The Great Unbundling: forecasting healthcare in 2035 — a view from 2047

Over the years, I’ve been involved in a number of foresight activities linked to my work in health policy and business strategy development. This is an example from an essay (for a competition awhile ago) in which I identified a variety of signals and interpreted them to be suggesting that the future of healthcare would be characterised by ‘unbundling’ rather than the current focus on ‘integration’.

I should add that this was written before the current pandemic crisis. In light of that, I would add that countries that have struggled the most have healthcare systems that this scenario suggests are dysfunctional attributes.

To put the difference into perspective, healthcare, as a complex (hopefully adaptive) system can follow one of two design trajectories:

• integration is designed to being service groups closer together, and is broadly monolithic. It is also believed to be more cost-efficient by health economists; it may not be particularly cost effective if measured in terms of clinical and patient outcomes. It is seen by many as favouring equity of access to care as a political goal.
• unbundling involves allowing a variety of types of organisational arrangements to exist, and is broadly pluralistic. This approach is believed to be less cost efficient as it produces duplication, (surplus/idle capacity). However, it eschews equity (as a political goal) for effectiveness and may produce better outcomes as a result.

Knowing where the boundaries and spectrum of options are for health reform are useful in assessing the challenges ahead, and has the additional benefit of avoiding doctrinaire suppression of alternatives.

From an organisational perspective, though, integration strategies tightly couple the healthcare system’s components by removing duplication and redundancy in favour of consistency. It also means that when there is a crisis, there is little spare capacity or flexibility to respond, so patients wait and queues pile up. Unbundling in comparison is loosely coupled and hence has a flexible response to crisis and while features inconsistency, enables a variety of solutions to meet manifest needs.

Since we could argue that healthcare is in a constant state of crisis, paying attention to more loosely coupled options may be worth thinking about. Hence this essay which I have revised from the original. It is written as a retrospective essay from about the year 2047, about the time the Millennials will be in their 70s.

The Great Unbundling, 2035: a future scenario based on signals today

By 2035, the way that people worked had substantially changed by widespread digitisation of information. Smart machines and robots had moved from doing physical work to being central to much cognitive work and which led to fundamental restructuring of the economy. And by 2035, taxation was changing from taxing people to include taxing the work done by devices, cognologies, and robots.

The fault lines between reality and expectations were starkly evident during the 2020s, as public investment in health and social care struggled to cope with the rapidly changing world. People were becoming accustomed to flexible access to personalised services that came to them and expected the same from care provision. Rising displeasure at service decline led to middle-class flight to alternatives with rising use of private medical insurance, progressively fracturing the social contract that legitimated publicly-funded care. Indeed, by 2028, 38% of the population used private care, with over 55% amongst Millennials.

Fearful health and social executives and worried Ministers of Health had reacted to these stresses by pulling the system even more tightly together, to protect jobs and avoid the failure of publicly-funded institutions.

This fed further public displeasure by the dominant middle-aged Millennials (Gen Y) who challenged the traditional approaches to health and social care. In the United Kingdom, for instance, this unrest led to the 2028 Referendum on their tax-funded healthcare system (the National Health Service), leading to the replacement of this system with social insurers and personal Social and Health Care Savings Accounts. By the same token, pressures in the US to adopt a single payer system, modelled on Canada, demonstrated significant public displeasure as evidence mounted that patient choice would flee the system.

The process of changes in health and social care around the world has become known as Unbundling. This brief historical retrospective outlines three of the key components of that unbundling as we know it today in 2035.

The 1st Unbundling: of knowledge and clinical work

Professional knowledge was affected by digital technologies which had unbundled knowledge from the human expert. This changed how expert knowledge was organised, used and accessed. Research institutions and knowledge-based organisations were the first to feel the changes, with librarians being one of the first professions to face obsolescence. Rising under-employment, particularly in traditional male-dominated occupations was still being absorbed by the economy.

