In 2015, the World Health Organization (WHO) published the first world report on ageing and health. This was followed in 2016 by the World Health Assembly’s adoption of a global strategy and plan of action on ageing and health. Both documents reflect a new conceptual model of healthy ageing that is built around the functional ability of older people rather than around the absence of disease. At the same time, the United Nations adopted the 2030 Agenda for Sustainable Development.

These documents call for major reforms to health and long-term care systems and for the prioritising of interventions that optimise older people’s physical and mental capacities over their life course.

As people age, their health issues tend to become more chronic and complex and older people can develop complex health states (frailty, increased risk of falls). If not properly managed, these conditions can lead to polypharmacy, hospitalisation and death. Providing care for older people is also increasingly complex with the involvement of many types of health workers. Healthcare services to the older population will need to serve people with a high and stable level of intrinsic capacity, those with a declining capacity and those whose capacity has deteriorated and thus require additional support.

Instead of trying to manage numerous diseases and symptoms in a disjointed fashion, several countries are placing increasing emphasis on interventions that optimise older people’s physical and mental capacities over their life course. This requires greater integration within the health system and between health and social services to provide a coordinated service. Evidence suggests that this integration leads to better health outcomes at the same or even lower cost.

At the level of clinical care comprehensive assessments are recommended in order to optimise the functional ability of the seniors. This requires supportive policy, plans and regulatory frameworks, workforce development, improved communication technologies; and pooled and bundled payments (with incentives if necessary).

Emphasis ought to be on the older person’s physical and mental capacity and the starting point for, coordinated health interventions.

WHO’s approach hinges on the premise that care can be integrated at: (i) the macro level (i.e. at the policy or sector level); (ii) the meso level (i.e. at the organisational or professional level); or (iii) the micro level (i.e. at the clinical or interventional level). In addition, it is also older person-centred, aimed at individuals with unique needs and preferences, as members of a family and a community.

The framework proposes five interdependent strategies that must be implemented to enable health services to become more people-centred and integrated: (i) engaging and empowering people and communities; (ii) strengthening governance and accountability; (iii) reorienting the model of care; (iv) coordinating services within and across sectors; and (v) creating an enabling environment.

There is also a lack of consensus on what constitutes a positive outcome for older peo¬ple. Traditionally, healthcare research has used indicators of disease, disability, longevity, patient and provider satisfaction, healthcare utilisation, hospitalisation, institutionalisation and cost. In contrast, the main aim of integrated care for older people is not to manage disease or prolong life but is, instead, to optimise older people’s intrinsic capacity over their life course and, hence, ensure healthy ageing.

A different set of outcome indicators is needed – indicators that reflect intrinsic capacity, functional ability, quality of life and the attainment of goals defined by the older person. Finally, only a few easily accessible, policy guidance and implementation tools exist.

Requirements for Integrated Care

Achieving the goals of WHO’s global strategy and plan of action on ageing and health requires political commitment to integrated healthcare for older people, the development of coherent health systems policy, and normative guidance on the implementation and evaluation of integrated care both nationally and internationally.

To achieve best outcomes for older people, one should organise care around the concerns and priorities of older people themselves — and integrate the assets, which can contribute to healthy ageing (strengths of the older person, family care, support from local resources).

A comprehensive approach is needed to understand the complex factors contributing to the older adults needs and to integrate care around the specific priorities and goals of the older person. Personalised approaches in care emphasise the empowerment of the older persons and their families to participate in making decisions about their health.

An essential strategy to attain integrated, people-centred health services is to build strong primary care-based systems due to their outreach to the wider population of older adults in the community. This approach involves not just multidisciplinary health professionals but a range of other formal and informal caregivers. The gold standard in assessment of older people is comprehensive geriatric assessment.

In many people’s lives there will come a stage when they experience a significant loss of mental or physical capacity, particularly in old age. The functional ability of the older persons is determined not just by an individual’s capacities, but also by the environments they inhabit and the care and support that is available to them.

Long-Term Care

The term “long-term care” describes the full range of efforts, all directed to ensure the best possible trajectories of an individual’s capacity and functional ability over time. WHO defines long-term care as “all activities undertaken by others to ensure that people with, or at risk of, a significant ongoing loss of capacity can maintain a level of functional ability consistent with their basic rights, fundamental freedoms and human dignity.”

“Long-Term Care is About People, Not About Services” 

An effective system of long-term care will also ensure that all caregivers are adequately trained and supported. Educational curricula need to be tailored to ensure graduates have the skills and understanding necessary to fill their role, and continuing professional development will be important if professional caregivers are to maintain them. Many paid caregivers have received little training and an effective system of long-term care can ensure general standards in the paid workforce and might establish accreditation mechanisms to ensure staff and care providers develop and maintain appropriate competencies. Moreover, since most care is provided by family caregivers, a core element of any system must be to ensure they receive adequate training, are supplemented where necessary with professional support and have access to services such as respite care.

WHO (2017) has identified three global actions that can facilitate the development of long-term-care systems:

a. Building understanding and commitment to developing long-term-care systems. 

b. Mapping the current situation in long-term-care provision 

c. Providing guidance and technical assistance for countries at all levels to meet the needs of adults with significant losses of capacity. 

Acknowledgments

This concept paper has benefited from four background papers made available at the Global Consultation on Integrated Care for Older People: The Path to Universal Coverage and from the symposium of the Global Alliance for Musculo-skeletal Health on “The Importance of Musculo-skeletal health for Healthy Ageing”. 

References available on request.

Like most classically trained orthopaedists, a decade ago I was highly sceptical of stem cells and their therapeutic value. Today, as a treating physician at the Knee and Hip Institute in Munich, Germany, and at the Okyanos Center for Regenerative Medicine in Freeport, Bahamas, I’m a passionate believer. For friends, family and patients with knee problems due to tissue and cartilage issues, I recommend stem cell treatments well before a knee replacement, provided their condition hasn’t progressed to bone-on-bone damage.

But not all stem cell treatments are equal. The right types of cells in the right potency affect clinical outcomes. Expert physicians who can properly deliver the cells are critical and carefully matching the patient’s condition to the proper therapeutic is essential.

These factors determine whether I treat a patient with orthopaedic surgery, a combination of scoping or surgery with adjunctive stem cell treatments, or stem cell treatments alone.

Stem Cell Sources

There are multiple sources of adult stem cells. The most commonly thought of is bone marrow. We’ve done bone marrow transplants for 50 years, using the stem cells from bone marrow and transplanting them into the recipient. Another source is adipose, or fat tissue, recognised in the last 20 years as a very rich source of stem cells.

However, as we age bone marrow becomes fibrotic and fatty. So, we end up with fewer stem cells as we get older. At baseline there are few therapeutic cells for tissue repair in bone marrow, in contrast to fat, which maintains its stem cell population and is a much richer source of therapeutic cells – including mesenchymal stem cells, which are really the conductor or the regulator of the stem cell repair. So, fat turns out to be a very rich supply of stem cells, which is maintained throughout our life and has been shown by multiple groups to be very effective in tissue repair.

