted gatekeeper, a place you have to go before you can get through to the specialist you think you really need. In fact, during these days of choice, demand and immediate access, in many markets people don't go through a GP at all - they go straight to a specialist.
However, when you break it down, it's actually primary care that enables the sustainability of health care systems, contains extortionate cost inflation over time, safeguards responsible medical practice and ensures coordination across a range of medical conditions. In fact, it's a crucial first check mechanism before people get into secondary care. And that's why we're now seeing primary care having its resurgence.
So, in a time of scientific break-through and medical innovation, why do we need to continue to champion the underdog that is primary care?
One way to give a contextual answer is by looking at the percentage of GDP that we spend on health care. Here in the UK with our national system, it's about 8%. In other countries, such as North America, we are fast approaching 20%.
The thing is, when you work on a "fee-for-service" model, when people go straight into secondary care and doctors are reimbursed for everything they do (rather than being salaried), there's no-one to put balance and checks into what is done to people. Therefore, a lack of a fundamental primary care system can lead to a lack of co-ordination, unnecessary care and unwarranted expenditure.
The NHS is a wonderful example of how we can avoid many of those mistakes. Our GPs are part of the common vernacular - it's common knowledge that they are the first port of call for everything, from emerging ailments, to mental health issues, to chronic care management.
With such a strong primary care infrastructure, the vast majority of care in the UK is conducted outside of a secondary care environment setting. Think about it. Hospitals should be places you only visit occasionally, when specialist intervention is required (surgical, emergency or otherwise). For over 80% of health care, ranging from keeping healthy to everyday conditions, care is effectively delivered at home, in the community, or at the GP's practice. And that's how it should be in all health systems.
Reimagining the ordinary
So, there is a clear argument to be made that a dominant reason for the lower GDP spend in the UK is on account of the very strong NHS primary care foundation. However, that doesn't mean GP consultations always have to be delivered in the manner or in the location they traditionally have been.
In fact it's my argument that, in the majority of cases, there is much to be gained from substantially disrupting this. And covid-19 has shown us how.
Quality primary care has long been associated with a strong physical infrastructure, and with good reason. How can you fully examine a patient, take bloods or administer injections unless that person is in front of you? Nonetheless, there is an argument that advocates against the vast over-provision of the physical infrastructure that we currently have - and it's a compelling one.
The social distancing and self-isolation that half the world's population has endured as a result of covid-19 has brought a paradigm shift to many behaviours. One of which is in how we choose to interact with doctors. Virtual care has had its ‘black swan' moment, and the world has opened its eyes toa new way of medical consultation.
Digital consultations have gone up 100s of percentage points, consumers have quickly adapted to the change, and even the medical fraternity has embraced a new way of working. covid-19 has done for digital health in a month what CTOs, CEOs and entrepreneurs have been trying to do for a decade.
Away from coronavirus, if you cast your mind back twenty years, you may remember that GP appointments were only available Monday to Friday, 9am to 5pm. This made life very difficult if you were a full-time employee, a working parent or simply needed a doctor out of hours.
Now consider that more than 60% of primary care can be done without physically touching the patient. Taking a good history, getting some vital sign readings and/or conducting a virtual examination can be exactly what is needed for an effective consultation.
It therefore makes sense to incorporate more accessible, cheaper, lighter models of delivery into the traditional system, which is precisely what the digital environment enables us to do. In 2020, technological advances mean the potential to access a GP virtually - any time, any day, any place - opens up significantly.
Location, location, location
On occasions when physical provisioning is needed, a second issue to contemplate is where we should be offering it. Again, medicine needs to move with consumer demand. As the high street starts to disappear and people increasingly look to home delivery in their shopping, it's time for us to be thinking about similar models for the delivery of primary care.
For a start, it's simply no longer practical for primary care to be restricted to limited hours at surgeries in the middle of nowhere. Instead, we need to think about expanding the infrastructure to include the most accessible prime retail locations, places with good footfall and extended opening times. As a result, we're going to increasingly see a real push towards supermarkets and pharmacies offering GP units where you can go in and be diagnosed, treated or be given a prescription for minor illnesses.
It's something that is already ubiquitous in the US, for example, where CVS already provide retail clinic services, staffed by nurse practitioners and physician assistants who specialise in family care. These are open seven days a week, and no appointment is needed, offering maximum convenience.
Another strategy is having the capacity to consult digitally but to have an UberEats-type network of technicians to take bloods and deliver medicines where it's convenient for patients, whether at their home or office. This is something as we have seen work with our company in India, IHO (Indian Health Organisation). Combining this with the latest digital capabilities such as booking a consultation online or via an app can greatly reduce waiting times for patients.
The final point to consider in this brave new world is where governments and private organisations should be placing their money. The last five years have been flush with venture capitalists and private equity houses going full speed into the space, and large health corporations ringfencing funds. On the other hand, Governments have been starting to change regulation to facilitate further investment, and there has obviously been fast deregulation to meet the coronavirus-induced demand, most witnessed in the Middle East.
In the future, all the signs are pointing to the fact that we're going to see a lot more private and then public investment into getting primary care right, particularly in countries where this infrastructure has been traditionally lacking. Without this, we as a society are not going to be able to meet our own demand for health care.
In short, it all adds up to an urgent, urgent mandate to change.
Dr Sneh Khemka is vice-president for population health at Aetna International.