There is a tension between health systems and their need for innovative technologies and the absorptive capacity of the health system itself to both adopt an innovation and modify existing clinical practice to release the full benefits of the innovation.  From a policy perspective, this presents a variety of problems not the least of which is that it is largely pointless to put more money into unreformed health systems.  From a commercial perspective, how is business to decide what are priorities, what are the innovations to back and what markets will adopt them.  Governments and payers can do much to signal markets what their priorities are and back that with appropriate reimbursement policies to enable these technologies to earn their way in the world.

But it is not that simple, and there is a clear need for policy makers and ‘the market’ to interact productively, so both win.  In the absence of this, we will have the continuing saga of the medico-industrial complex driving technologies forward but with no payers.

Competing interests characterise what people think are healthcare technology priorities.  With the often overbearing weight of government, healthcare technologies often reflect preferences that emerge from the policy priorities of governments  locked in an iron triangle with industry and (usually) doctors.  This medico-industrial complex leads to technologies that are sought by doctors, and when companies seek guidance for their own product development priorities, they consult doctors, and around we go. There is some good reason to do this, as it is widely argued that it is doctors who decide what services, medicines and devices patients will end up using, so it is sensible to ask them what they would like.  The problem with this is obvious, as doctors are not consumers of the functions of the medicines or devices they prescribe.  That countries are invariably forced into some form of economic evaluation of health technologies and the use of prescribing guidelines offer some evidence that doctors, in this case, cannot in the main be trusted to make appropriate decisions in this respect.

Let’s take e-health as a case in point.  Often confusingly called ‘telemedicine’, the priorities range from devices and services that patients may actually use, to technologies to facilitate consultations and information exchange between health professionals.  The latter, though, is really just the automation of existing clinical practice.  The former is far more interesting, and far more disruptive of existing practices — perhaps that is why we don’t have much of it?  Then there are technologies that really have a major impact on disease diagnosis, but which are expensive, but through elaborate clinical protocols are restricted or limited — why not adopt ‘best technology first’ and stop wasting the patient’s time.

Some priorities for further thought:

1. Following work by Christensen and others, how can health systems identify technologies that will have the positive benefit of disrupting in the nicest possible way stale clinical practices and yield an order of magnitude improvement in health system productivity (with a corresponding decrease in per-capita costs)?
2. What technologies are most effective from a patient/end-user’s perspective and that they will actually value and use?
3. What commercial realities are needed to enable sensible reimbursement of e-health services by payors?
4. How do we research, invest in and commercialise winning technologies and move them very quickly into use?

That is to say,

• how much do we really want to reform health care delivery using innovative technologies, and what implications will that have on our current approaches and assumptions — this is as much about clinical change as political will;
• what technologies can we have now, today or soon;
• how can we use reimbursement/payment systems to encourage use and uptake, and
• why is healthcare so slow to adopt new technologies?

Progress in healthcare can come from changes to the way clinical work is done.  An example is interventional radiology, which combines radiological investigation with treatment, in a single step.  It moves radiological technologies, such as MRI, CT, Ultrasound, from being mere diagnostic technologies to integration into the surgical work itself.

So why the slow uptake in the UK where a couple of years ago the Healthcare Commission, in one of its investigations, noted that this approach to treatment would have probably saved lives?

The NHS is a slow and late adopter of technologies.  Difficulties giving the necessary clinical freedom to health professionals means that important leading edge, but proven technologies, are slow to be adopted.  The exploration of novel approaches to offering clinical services, outside of hospitals, for instance, in free-standing “theranostic” (therapy and diagnostic) clinics would not only advance the cause of patients, but achieve a step change in service delivery by NHS providers.  Why aren’t the newly freed Foundation Trusts getting on the business of developing services wrapped around this approach to care?

People are obviously of good intent by urging reviews of funding to elected officials in the suitably hushed setting of the House of Commons, but in the gritty reality of healthcare delivery, creative solutions are needed to address not only the timely implementation of interventional radiology, but also overcome the fear of change, of novel technologies and of changes to  clinical practice that change and technology brings.

A recent two week work schedule in Toronto had me reflecting not only on how much snow there can be in my homeland, but also the need for a real electric charge to the province’s policy making.  The province is facing near meltdown, after an ill-conceived pursuit of manufacturing jobs in the automotive sector, with some 150,000 manufacturing jobs lost over recent years, never to be seen again.  Trying to jump-start this industry with taxpayers’ money seems a bit like investing in buggy whips while watching Henry Ford’s Model T drive you to town for a nice lunch!

Investing in universities and research has been coupled with a punitive tax regime, that drives new businesses into the arms of other provinces, or to the US.  Early-stage venture capital is scarce, and the mandarins on Bay Street that do profess to know what to do are more focused on generating returns to their funds (or these days just keeping the rent going on their plush offices), than on understanding the driving force that is the commercialisation of research.

Brains not brawn should be the cornerstone of provincial policy.  This will become especially important as the US, largest trading partner with a 10:1 ratio of US scientists to Ontario/Canadian scientists ramps up scientific investment after a near-decade of scientific politics under the last elected regime.  That sucking sound you will hear (apologies to Perot) will be American scientists returning home to the US.

Ontario, time to get the boots on, review taxation policy, look to rethinking what the best use for bail-out money really is.  Some industries will go and that is sad, but what will replace it will establish the future credentials for the province for at least this half of the 21st century.

Unless, of course, you like buggy whips.