Adult stem cells have multiple functions and come in different types, but ultimately what they do is lead to healing. Mesenchymal stem cells (MSC) activate the bone marrow system and other stem cells to start repairing tissue. Mesenchymal stem cells are known as the conductor of the repair process. Endothelial progenitor cells are the foundation of building new blood vessels. They can inhibit the immune system and be anti-inflammatory, and they can activate other stem cells in the body and force them to start repairing tissue.

Beyond MSCs: SVF and its Benefits 

Stromal vascular fraction, or SVF, is a mixture of stem cells that exist in our adipose, or fat, tissue. SVF contains mesenchymal stem cells and endothelial progenitor cells as well as endothelial cells. As we age, we don’t lose mesenchymal stem cell function from fat as we do from bone marrow. There are multiple forms of SVF that vary in potency and usability. At Okyanos, we use enzyme-derived SVF because studies have shown that it is the most potent form of SVF. It produces a very rich mixture of stem cells that can be delivered two ways: by injection into joints and organs that have been injured, and by IV to activate the endogenous stem cell system and induce a better repair for the patient.

SVF is also an autologous treatment, because the patient’s own cells are returned to them – released from the fat – and delivered by injection directly to the area in need as well as intravenously to help activate the body’s own endogenous system. Other clinics that use fat-derived stem cells often only deliver the mesenchymal fat-derived stem cells, not the SVF. These mesenchymal stem cells have been cultured, leading to changes in the stem cells that can adversely affect their ability to induce tissue repair. Studies have suggested that delivering the mixture of the SVF is better than delivering any single stem cell type.

At Okyanos, the most common conditions that patients present with are orthopaedic. The adult stem cell treatments can be given as an adjunct to surgical treatment or as a primary therapy. We perform liposuction and isolate the SVF with an enzyme. Then, we directly inject the patient’s cells into the joint space. Finally, the patient receives an IV infusion of stem cells, again, to get the bone in a healing state.

Currently, the Tissue Genesis Icellator is the best point-of-care system for processing enzyme-derived SVF with a safe and sterile single-use cartridge. Designed and made in the U.S., based on research by the U.S. Department of Defense and NASA, the Icellator is approved for use in Japan, South Korea and the Bahamas, all regulated medical jurisdictions. It is also being used in multiple FDA cleared trials in the U.S., but is not yet approved for clinical use there or in Europe. Using SVF processed by the Icellator delivers the greatest number and best mixture of cells, at the highest potency, as the cells are freed from the fat matrix.

The combination of mesenchymal stem cells and endothelial progenitor cells can decrease inflammation, induce stem cells to be recruited to the joint space, and help nourish the cartilage by bringing blood supply. The goal of microfracture surgery, which is quite popular, is to get stem cells out of the bone marrow space and into the joint space to promote repair. By delivering stem cells directly to the joint, we create the same conditions for healing, without causing more harm. The added IV infusion activates bone marrow that might sit right at the end of the bone near the joint to encourage stem cell support of that tissue.

Improving Osteoarthritis

In addition to treating knees, shoulders, hips and other joints, adult stem cell therapy can really improve or prevent severe osteoarthritis by either regrowing cartilage or decreasing inflammation of bone edema. With early treatment, we can preserve and enhance patient function through prevention of the progression or repair of the loss of cartilage, and the severe pain that accompanies bone-on-bone damage. When treating people later, our goal is to preserve or enhance patient function through the regrowth of cartilage or decrease the bone inflammation and edema such that the patient gets relief and can return to activities of daily living.

The benefits last quite some time, months to years at this point. We’re seeing patients with significant visual analogue scale scores – meaning less pain, more activity, and more motion.

The goal at Okyanos for treating any condition is an enhancement in quality of life. We want patients to go back to the tennis court, back to the golf course, back to being fully active with restored joint function.

A Promising Future

Today, I’m an orthopaedic surgeon who loves what I do, but my whole thinking has turned around. Instead of focusing on surgical options, I think about what can be done with high potency SVF. Now I discuss with my patients how we can achieve natural healing and regeneration through stem cell therapy and avoid surgery.

Stem cells are the future in treating orthopaedics. Regenerative medicine has value in many more fields as well, but with orthopaedics, outcomes are measurable. Someone not able to walk without pain and can walk afterwards is a quantifiable success. Radiographic tools, such as MRIs and x-rays, show the reconstructive changes stem cells can have on injury or degeneration. Much of the pain caused by inflammation in orthopaedics is reduced by stem cells. I see stem cell treatments growing in importance, as improvements in SVF therapy, rich cell yields and precision delivery continue to speed patient healing.

The need of having a more functional hand stimulated the development of silicone implants for small joint arthroplasty in 1962. Silicone implants were studied extensively in laboratory tests, animal experiments and long-term human retrievals to determine the local and systemic host responses while a number of different designs of the double-stemmed hinged finger joint implants were evaluated in a flex-test machine, and after extensive studies, the implant midsection was volarly hollowed out to accept a redistribution of compression forces generated in the volarly reinforced base of the distal stem during flexion. This distributing-load flexible hinge design was tested to 600 million flexion repetitions without change, having the least resistance to flex-load forces, and offering adequate stability to prevent vertical buckling.

This silicone double stemmed hinges were first used by Swanson for metacarpophalangeal joint (MCPJ) reconstruction in 1964 and then in 1965, were developed for the Proximal Interphalangeal Joint (PIPJ).

Bone response to this kind of arthroplasty with encapsulation of the implant has enhanced implant stability, eliminating the need for permanent fixation, improving bone tolerance, the distribution of weight forces and prolongs the life of the device. Although these kinds of implants have provided a means of treatment for arthritic joints, the limits of range of motion and stability they produce have gradually reduced their indication, living space to the new developed implants.

It was also reported that silicone implants were submitted to sharp bony edges and shearing forces that eventually would fracture the implant. Despite the above, the rate of complications is clearly low making those implants to remain the U.S. FDA (Food and Drug Administration) benchmark against which all other finger joint arthroplasties are judged.

Due to the advancements in fingers joint replacement, the silicone implants have been left as the treatment of choice for patients suffering from Rheumatoid Arthritis, Inflammatory Arthritis and severe degenerative destruction of the joints, mainly because of the limited range of motion and the less demand on the patients. Good control of the rheumatic disease by the rheumatologist is paramount to achieving a greater longevity of the implant, and to prevent recurrence of ulnar drift.

The surgical technique is quite simple, keeping in mind that the size of the implant is always given by the proximal phalanx in MCPJ and for the middle phalanx in the PIPJ; and that excessive shortening in the MC head resection of the middle and ring fingers will alter the MC arch and impair the function of the hand and diminish grip strength.

The NeuFlex MCPJ silicone implants came to the market in 1999 trying to improve upon Swanson’s implants, reduce their complications and improve results. This implant has a 30° pre-bend in flexion and a hinged design to mimic the normal centre of rotation of the MCPJ, decreasing stress of the material and improving overall functional arc and ROM (range of motion); also minimising abrasion and wear debris from forming.

My experience with the Swanson implants started almost 30 years ago, followed by the move to use the NeuFlex prosthesis later on. I have recorded over a 18-year period, 81 cases of MCPJ silicone implants in 48 patients, with an improvement of the ulnar drift to almost neutral or less than 5°. The extension deficit that presents the patients with the disease improved after surgery to only 5° or 10°, associated with a good grip strength and a more functional and cosmetic hand. But every pathology has their own characteristics. In all the inflammatory arthropathies we know that most of the joints will be affected that is why we are not forcing to recover a strong hand.

