Editorials

Hamster health care

Time to stop running faster and redesign health care

Across the globe doctors are miserable because they feel like hamsters on a treadmill. They must run faster just to stand still. In underdoctored Britain they must see ever more patients, fill in more forms, and sit on more committees just to keep the NHS afloat. In the government sponsored, single payer system in Canada; the mandatory insurance systems in Japan or continental Europe; or the managed care systems in the United States doctors feel that they have to see more patients to maintain their incomes. But systems that depend on everybody running faster are not sustainable. The answer must be to redesign health care.

Doctors are increasingly dissatisfied with the amount of time they can spend with patients. A recent survey by the Commonwealth Fund found that three quarters of doctors in the five countries studied believed that "spending more time with patients is a highly effective way to improve patient care."¹ Evidence from general practice in Britain shows that longer consultations are of higher quality,² and patients want more time with doctors. Yet 62% of doctors in Britain, 43% in the United States, 42% in Canada, 38% in Australia, and 32% in the Commonwealth Fund study reported that "not having enough time with patients is a major problem."¹ The result of the wheel going faster is not only a reduction in the quality of care but also a reduction in professional satisfaction and an increase in burn out among doctors.³ Retirement seems the only way to get off the wheel.

Hamster health care has its origins in the increasing complexity of health care, the way it is paid for, and the rising expectations of patients. Whether in a formal fee for service system, salaried practice, or in systems where doctors are paid a certain amount for each patient each year, doctors have been brought under increasing pressure as they try to provide better care, and they are caught between stingy payers and patients with high expectations.

Perhaps the purest examples of hamster care are in Canada and Germany. In these countries there is a fixed budget for all services provided by doctors and a standardised schedule of fixed fees. Doctors try to earn their target income by providing more and more services. But as the number of services provided by all doctors rises and exceeds set total budgets, so the fee for each service goes down. Like frantic hamsters the doctors run ever fasterbut to no avail. In Canada the decline in fees is reinforced by limits on total income. Once that income limit is reached there is no incentive to see patients and so physicians take what is euphemistically called "reduced activity days." In other words, there is little incentive to keep practice doors open after a certain amount of income has been reached. After that point the doctor's time has no value even though demand continues from patients who have free access to primary care.

Hamster health care is not unique to fee for service or single payer systems. For example, in the United States, most doctors participate in the traditional Medicare system (a discounted, fixed fee for service system) as well as several managed care plans, most of which are typically preferred provider organisations, that reimburse doctors through a system of discounted fees for services. Because the managed care insurance market has consolidated both nationally and regionally, the typical American doctor is receiving payment from a smaller number of more powerful managed care plans. Pressure from the powerful payers has meant falls in fees in real terms in most managed care markets. Even in large health maintenance organisations, such as Kaiser Permanente, where doctors are salaried, doctors complain of the hamster care problem. It is known within Kaiser as the "Kaiser reward"the more efficient you are in seeing patients the more patients you get to see.

British doctors will recognise the Kaiser reward. Within the hospital system good performance can mean more patients but not proportionately more resourcesand there is no increase in salary. Rising emergency admissions swamp the system, and harder work is accompanied by rising waiting lists. There is a sense of going backwards. In primary care doctors work harder but patients must often wait longer to see them, leading to growing dissatisfaction all round. ^{3 4}

Many health economists see no problem with hamster careafter all, it is more service for less money. But a system that exhausts doctors and other healthcare professionals is not sustainable. In part it is the result of organising medical practice in a way that is ill suited to an information age and a world of sceptical, better informed patients who know about and want the best care.

Solutions to hamster health care will come from getting off the wheel, not running faster. Doctors need to redesign their work to meet their patients' needs within the economic constraints, just as we have seen in the financial services and other service industries. That means using information technology creatively (particularly the internet) to communicate with patients and manage the process of patient care as part of a fundamental redesign of clinical practice. Kaiser Permanente is committing a billion dollars to this task in an effort to redesign the way it offers health care. The Institute of Medicine in the United States will soon produce a report on redesigning health care, and Britain's Foresight report on health care contains many ideas including the creation of virtual cyber physicians and rolling back healthcare into the community.⁵ These groups are to be applauded for their efforts and thoughts, but globally we need experiments that redesign care to take advantage of new technology. To date we have just bolted these technologies onto hamster care, spinning the wheel ever faster.

Ian Morrison, president emeritus. 

Institute of the Future, 2744 Sand Hill Road, Menlo Park, CA 94025, USA

Richard Smith, editor. 

BMJ