The Four Horsemen of the Healthcare Apocalypse

The Four Horsemen of the Healthcare Apocalypse
Launch seminar of the Health and Care Seminar Studies Initiative, 25 May 2017

By Trish Greenhalgh
Senior Research Fellow, Green Templeton College

The new Green Templeton College Health and Care Studies Initiative started with a bang with a provocative and fast-paced presentation from Dr Josep Figueras, Director of the European Observatory on Health Systems and Policies and Head of the WHO European Centre on Health Policy in Brussels.

Josep has worked at the sharp end of international policymaking for two decades, collaborating with the European Commission and World Bank, and advises governments at the highest level across Europe and beyond. His research focuses on comparative health system and policy analysis.

Another distinguished guest, who served as discussant, was Nigel Edwards, Chief Executive of the Nuffield Trust.

Launch of the Health and Care Studies Seminar Series - Blog by Trish Greenhalgh

The event began with a ‘closed-door, invitation-only’ afternoon seminar at which postgraduate students, early-career researchers, seasoned professors and the Principal of Green Templeton, Denise Lievesley CBE, cornered Josep with a brainstorm of questions over tea and muffins.

In time-honoured Oxford tradition, they were the kind of questions that had no easy answers – but they provided excellent warm-up material for the lecture that was to come later.

With so much evidence available (and so little time…), how do you decide which to use in policy decisions – and how can researchers frame their findings to make them policy-useful?”

“How can our health systems cope with an ageing population (and is there a ‘best’ way distributing a finite amount of funding to meet rising need)?”

“To what extent do political self-interest, lobbying or socio-economic realities trump science in the effort to ensure evidence-based policymaking?”.

In his answers, Josep drew on both his extensive practical experience of realpolitik and a wide range of conceptual frameworks from policy studies (Kingdon’s ‘policy windows’), social psychology (Rogers’ diffusion of innovations), political science (Lipsky’s street-level bureaucrats) and many more.

What was impressive was not so much the depth of his academic knowledge – he readily acknowledged the expertise of others in the room in relation to particular theories or methodological approaches – but the deft and intuitive way in which he matched a question to an appropriate theoretical perspective and then bounced the topic to an academic (real or imagined) to fill in the detail.

As Andrew George observed a generation ago in his famous ‘two cultures’ metaphor (Political Psychology 1994; 3: 143) few policymakers – and even fewer academics – possess the skills to bridge this divide effectively.

Josep’s evening lecture was entitled ‘European Health Systems: Quo Vadis? Challenges, options and evidence’. He began by introducing what he called the “four horsemen of the healthcare apocalypse”:

population ageing and the rising burden of chronic disease (“famine”);
spread of technology that is often expensive and of unproven value (“pestilence”);
rising citizen expectations and demands (“war”);
and financial unsustainability (“death”).

The issues were well-known to most people in the audience – but the metaphors (technology as pestilence?) exhorted us to think deeply and differently about them.

Health systems – which link of course to care systems, economic systems, political systems and many more – are constantly evolving. They follow non-linear dynamics and cannot be meaningfully studied by isolating out variables and manipulating them experimentally. Perhaps this is why the randomised controlled trial barely featured as a source of evidence in Josep’s slides.

Rather, he presented (mostly) observational data across multiple countries to support a complex narrative of the many interacting influences on health status, demand for (and provision of) health services, health outcomes and health system financing.

Josep cautioned his audience against running fast and loose with international comparative data. Whilst accurate statistics can certainly inform both policymaking and academic inquiry, such data taken out of context can be misleading. For example:

Europe’s plummeting old age dependency ratio (the ratio of people of working age to those post-retirement), for example, is well-known – but too often it is used to support an un-nuanced narrative of ‘workers’ supporting ‘retirees’. In reality, Josep reminded us, the recently-retired (60-69s) contribute significantly to the care of the over 80s. The real problems will come when countries push their retirement age to 70 and beyond, substantially diminishing the next generation of ‘hidden carers’.

The current rise in the numbers of ‘old elderly’ is often depicted as presaging an apocalyptic collapse of the healthy population pyramid over the next few decades. But as Josep pointed out, current figures reflect the ageing of the post-war baby boomers (1946-64); as this generation is replaced by the smaller cohorts that followed them, the pyramid will regain a healthier shape.

We all know that multi-morbidity (several diseases coexisting in one individual) is rising exponentially – but the absolute numbers of people with multi-morbidity are highest among the 50-70 age group, not the over 70s (partly because of a survival advantage in those without multi-morbidity). Don’t blame the elderly for draining our
health budgets.