But in post-traumatic arthritis or degenerative arthritis, one or maybe two joints are only involved, while the others are completely normal. This brings us to the situation where the silicone implant we are using is less indicated due to the resulting reduced range of function. With this problem in mind and looking at the good results of the knees and hips arthroplasties, the idea of having an artificial joint that can be anchor to the bone using cement or cementless technique developed and the term ‘osteointegration’ began to be applied to the arthroplasties for small joints.

Many short-lived designs have been introduced aiming to improve long-lasting stability and range of motion. In 1997, Linscheid developed at the Mayo Clinic a surface replacement (SR) concept with a meta-polyethylene device where both parts of the prosthesis were cemented, producing a very good improvement in the range of motion. This implant has the advantage of minimal bone resection, with accurate restoration of the centre of rotation and more reliable restoration of tendon movements in the joint, and due to the clear disadvantage of using cement, which makes revision procedures difficult, an uncemented version came later to the market.

The two pieces’ unrestrained prosthesis use a chromium-cobalt proximal component and an ultra-high molecular weight polyethylene (UHMWPE) in the distal component. It needs a minimal bone resection with preservation of the collateral ligaments, providing a more stable joint, particularly to imposed lateral forces. The great articular congruency adds a better distribution of the compressive loads assisting for the great joint stability. The stems are rectangular to maximise rotational stability and are slightly curved to match the curvature of the medullary canal.

The kinematic of those implants in the PIPJ has been studied, showing a similar movement to that of the normal joint, with a maximum 5° of angular displacement and 9° of rotation movement during passive flexion and extension motion.

For all the above, perichondral resurfacing arthroplasty (SRA) has been proposed for young or middle adults with post-traumatic or degenerative arthrosis, with functioning collateral ligaments or reparable. Those patients are more active and need to recover a good range of joint motion. These results have been proven in several papers confirming also a pain relief of 70-90 per cent.

But disadvantages have also been reported such as the higher risk of dislocation or subluxation compared to silicone implants. Tendon balancing and ligament functioning are extremely important to prevent this happening. Meanwhile, the difficulty of revision due to the cement fixation in the first implants had been resolved with new stems that are coated to encourage the osteointegration.

SRA are technically more demanding and much less forgiving than silicone joint replacement. 

During my service in the UK, I did 23 MCPJ replacements in 11 patients followed by SRA. I had two cases of lucency in the phalangeal component, without symptoms. 19 had no pain and two had minor discomfort. Their arch of position went from 27° pre-surgery to 60° post-surgery and the disability score improved from 70 per cent disability to 9 per cent after surgery.

Pyrocarbon was developed in the 1960s from a collaboration between CEA (French Commission for Atomic Energy) and General Atomic (U.S.) and was for nuclear applications, as a coating for nuclear fuel. Pyrolytic carbon is a synthetic material formed by the pyrolysis of a hydrocarbon gas at approximately 1300 °C. In 1969, this material was successfully used to make components of artificial heart valves, and since then it has shown exceptional reliability.

The mechanical properties of this material has the nearest Young’s modulus (modulus of elasticity) similar to cortical bone, does not cause adverse reaction to surrounding tissues, and has no evidence of wear or debris production and excellent bone-implant incorporation. Pyrolytic carbon finger joint arthroplasty was introduced in 1979, and their use for carpal implants developed in the 1990s. But it was not until 2001 that the EEC authorised the use of the PIP prosthesis, designed by J. Stanley (Wrightington Hospital, UK) and R. Beckenbaugh (Mayo Clinic, Rochester, U.S.).

The results of these implants show an improvement in the range of motion, relief of pain, adequate biological fixation and only few complications. 

For the last 20 years, I have been using more Pyrocarbon implants, 17 altogether, than the metallic ones, with the same indications, but providing a better range of motion, less complications and better survival rate, not seeing bone loosening in five years of follow ups.

Similar implants have also been developed for the trapezio-metacarpal joint (TMCJ), and since 1973, when Caffiniere presented his first model, there has been a countless number of implants to deal with the osteoarthritis (OA) affecting that joint.

My own experience had been mainly with the Avanta SR, which in my opinion reproduces better the anatomy of that joint. In the UK, I did 43 thumbs in 34 patients in stage II and III of Eaton, mainly females, mean age of 56 years, with a survival rate after five years of 93 per cent and producing a good function of the hand, recovering strength, grip and pinch function in all the cases. Only three cases presented bone reabsorption without clinical correlation and only four complained of unspecific pain, which were classified as implant failure. But despite some good results provided by this arthroplasty, years later, the company withdrew the implant from the market.

In the following years, and due to the implementation of the pyrolytic implants, I have started using those type of prosthesis, hemiarthroplasties or pyrodisk with similar results in improving the range of motion, pain control and grip strength. Complications of dislocation has also improved with those pyrolytic implants.

In conclusion, the overall results of the arthroplasties of the hands have proved to be good enough to recommend these implants for the treatment of stiffness, pain and lack of functions affecting the hand. They are technically demanding, so the experience of the surgeon is of paramount importance to achieve the best results. Thankfully, the recent interest of the industrial companies in hand pathology and the need to develop joint replacements have improved the implants available in the market in recent years, but still they are not able to match the success of large joint arthroplasties. Fingers provide a more challenging mechanical problem than that of the large joints, but results are encouraging and continuing to improve with further investigations.

There are innumerable advantages both for patients and their relatives with the development of hospitals as many an ailment, which need intervention of specialists is available under one roof.

Technological advancement in medicine has revolutionised the diagnosis, treatment and patient care. The network technology has added another dimension to partnerships, communication and accessibility of specialists across locations.

The hospital setting, as we know, brings together patients, their families, doctors of various specialties, nurses, pharmacists, support staff like technicians, dieticians, physiotherapists and others. Insurance companies and Third Party Administrators (TPAs) nowadays play an important role in decision making too. Keeping this in view, there is a need to enhance engagement of all involved in the process for an effective healthcare delivery system. The patients and their families’ engagement could be enhanced using the 4P’s - Person, Problem, Place and Process, a framework frequently used in professional social work. 

1. Person: A patient who approaches a hospital with expectation that the care giver would resolve the health problem. The patient is unique, a product of nature and nurture. The care givers have to take into account the patient in his entirety to plan out the engagement process to personalise the treatment and recuperation process. 

2. Problem: The patient comes with a problem or ailment and this could be physical or may have many overtones of psychological or emotional stress. Their individual perception of the problem could vary as each individual is unique. 

3. Place: The place or the environment where the treatment or services are rendered may vary between organisations and the programmes. 

4. Process: The process involves Study, Assessment, Intervention, Discharge and Evaluation or Follow-up. It gives an impression that these steps are to be performed in sequence but these steps are woven in and out, one process paralleling another. 

