1. www.haciric.org The healthcare infrastructure challenge. Are we creating the right infrastructure for emerging healthcare business models? Hospitals of the New Generation: The options for decision-makers Bratislava 6 March 2014 James Barlow

2. www.haciric.org THE CONTEXT – A GLOBAL SUMMARY

3. www.haciric.org #1 The pattern of global healthcare demand is shifting

4. Projected changes in rankings of leading causes of disability-adjusted life years Howitt et al. (2012) ‘Technologies for global health’. The Lancet Commissions. http://dx.doi.org/10.1016/S0140-6736(12)61127-1 http://dx.doi.org/10.1016/S0140-6736(12)61127-1 Health service model and infrastructure implications?

5. www.haciric.org #2 Technological innovation is a mixed blessing for policy makers and healthcare organisations

6. Technological innovation often has unintended consequences Medical & diagnostic equipment innovations increase access to care close to / at home....... New pharmaceuticals reduce the requirement for in- patient care....... Advances in surgery improve outcomes and reduce lengths of stay.......... this generates new costs in primary / social care sector.... this increases demand for long term support... this extends the range of eligible patients BUT

7. #3 Health policy will be dominated by a need to address deep structural and economic challenges over the foreseeable future

8. Based on a figure by Laurie McMahon A ‘perfect storm’ for health and social care budgets? €€ ££££ $$$$ ¥¥¥¥ 2008 Ageing population Public expenditure constraints Healthcare cost inflation Rising chronic disease Patient demand driven by better information

9. www.haciric.org What are the common responses of governments and healthcare providers to these trends ?

10. Implement structural reforms to improve health system productivity and economic sustainability, facilitated by innovation and new technology Make health systems more ‘patient-focused’ by strengthening primary care, preventative models and integrated services Promotion of a wider range of independent service providers

11. www.haciric.org WHAT DOES THIS MEAN FOR HEALTHCARE INFRASTRUCTURE?

12. Build and Beyond: the (r)evolution of healthcare PPPs. PWC, Health Research Institute, December 2010 #1: Global demand for healthcare infrastructure won’t diminish in the foreseeable future Total global healthcare infrastructure spend is $300 – 400 billion

13. Old infrastructure needs to be replaced and new hospitals are still essential

14. #2: Infrastructure needs to be fit for purpose 2014 … 2034

15. www.haciric.org #3: Planning and coordinating healthcare innovation is hard because the pace of change across the system is mismatched

16. Mismatched lifecycles … 5 year cycle 2 year cycle 1-3 year cycle 20-50 year cycle (built infra) 10-20 year cycle Range from instant to long term

17. … these make system-wide innovation hard “Where’s the evidence I will benefit?” – makes introduction of some complex technologies slow, eg telecare Rapid pace of change for in-hospital services, eg A&E … but much harder to reorganise services out of hospital Political rigidities make it hard to rationalise infrastructure, ie close units or hospitals

18. www.haciric.org #4: Technological innovation is changing how we define healthcare infrastructure

19. There is an emerging faultline around the traditional general hospital Tertiary care Traditional in-patient hospital care ‘Community’ care Home and family Based on a diagram by Laurie McMahon

20. All this is the new infrastructure for healthcare Tertiary care Traditional in-patient hospital care ‘Community’ care Home and family

21. www.haciric.org SOME TAKE AWAY LESSONS

22. Flexibility Inflexibility #1 It’s not just about flexible hospitals

23. Increasing scope of “bundled” services Increasing role of private sector and other partners Increasing contractual and organisational complexity #2 We need innovation in finance for healthcare infrastructure and services Franchising – Rhön Klinikum (Germany) Population full service PPP – “Alzira model” (Spain) Franchising / “public-public partnership” – Coxa (Finland) “Traditional” public sector – NHS (UK)

24. THE NATIONAL CONTEXT THE LOCAL CARE SYSTEM HOSPITAL SYSTEM HOME AND COMMUNITY SYSTEM HOSPITAL SUBSYSTEMS PATIENTS REGULATORS CENTRAL GOVERNMENT POLICYMAKERS INTEREST GROUPS TECHNOLOGY AND SERVICE SUPPLY CHAINS SOCIAL CARE ACUTE CARE PRIMARY CARE EMERGENCY DEPARTMENT INPATIENT DEPARTMENTS HOME CARE PROVIDERS RESIDENTIAL CARE PROVIDERS DIAGNOSTICS TERTIARY HOSPITALS SECONDARY HOSPITALS AMBULANCE SERVICE GENERAL PRACTITIONERS ASSISTIVE TECHNOLOGY SUPPLIERS Change programmes usually focused here Hard to achieve change at a wider system level #3 We need to think carefully about where in the healthcare system and how to effect change

25. Thank you James Barlow j.barlow@imperial.ac.uk