Technology often promises much (sometimes on the basis of a simplistic experimental trial in a narrowly-defined sub-group) but typically delivers significantly less. This is partly because we consistently fail to define who is likely to benefit from a particular technology and target it accordingly and partly because incentives are so often misaligned at every step in the technology development pathway.

Mortality rates are seductive and make for over-simplistic international comparisons. Far better to focus on the more sophisticated metric of amenable mortality (deaths that are preventable through effective and timely health care).

Another well-known statistic on which Josep invited his audience to think differently was that 10% of the population accounts for around 70% of health expenditure. High-need, highcost conditions (dementia, cardiovascular disease, diabetes, chronic lung disease, cancer) are linked to lifestyles and social determinants (though not deterministically ‘caused’ by these).

If we are to make inroads into the human and economic burden of these conditions, we must take prevention seriously through ‘health in all policies’ (e.g. food, transport, education, trade) as well as addressing what is increasingly being referred to as ‘patient activation’ (that is, an individual’s motivation to engage in positive health behaviours).

Josep addressed his ‘Quo Vadis (where are we going)?’ question not with a tidy, one-sizefits- all plan but with a list of options, none of which could be a solution in isolation. As well as health in all policies, he considered different options for increasing healthcare funding and reducing or rationing benefits – policies with many and varied political implications depending on the country.

He also considered measures to increase the efficiency of health systems such as increasing (or indeed decreasing) competition between providers, strengthening primary care, enhancing integrated care, promoting self-care, reducing low value investigations and treatments and improving the skill mix of health professionals.

Different approaches will suit different contexts – but one recurring problem is that governments tend to focus on short-term solutions achievable within election cycles and draw back from measures that are costly up-front but likely to reap benefits many years later (when some other party is in power).

Josep sidestepped the question of whether a tax-based healthcare system (such as the NHS) or social insurance systems (as in France, Germany and the Netherlands) are “best”. More important than differences in how European healthcare systems are paid for, he suggested, are our common values of universal health coverage and the responsibility that society as a whole assumes for meeting the needs of its most vulnerable citizens.

But as he showed using data from the European Health Observatory, substantial inequalities in health outcomes remain (and are widening in some countries) despite our widely-held progressive values. Unmet need remains highest in the poor, the unemployed, the least educated and the over 65s. Furthermore, notwithstanding claims to “universal coverage”, patient-borne healthcare costs are high in many countries.

Discussant Nigel Edwards responded impressively to Josep’s lecture with some quick slides made on-the-hoof. He admired (in broad terms) the canvas Josep had pained; highlighted a few topics that cried out for further exploration (e.g. the role of the market, patient engagement, workforce); agreed there were no easy solutions to these and other health system issues; and offered some insightful proposals for where our exploration of the academic policy interface in health and care might go next, including:

  1. We need to ask better questions rather than go straight to the answers.
  2. We should look critically at fads and fashions in healthcare delivery and policymaking.
  3. We should understand and challenge the mental models and assumptions held by policymakers and clinicians.
  4. We should develop and apply the evidence base on how to achieve change in complex systems. (There is, for example, growing evidence that “disruptive innovation” produces more disruption than innovation and that dogged incrementalism generates better and more sustainable improvements than attempts at “transformational change”.)

Appropriately, most of the empirical data offered by Josep in his lecture belonged on the epidemiology or health economics shelves. But his responses to questions, along with the above list of next steps for debate from Nigel Edwards, suggest that the study of health and care policy and systems requires a broader and more interdisciplinary evidence base.

Relevant academic disciplines include human geography, business and management studies, political science, computer science, the social and behavioural sciences and moral philosophy. Future seminars in the Health and Care Studies series will no doubt touch on these and more.

After two and a half hours of stimulating discussion (all of which I enjoyed but not all of which I agreed with), it was my privilege to welcome members and guests of the College – by way of a short stroll through Green Templeton’s gardens, which were looking their very best as late spring gave way to early summer – to a glass of champagne and a splendid dinner.

The conversation continued to buzz for hours and even days afterwards, as we reflected, individually and collectively, on how we might build on this ‘launch’ event for the Health and Care Studies series. We would welcome suggestions (via Ruth Loseby in the first instance) for other topics – grand challenges, hot topics, new perspectives – along with speakers who can rise to the occasion. Already in the planning pipeline are guest lectures on social care, global health and patient-led research.


To join our e-mailing list on future seminars, please contact:
Ruth Loseby, Academic Projects Manager