All these four components are almost common both to healthcare delivery and for social case work. But with reference to the engagement process, there are some major differences which are examined here under: 

The Difference 

Generally counselling is done by a single trained professional who knows how to use the principles and components wisely whereas in a healthcare setting, it is a whole team of professionals along with less experienced proletarians that include the frontline staff. Professionals such as doctors and nurses are experts in their own domain like medicine and nursing. Though they are trained in their own specialties, many lack required skills in using the 4Ps efficiently, especially when it comes to crisis management, whereas, most of the frontline staff doesn’t have any formal specialised coaching on utilising the 4Ps. It is important that the entire care delivery team, both professionals and frontline staff, be proficient in using the above four components and casework principles wisely for engaging patient and their families to enhance quality of care. It’s a big challenge to train people to use these elements and get the intended results.

Challenges

Patient Engagement means providers and patients are working together to improve health delivery system. When we deliberate based on this definition, all the care givers have an important role in engaging patients and their families in a broad range of activities. The requisite ambience needs to be created and the care givers should realise that the process is a dynamic activity and involvement in safety is the right of a client. Organisations also vary significantly depending on the structure, access, services and the programmes. Some are public, while others are private, profit centred, charity organisations, primary care, tertiary and/or super specialty hospitals. All these organisational differences also adds to the problem of the client. 

Care givers are always familiar in using their own vocabulary that’s incomprehensible for most of the patients and their relatives and this situation is not conducive for seeking clarification. Moreover, in order to save time, some of the care givers utilise this as an opportunity that compromises patient engagement. Leadership of various healthcare organisations, mostly private profit centred hospitals influence professionals to achieve specific targets that conflicts with patient objectives. Fear of losing a customer is another roadblock for the service providers. In few instances, we come across situations wherein, care givers develop a feeling that patients are hostile and ungrateful. Some of the care givers also have reservations about the patient’s capacity to contribute. In addition to the above challenges, time constraints and dearth of informal opportunities for detailed discussion compromises effort in building trust between core care giver and the client.

The concept of continual improvement theory applies in patient engagement. Patient engagement is continuous and it is an important factor to maintain momentum while all efforts are in place to improve for the long-term success of an organisation. The more we try to increase patient engagement, the better our patients will be prepared to ask right questions. The support staff plays an important role in improving patient engagement and it is the responsibility of the core service provider to introduce and empower his colleagues so as to build confidence amongst patients for better outcome. 

Employees are the main source of inspiration and strength of any organisation and its most valuable assets. Respect for people and continuous improvement should be embedded in the organisational culture. Creative ideas of frontline staff should also be taken seriously and implemented to improve wellness at the workplace. Leaders have to provide them with world-class working conditions and opportunity for them to grow and excel. Ensure a work environment where trust is foremost.

Common Tools for Engagement

Nowadays, since the healthcare organisations give much attention to patient engagement, many IT vendors have started specialising in patient engagement technology. Biometric wireless devices such as wireless scales and glucometers communicate the data through EMR. Many applications help patients to manage their medications and access their records for better outcome. Some of the IT vendors have developed medication adherence tools to remind patients to take their medications on time. Most of the hospitals have started using SMS appointment reminders and of course, social networks are useful for patient education and as an engagement tool. All these systems, both mobile and fixed, are prone to various types of attacks and it is important to ensure confidentiality and security of pertinent protected health information. This is another major challenge for the organisation. Patient portals and eloquent information leaflets developed and shared by various agencies, checklists and informed consent forms are few tools that help the patients and their families to raise relevant questions for clarification. 

Benefits 

We all agree that patient engagement is beneficial for the patient, clinician, and healthcare organisation and to the society at large. It helps to deliver more detailed and comprehensive care, better and easier communication and improves customer satisfaction. It helps to increase efficient service delivery and improves healthcare outcome as there will be more clarity in decision making. In addition, it reduces cost to the patient and increases revenue for the organisation as there will be enhanced continuity of care. The highly engaged patients are more likely to take preventive measures, will have regular health check-ups and participate in immunisation programmes. It is more likely that people will start eating healthy foods, exercise regularly and avoid risks such as smoking.

Conclusion 

All these tools will help to improve patient experience, compliance to healthcare management strategies and provide better outcome of care and add value by making it more personal, convenient and interactive. While these tools and techniques enhance the ability of the service providers to interact with patients, real patient engagement requires a shared understanding and an open mind for including patients’ needs, expectations and beliefs. This is required in each encounter from the ‘point of first contact’ till discharge and subsequent follow up and it requires an empowered team of specialists who are proficient in using the 4Ps. 

Background
As has been known for almost two decades, healthcare is not as safe as it should and could be. Although patient safety is only one of the six domains of quality of care defined by the Institute of Medicine (IOM [now the National Academy of Medicine]), it is undoubtedly one of the most important.

Since the publication of the 1999 IOM report, “To Err Is Human,” there have been dramatic increases in research, standards, collaborative efforts, education, and measures focused on patient safety. However, despite increased awareness, harm to patients is still common and has not shown a significant decline. At least one out of 10 hospitalised patients is being hurt by us and at least half of these events are preventable. In paediatrics it may be even worse: errors still affect as many as one third of all hospitalised children and an unknown number of children in ambulatory settings.

Seven principles are being used to diminish harm and achieve high reliability in the daily performance of any organisation, including hospitals. They include:

Preoccupation with failure: Real time awareness of failures, achieved by daily monitoring of processes, reporting of near misses, and an enhanced sensitivity to processes that could potentially fail before they actually do.

Reluctance to simplify: The first, obvious explanation for a failure may not be the right one, and it is rarely a single issue that leads to the error.  

Sensitivity to operations: Leaders and staff are constantly aware of how processes and systems affect the organisation. Any process that does not work is highlighted and modified in real time. Transparency is a valuable tool to increase sensitivity to operations.

Commitment to resilience: Failures and especially near-miss situations are considered learning opportunities. High reliability organisations are constantly learning, improving, and testing new ways of operating.  

Deference to expertise: This includes taking advantage of the different levels and areas of expertise that team members contribute, and the recognition that the most senior person is often not the most knowledgeable.

Deliberate leadership practices and organisational commitment are needed to establish a culture of safety and foster the journey to high reliability. Although no single intervention will suffice, the importance of leadership presence and support has been emphasised by many organisations, including the Joint Commission. The commitment to zero harm has to come from the top leaders in an organisation and permeate through both clinical and non-clinical areas. Involvement of the Board of Governors is crucial but requires a well-informed Board familiar enough with the issues of hospital-acquired conditions (HACs) to be able to set certain expectations. Management of the hospital, from the CEO to frontline staff, have to be trained to recognise their role in eliminating harm and commit to a culture of constant vigilance and willingness to improve. It is important to realise that zero harm does not mean zero errors and that it is instead essential to create a culture that supports the principles of a highly reliable organisation as described above.

Organisations can introduce Executive Safety Rounds to increase awareness of safety concerns among executives. This provides an opportunity for frontline staff to share safety concerns that affect either the delivery of care or their personal safety, and for executives, if possible, to provide solutions. The Executive Safety Rounding team at our hospital is comprised of an executive leader (such as the Chief Patient Safety Officer), other executives or senior clinical or non-clinical leaders, a member from the Patient Safety and Quality team, and ad hoc members (residents, Patient Family Advisory Committee or Hospital Board members, etc). The one hour rounds can either occur on different days of the week and at different times, including evenings and early mornings, or on a fixed schedule.  Ideally, it would include both clinical and non-clinical areas, both within the hospital as well as in outpatient settings.

Another way to raise awareness about safety issues is a daily, organisation-wide, short (15 minutes) safety call or meeting where different areas report out about any safety issues that occurred during the u last 24 hours or any concerns regarding the next 24 hours. This should include clinical and non-clinical areas, such as facilities, information services and security. Issues discussed can range from census numbers to staff shortages or equipment problems, but could also include weather alerts, reminders about participation in organisation-wide initiatives, such as the annual influenza immunisation campaign and many more.

Peter Drucker, a leader in management principles, supposedly said, “If you can’t measure it, you can’t improve it”.  To know whether we make progress in our culture of safety, and even more importantly, where we have opportunities for improvement, it is helpful to deploy a standardised safety culture survey at least every 18-24 months. An example of a freely available tool is the survey created by the Agency for Healthcare Research and Quality (https://www.ahrq.gov/sops/quality-patient-safety/patientsafetyculture/hospital/index.html).

Another important step is the creation of a dashboard with established benchmarks that are updated regularly. This dashboard needs to be prominently displayed and the results discussed at staff as well as Board meetings. A list of items to be addressed can also be created locally. Comprehensive Unit-based Safety Programs (CUSP) teams are comprised of multidisciplinary frontline staff who concentrate on solving safety concerns that occur at the local level. An executive member of the team can help overcome any logistical or administrative hurdles. This concept has been successfully introduced around the world.

Children’s hospitals have some unique challenges due to the wide range of weights and ages of their patients. Paediatric patients can be harmed in different ways. Medication errors are the most common adverse event in children, in part due to the necessary weight and age adjustments for dosing. Errors can happen at any time during the process of prescribing or administration, and they can occur both in the hospital and the ambulatory setting, including in the child’s home. An additional source of error can be introduced when substitute medications need to be used due to drug shortages, a relatively common problem both in industrialised and developing countries. Diagnostic errors or a delay in diagnosis may be caused by a failure to order indicated tests, the use of inappropriate or outmoded tests or therapy, or a failure to act on results of monitoring or testing, or they may occur because of the age of the child and the inability of the young child to verbalise complaints. Therapeutic errors can, like in adults, occur due to the failure to adhere to guidelines, staff fatigue, or interruptions during critical actions.

However, what has received the most attention are infectious complications, especially surgical site infections, catheter-associated blood stream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs). Many of them have successfully been targeted with standardisation of care. Interventions such as strict adherence to hand hygiene, asepsis during catheter insertion, adherence to a maintenance bundle and the use of an appropriate dressing, have drastically decreased the incidence of CLABSIs and CAUTIs. Networks, such as Solutions for Patient Safety (https://www.solutionsforpatientsafety.org/) provide an opportunity to learn from peers and to share experiences and best practices. Some organisations have been able to maintain zero infections for months and even years, an achievement that previously was thought to be impossible.

As we have learned over the years, zero harm can only be achieved and maintained with constant vigilance. New staff has to be trained and current staff practices must be monitored on a regular basis, since deviations in practice (for example, short-cuts) tend to creep into routine tasks. For example, when we asked each of our nurses to demonstrate their techniques of caring for a central venous line we realised that, although everyone had been properly trained, a wide variability in practice had become established, possibly increasing the risk for infections. A periodic retraining in proper techniques may help avoid such situations.

Finally, we cannot underestimate the value of including families in our patient safety efforts. For example, if a family helps make sure that all healthcare providers and other staff (registration, food services, etc.) as well as visitors adhere to good hand hygiene procedures, they help us protect our patients and keep us all accountable.We still have a long way to go, but we have developed many different tools to help us achieve our goal of zero harm.

References available on request.

Everybody knows healthcare is expensive. And as science and technology continue to advance, medical devices and treatments are becoming more sophisticated and certainly more expensive. Even more, the costs are naturally and artificially increasing in order to cover not only the medical service per se but also medical education, research, pharmaceutical industry profits, luxurious hospital buildings, etc. The last addition to the medical cost is the insurance industry profits. Worldwide, healthcare spending is increasing but the rate is very much different and not necessarily reflected in the quality of care or population health status.

For the relation between patient and doctor to even exist, few more additions are necessary e.g. nurses, laboratory, pharmacy and auxiliary services, such as cleaning, laundry, catering, safe/protection, IT, maintenance, etc.

The more complex the structures are, the larger the managerial team, including HR, marketing, quality control, and so on and so forth, will be. All these are built and sustained by patient-doctor binomial.

From the financial point of view, a healthcare entity can be categorised as either non-profit (generally administered by government) or profit making (typically private). While the non-profit hospitals largely accept and treat all ranges of age/social/pathology and diversity of patients, the profit-making hospitals have the tendency to treat selected population groups.

While the non-profit hospitals – under the umbrella of national plans – concentrate to reduce costs and maximise population health, the profit-making hospitals focus on reducing costs and maximising profits. Even so, the difference in the strategic targets should not impact the quality of clinical care.

In many EU countries, strict laws and regulations ensure that profit healthcare organisations are not a threat for medical ethics, traditional mission and values of healthcare, and the autonomy and ideals of the medical profession.

So, Who Is Paying?

There are more than 200 countries on our planet and each struggle with its own healthcare problems and cost cover. In some countries the burden is shared between the patient and the government in different scales of participation. In others, the patients cover all treatment costs through lifetime instalments paid through taxes or insurance companies, or ad-hoc at the point of service.

Generally, there are four systems which are applied with some local variations:

The Beveridge Model

It is named after William Beveridge, the social reformer who designed Britain’s National Health Service (NHS). In this system, healthcare is provided and financed by the government through tax payments, just like the police force.

Many, but not all, hospitals are owned by the government. In Britain, you never get a doctor’s bill. These systems tend to have low costs per capita, because the government, as the sole payer, controls what doctors can do and what they can charge.

Countries using the Beveridge plan or variations of it include Great Britain, Spain, most of Scandinavia, New Zealand and Hong Kong. Cuba represents the extreme application of the Beveridge approach; it is probably the world’s purest example of total government control.

The Bismarck Model

It is named after Prussian Chancellor Otto von Bismarck, who invented the welfare state as part of the unification of Germany in the 19th century. This system uses an insurance system – the insurers are called “sickness funds” – usually financed jointly by employers and employees through payroll deduction.

Bismarck-type health insurance plans have to cover everybody, and they don’t make a profit. Doctors and hospitals tend to be private, but tight regulation gives government much of the cost-control clout similar to the single-payer Beveridge Model. The Bismarck model is found in Germany, France, Belgium, Netherlands, Japan, Switzerland, and, to a degree, in Latin America.

The National Health Insurance Model (NHI)

This system has elements of both Beveridge and Bismarck. It uses private-sector providers, but payment comes from a government-run insurance programme that every citizen pays into. Since there’s no need for marketing, no financial motive to deny claims and no profit, these universal insurance programmes tend to be cheaper and much simpler administratively than American-style for-profit insurance. The single payer tends to have considerable market power to negotiate for lower prices. The classic NHI system is found in Canada, with variants in Taiwan and South Korea.

The Out-of-Pocket Model

Only the developed, industrialised countries – perhaps 40 of the world’s 200 countries – have established healthcare systems.

This model applies to most of the nations that are too poor and too disorganised to provide any kind of mass medical care. The basic rule in such countries is that the rich get medical care; the poor stay sick, die, or have some medical care depending on urgency and ability to afford.

Where Does The Doctor Stand?

The intellectual, emotional and psychological challenges a doctor faces day-by-day are extremely complex. Medical decision is one of the most intense brain processes, involving memory, situational analysis, perceptions, emotions and sometimes instincts, not to mention that this exercise is done multiple times in a day in an expected empathic way. There are in addition education, teaching, coaching and leading/managerial activities. New applied technologies require one of the fastest professional adaptation.

This is a profession where quality is demanded to the highest and there is no place for error or second chance. Historically, the doctor-patient relationship was built on equal trust and need. A doctor had a large grade of independence and his/her name or reputation was mostly based on clinical results, ethical behaviour and community recognition.

As societies developed, the health systems changed gradually to an extent where the doctor become a crushed layer between the patients and the medical organisations.

While the patient is interested to have the best possible care provided at the lowest possible cost, the organisation is interested to have the lowest possible costs for the unit of care. Even a non-profit organisation wants to be on a positive financial balance. When the hospital is a profit-making organisation, the financial pressure is significantly higher.

The doctor is faced with a dilemma of being a patient advocate but at the same time needing to respect and represent the hospital interests. Although intermediary structures were created to ease medical reporting and deal with the revenue, they are rarely appropriately and adequately staffed or have enough expertise. They usually have limited decision making authority and ultimately refer all problematic cases back to doctors.

To make things worse, financial temptations often challenge the ethical balance. Performance incentives (mostly volumes without quality), covert bribes from suppliers, research temptations etc., become daily threats to medical ethics and morality.

How Is A Patient Protected?

Overtime, various mechanisms were created to safeguard the patient during the tenure of medical care. They are all oriented towards medical units headed by doctors. Each hospital, each national policy maker or administrator, produce an impressive amount of quality checks and indicators to protect the patient once medical care has been initiated. Loss of health due to medical error is amply analysed, and ultimately, guilty or not, doctors usually face the blame.

There is no tool to evaluate or ensure quality of medical care when there is no actual treatment offered. This means nobody can protect the patient against barriers in accessing medical help. Unaffordable medical care or refusal of treatment from insurance companies make far more victims than medical errors; and no one quantifies this.

How Are Hospitals Ensuring Revenue Protection?

Both non-profit and profit, hospitals aim for a positive financial balance. Various services, internal or commissioned, were put in place to ensure this task. The more sophisticated and competent the service, the higher costs for operation. Mind that this operational price is paid by the doctor’s service, which the doctor will afterwards be scrutinised on for productivity.

Positive and negative incentives were created in order to stimulate doctors to work hard. Enforcing volumes before quality typically increases income but is detrimental to clinical accuracy and evidence based best practice.

Whenever a profit insurance company is collaborating with a profit hospital and either of them has an unusual high revenue, there will be a large element of suspicion and distrust.

Who Is Protecting The Doctors?

Interestingly, in spite of having minimal or no quantitative targets for doctors in public sector and self-imposed plans in private sector, the majority of European countries own the most developed health systems (WHO Report 2000, 21 among first 25 are European). The U.S., where the productivity obsession applies, occupies the 37th position worldwide while having the highest spending.

In the majority of European countries there are professional organisations (physician colleges or councils) that are authorised to judge medical errors. They are independent, and their expert decision cannot be overruled by individual hospitals, Ministry of Health or court. Unless intentional crime is proven, a doctor cannot be judged under criminal laws.

These are also countries where physicians feel most secure and protected. In the U.S., in case of medical liability, the hospital’s defence strategy may or may not include a doctor, depending on financial loss. Reloading the initial question, the answer should be simple, but it is not. It is therefore fair to say that every system has and may use enough tools to encourage and protect doctors in making the right decision.

References available on request.

More than 400,000 pharmacies in Europe will be impacted by European Directive 2011/62/EU, ratified by the European Parliament in 2016 and effective in February 2019. The intent of this measure is to prevent the introduction of illegal medicine into the legal supply chain. This means pharmaceutical industry players must consolidate their medicine traceability practices to fight a rise in medicine counterfeiting. What lessons can be learnt from this supply chain revolution?

According to the World Health Organization, about 700,000 deaths worldwide every year are caused by the sale of counterfeit medicines. No country is immune from this scourge, with traffickers primarily targeting anti-cancer drugs, which can carry an annual treatment cost of more than $50,000. To counter this trend and alleviate patient concerns, the pharmaceutical industry has already established several defensive procedures, which  will be reinforced with the Parliament’s Directive. But how ready is the entire pharma supply chain to apply this new regulation?

The Pharmaceutical Industry is Committed to Patient Protection

One result of Directive 2011/62/EU is the introduction of a unique serial number to be applied to the packaging of all medication. Known as serialisation, this labelling process has set a race against time for all branches of the global pharmaceutical industry including laboratories, manufacturers and pharmacies who must integrate it to help ensure the meticulous monitoring of all medicines, from their manufacture to their sale in pharmacies. Updating the production lines and installing appropriate coding equipment is a complex task. It requires first-rate technical abilities and machines, which can deliver high-quality printing. Similarly, serialisation introduces substantial production investments for most companies in the pharmaceutical industry, as revealed in a KPMG survey published in May 2017. Europe’s pharmacies will also have to adapt by procuring 2D barcode scanners, which are critical in checking the compliance of any medicine sold. The result is a major upheaval throughout the supply chain, where monitoring of this new unique number is vital both upstream and downstream.

Traceability is Vital in Fighting Counterfeiting

This substantial investment is a critical support in fighting counterfeit medicines and vaccines. In fact, anti-counterfeiting and safety procedures will continue to play a significant role in the folding carton packaging sector. According to a report by the Smithers Pira design office titled The Future of Folding Cartons to 2022, traceability solutions represent one of the four major advances in technology set to transform the market by 2022.

Indeed, once it is possible to identify where a medicine package has come from, the risk of getting a counterfeit product is drastically reduced. An increase in traceability procedures should help scale down a massive global counterfeiting industry, estimated by the World Economic Forum to exceed $200 billion worldwide in 2017.

Serialisation Provides a Means to Secure Every Level in the Supply Chain

That which holds true for the pharmaceutical industry also applies to other sectors like the food, textiles and leather goods industries, which are also facing increasingly sophisticated counterfeiting schemes. In certain food industry scandals, serialisation would have helped in identifying fraudulent products or batches bearing inaccurate labels.

Thanks to a unique identification code, specific to each unit being sold, the origin and composition of a product could easily be ascertained. Using a basic 2D barcode flash, distributors would be able to follow their listed products in real time anywhere in the world. In the example of a bacterial contamination, distributors could react quickly to prevent it reaching consumers.

This trend involves the entire supply chain. Beyond printing and monitoring hardware, it also requires software to be integrated into the production line to generate unique codes that can be adapted to the MES (Manufacturing Execution System) and ERP (Enterprise Resource Planning) widely used by enterprises. With this in place, all that remains is applying the unique code to the primary package using printers that can produce a code, which will remain legible throughout the product’s lifecycle.

Boosting Product Traceability: A Key Objective for Other Sectors

The serialisation set to come into effect within the pharmaceutical industry should help monitor the supply chain and fight the spread of fraudulent medicines and vaccines. The process may also provide some additional benefits including a more accurate view of stocked products with better historical data of the origin and quality of the purchased goods. These benefits could also apply to other sectors confronted with the hazards of counterfeiting.

Serialisation represents an opportunity to modernise current traceability systems. Through this win-win model, any action taken against parallel markets would be significantly enhanced by controlling the supply chain and the application of data-driven best practices.

What is Artificial Intelligence?

In the contemporary era, the UAE government shifted its policy research agenda focus towards understanding and assessing uses of social media, e-services, digital transformation, smart cities, open government data, robotics, deep learning, machine learning, the blockchain, big data, and Artificial Intelligence. The phrase “Artificial Intelligence” was first coined by John McCarthy at a famously held workshop at Dartmouth College, Hanover, U.S. during the summer of 1956.

The father of Artificial Intelligence (AI), John McCarthy, defined it as “the science and engineering of making intelligent machines” and furthermore, researchers define AI as the aim to “mimic human cognitive functions.”

AI generally comprises of various activities such as deep learning, machine learning, and robotics. Deep learning is where there are artificial neural networks, such as AlphaGo. While machine learning is making machines that learn from data, for instance, Automatic Teller Machine cheque readers. Robotics is creating devices and machines that move such as autonomous vehicles.  

Some researchers and even practitioners may debate that the drivers for fuelling the rise of AI come from many sources of big data including the geospatial data, Internet of things (IoT), sensors data, machine to machine data, security systems data, financial transactional data, and other drivers. For instance, the Arab World Online Report 2017 highlighted that by 2021 over one billion personal IoT devices will be in existence, mobile penetration will be up to 100 per cent, with social media penetration of at least 80 per cent across the Arab World.

In October 2017, the UAE Government launched ‘UAE Strategy for Artificial Intelligence (AI),’ one of the ‘handful of countries worldwide’ to develop and adopt a National AI strategy, which marks the post-mobile government phase that relies on various future services, sectors and infrastructure projects. While there are many benefits of AI, there are some public concerns and risks on AI black box including ‘auditability’, certification, transparency, misuse of data, faulty analysis, ethical dilemmas, wide-scale infringement of privacy, misinterpretation of digital behaviours, automation bias, algorithmic bias, and unrestricted mass surveillance and also, weaponising data. According to Gartner Inc., by 2020, AI is projected to create 2.3 million new jobs worldwide while eliminating 1.8 million traditional jobs. In the UAE, the financial services, healthcare, and transport sectors reported benefiting the most from AI according to a report done in 2018 by Accenture and Frontier Economics. The AI revolution in healthcare has been focusing on defining ‘New Health’ with focus on improving training, research, keeping good and well-being status, having earlier detection, making clear-cut and informed decisions on diagnosis, treatments, and end of life, according to PwC in 2017.  

Figure 1

Current Applications of AI in the Health Sector

AI enables greater access and democratisation of quality healthcare. For instance, AI allows for faster, cheaper and better medical services. In addition to cheaper options (such as AI doctors, nurses, therapist, etc.) in areas that are more rural and promotes apps for access to rural and low-income communities and avoiding higher travel costs with specialists. Some of these remote healthcare apps include snake-bite diagnostics, skin cancer detection, malaria and malnutrition diagnosis, and cardiovascular abnormalities.

A PwC study (2017) highlighted that 67 per cent of respondents in the UAE are willing to use an ‘intelligent healthcare assistant’ via a smartphone, tablet or personal computer; while, in Nigeria, the willingness to use an ‘intelligent healthcare assistant’ via a smartphone, tablet or personal computer is 95 per cent. The study highlighted the top advantages of using Robots and AI for healthcare as illustrated in Figure 1, while the disadvantages are displayed in Figure 2.  

Figure 2

Health insurance companies today are using AI and machine learning to assess better and pinpoint at-risk individuals to reduce costs according to reports from Healthcare Finance. Apart from reviewing previous medical records, the application of AI and machine learning algorithms to risk management is performed, which allows for better understanding the specific patients in need of disease management. Additionally, doctors are utilising AI to optimise health; moving from conventional patient care management to more standardised and proactive management of patient care.

Healthcare administrators have been looking to bend the cost-quality curve in the sector regarding utilising AI and machine learning, according to reports from Healthcare Finance. The areas of opportunity that may be most beneficial to improving the revenue cycle are predicting claim denials, patient billing, and cut readmissions. AI could be transformational in predicting claim denials through the appropriate reasons and then preventing the issues before it occurs. Using AI to cut readmissions was dependent on how the data and the risked patients were utilised and interpreted. Measures include sending out healthcare professionals post-outpatient to those high-risk patients to ensure that the medication regime is adhered to, and the appropriate food and nutrients were met, according to the Executive Director at Grady Health System.  

Furthermore, revolutions in healthcare particularly for pharmaceuticals, the ‘new drug development’ and ‘repurposing of existing drugs’ are two examples of applications of AI. The new drug development can teach a machine learning model the rules of drug design, for instance, the structure of therapeutic molecules; afterward it can apply models to improve the existing drugs or even generate novel compounds or combinations of drugs. A case in point, BERG Health, a biopharmaceutical start-up that uses an AI platform for drug discovery, initiated a phase II clinical trial in April 2016 for a drug compound that could potentially treat pancreatic cancer. For the repurposing of existing drugs, AI allows for the learning of complexed relationships among drugs, pathways, conditions and side effects while conducting large-scale testing and data analysis using the machine learning-driven data analysis. For instance, in December 2014, Atomwise found two existing drugs- reportedly in one day using AI technology that may significantly reduce Ebola infectivity.

AI revolutions in healthcare range from imaging diagnostics through medical imaging to tackle medical conditions such as cancer, diabetes, eye health, brain disease, and heart disease. The medical imaging team at IBM include data from medical journals, electronic health records, lab results, radiology and pathology reports, doctors’ progress notes, clinical care guidelines, and published outcomes studies. In doing so, such efforts and data may help physicians make personalised care decisions relevant to a specific patient while building a body of knowledge to benefit broader patient populations, according to IBM reports in 2016. Recently, the U.S. Food & Drug & Administration and the National Institute of Health approved the first medical device, IDx-DR, which employs AI to improve the quality and speed of various imaging methods to detect retinopathy among the diabetic population. Researchers have unanimously concurred that this new medical device could help hospitals reduce costs in the long-run.

In the UAE, the ‘Dubai 10X’ initiative part of the Dubai Future Foundation, sets the Government of Dubai on a mission to be 10 years ahead of all other cities. The programme ‘10X DCAS’, where the Dubai Future Foundation in collaboration with the Dubai Corporation for Ambulance Services have leveraged AI for the quick response before the ambulance arrives where the patient’s vital signs are being monitored through sensors on smart devices. Another example is the programme ‘10X DHA’ where machine learning and genomic analysis are conducted for early disease predictions such as the DNA sequencing (genome mapping) for the entire population, analysing genetic traits of existing patients to predict future cases and also personalising treatments based on the analysis.

As the UAE enters the AI era among other countries, it is paramount for governments to enable digital transformation, promote and foster capacity building and the right set of skill sets for medicine precision, to best adapt and deliver the ‘smart’ AI governance in healthcare particularly.

References available on request.

According to a 2018 report by the U.S.-UAE Business Council, expenditure on healthcare in the UAE is estimated to rise at an annual rate of 5.5 per cent to AED 73.52 billion (US$20.03 billion) in 2020. This figure is expected to reach AED 101.94 billion, or US$27.78 billion by 2025. Moreover, Alpen Capital’s GCC Healthcare Industry report predicts that the GCC’s current healthcare expenditure is expected to reach US$104.6 billion in 2022, at a compound annual growth rate (CAGR) of 6.6 per cent from an estimated US$76.1 billion in 2017.Numbers at this scale are causing governments across the GCC to monitor healthcare expenditure closely.

The causes behind these rises are varied and challenging. There’s the simple fact, for instance, that the healthcare sector itself is expanding. The U.S.-UAE Business Council notes that in 1971, the country had just seven hospitals and 12 health centres. In 2015, there were 126 public and private hospitals with a combined capacity of over 12,000 beds. This rapid increase has, in part at least, been driven by demand.  

Lifespans are increasing, and by 2050 approximately a quarter of the GCC population will be over the age of 65, according to Deloitte’s January 2018 report on Life Sciences and Healthcare Predictions: GCC Trends.

The UAE’s population is also expanding. Growth is estimated at approximately 1.5 per cent per annum, although this figure has been historically far higher. By contrast, Saudi Arabia is showing higher population growth figures at around 2 per cent.

The prevalence of chronic conditions such as diabetes is another challenge for the region, one that severely impacts healthcare expenditure. A recent survey has revealed that 19 per cent of Emiratis have diabetes, undiagnosed cases are at 11 per cent of the population and 18.6 per cent are in a pre-diabetic phase. By any measure, these numbers are significant.

Population demographics such as those noted above are perhaps the more obvious and influential causes of healthcare expenditure increases. However, a variety of additional factors are influencing the situation.Much is made of innovation, especially in drug development, but the reality is that innovation drives utilisation. New drugs can cause a short and medium-term uplift in demand before usage levels reduce more normal patterns. Drug improvements can arguably reduce the number of hospital in-patient days but, with so many factors involved, there is no easy way of measuring this.

Non-drug related innovations also affect usage. The popularity of MRI scans over a simple X-ray, for example, has raised costs. The unit cost of X-ray may increase from US$100 to US$104 a year, but the unit cost from an X-ray to an MRI can mean around a seven-fold increase. PET scans are another level again. And where hospitals have invested in new equipment they will be keen to use it, raising the demand again for more expensive types of treatment.

Demand will also increase the more a population becomes aware that high quality healthcare services are available to them. Private hospitals are becoming bolder in their efforts to promote their services and this heightened awareness will feed through into users of public sector facilities.Waste is another possible factor, and in 2016, The National cited expert estimates that as much as US$1 billion is lost to patient identity fraud and doctors over prescribing brand-name drugs.

Tackling Rising Healthcare Costs

Combatting cost and price pressures is a real challenge. The truth is that costs are rising year after year and as the sector continues to expand, the best governments can hope for is to minimise annual increases.

That said, many of the causes are being addressed, and with some success. In late 2017, a programme to detect the early onset of diabetes was launched in clinics throughout the country in an effort to reduce cardiovascular disease. And  in July 2018 the Dubai Diabetes Centre announced that it was to expand. To a degree these programmes do seem to be working. The Khaleej Times reported recently that diabetes had dropped from 19.3 per cent of the population in 2013 to 11.8 per cent in 2017.

Encouraging efficiencies through technology is another tool in the government’s kit bag. The Scope of Vision 2021 for Health programme, for instance, saw a AED 2 billion fund established to support innovators across the region, including those in the field of healthcare.

Education is also key, and initiatives such as the School Health Policy launched in early 2018 is a good example of how the government is investing in early stage health and wellness learnings.

An Insurer’s Perspective

Concerns over rising healthcare costs aren’t only the domain of the UAE government. Expats make up almost 90 per cent of the population, and, with compulsory health insurance regulations now in place, most will be covered by either a domestic or international programme.

With such a significant proportion of the population affected, it’s worth looking at the tactics insurers employ to manage costs among their customer groups. Certainly, I believe that the challenges and solutions for private and public healthcare cost increases are more aligned than many understand.

Careful network management can help to lock-in prices for some treatments. And by developing a deep and trusting relationship with each provider, insurers can make more accurate expenditure projections year on year. At Aetna International, we are certainly placing more emphasis on value-based relationships with providers, something we believe will ultimately increase the focus on outcomes and cost of care that our network delivers to individual members.

Encouraging patients to make appropriate healthcare choices helps cap cost increases. Pre-authorisation, the use of excesses/deductibles and educating patients to choose appropriate facilities, not just high-end options, are just some examples of how patient choices can be influenced.

Technology advancements and adoption such as telemedicine can bring costs down, too. vHealth, which we expect to launch in the region next year, allows members to have remote, face-to-face, consultations with a doctor via a mobile phone, tablet or computer and brings obvious time saving benefits, especially to those working in remote locations.

But vHealth is not about replacing physical care. In fact, it brings two major advantages. It provides a way to deal with minor ailments and routine check-ups in a more efficient manner, by avoiding unnecessary face-to-face consultations. It’s also a way to ensure employees in need of physical care are transferred to the right facilities and consultants first time around with a greater degree of certainty.

The type of efficiency benefits we will see from vHealth can apply to the public healthcare sector just as much as the private.

Excesses and deductibles are proven to influence behaviour, particularly when it comes to treatments such as vision, dental, and maternity. The length of stay and facility choice tends to be elective so if a patient knows they need to pay 20 per cent of the fee, they may decide to leave as soon as they have been medically approved to do so.

Pre-authorisation can deter doctors recommending unnecessary tests. Diagnostic tests such as PET/MRI and blood tests, for example, are frequently over prescribed and often unnecessary. Insurers will generally not look to deter this type of treatment, but if a consultant knows they have to call for authorisation there is a degree of deterrent to over subscribing.

Applying benefit sub-limits for elective treatments help to protect against excessive levels of treatment and ensure the insurer can intervene earlier in the cycle for what might be a more serious medical issue. A physiotherapy benefit, for instance, may be restricted to a maximum of 10 sessions before contacting the insurer. Once involved, the insurer can investigate the case further to understand whether a more effective treatment plan is necessary.

Healthcare costs across the Middle East remain under constant pressure. The situation in the UAE is no less acute and, with no let-up in plans to expand the medical infrastructure further, this is unlikely to change significantly in the near term. That said, there are signs that government initiatives are positively impacting some of the more challenging causes of rising costs so there is hope that long-term cost pressures might decrease.

References available on request.