Routine cognitive work including access to information and services was increasingly provided by cognologies (intelligent technologies) or personal agents as they were called at the time. Widely used across society, they were embedded in clinical workflow from diagnosis to autonomous minimally invasive surgery. By this time, jobs with “assistant” in the title had generally disappeared from the care system, despite having been seen as an innovative response to workforce shortages through to 2025. These jobs had turned out to be uninteresting, and being highly fragmented in terms of skill-mix, required time-consuming supervision.

The benefits of precision medicine were substantial by this time, enabling earlier diagnosis and simpler and less invasive treatments. Theranostics, the merging of diagnosis and therapy, unbundled the linear care pathway and the associated clinical and support work. This also led to the unbundling of specialist clinical services, laboratory testing and imaging from monopoly supply by hospitals where this was commonplace. Indeed, the last hospitals were being planned in 2025–2030, but by the time they opened in 2033–2035, were deemed obsolete. We now see widespread conversion into housing.

The 2nd Unbundling: of financing and payment

The unbearable and unsustainable rise in health and social care costs necessitated better ways to align individual behaviours and preferences with long term health and well-being. Behavioural science had shown that people did not always act in their own best interests; this meant the care system needed people to have ‘skin in the game’, best done by monetising highly salient personal risks.

Existing social insurance systems which used co-payments were more progressive in this direction, while countries with tax-funded systems were forced to reassess the use of co-payments, and financial incentives. The Millennials, having replaced the baby-boomers as the primary demographic group, were prepared to trade-off equity for more direct access to care. It also became politically difficult to advance equity as a goal against the evidence of poorer health outcomes as comparisons with higher performing peer countries demonstrated.

The use of medical/social savings accounts was one way that gave individuals control of their own money and building on consumerist behaviour, this directly led to improved service quality and incentivised provider performance as they could no longer hide behind the protecting veil of public funding or public ownership. This proved a challenge for statist models, where rising middle class power and improved literacy made this paternalistic role less viable. The social insurers were able to leverage significant reforms through novel payment systems, and influence individual health behaviours through value-based (or evidence-based) insurance, approaches prohibited in tax funded systems.

The 3rd Unbundling: of organisations

With people used to having their preferences met through personalised arrangements, care was organised around flexible patterns of provision able to respond easily to new models of care. This replaced the “tightly coupled” organisational approach known in the early part of the 21st century as “integration”, which we know led to constrained patient pathways, and limited patient choices unable to evolve with social, clinical and technological changes.

The “big-data” tipping point is reckoned to have occurred around 2025. Because the various technologies and cognologies had become ambient in care environments they were invisible to patients, informal carers, and care professionals alike; this enabled the genesis of smaller and more diverse working environments.

By 2032, medical consultants were largely office-based in the community as technologies supported decentralise care; while common in some countries, the hospital monopoly on the employment and hence supply of medical specialists became dysfunctional as an organisational model. This was given an extra boost from cheaper, smaller, portable, networked and intelligent clinical resources. Other care professionals had followed suit. These clinical groupings accessed additional clinical expertise on as-needed basis (known as the “Hollywood” work model); this way of organising clinical expertise helped downsize and reshape the provision of care and met patient expectations for a plurality of care experiences.

It takes time to shift from the reliance on monopoly supply of care from hospitals in those countries that continued to pursue a state monopoly role in care provision. However, most hospitals repurposed themselves quite quickly as focused factories (a lean methodology) while the more research-oriented university centres specialised in accelerating the translation of research into daily use, helped along by the new research discovery tools and the deepening impact of systems biology which was making clinical trials obsolete.

What does this mean as we reflect from 2047?

This Unbundling arose as a product of the evolution of social attitudes, informed by the emerging technological possibilities of the day. The period from 2016 to 2025 was a critical time for all countries, exacerbated by shortages in the workforce coupled with economic difficulties and political instability.

Today, in 2047, we are well removed from those stresses that caused such great anxiety. We must marvel, though, at the courage of those who were prepared to build what today is a leaner, simpler and more plural system, removed from politicised finance and management decisions.

It is hard to imagine our familiar home-based thera-pods emerging had this trajectory of events not happened. As our Gen-Zeds enter middle age, they will, in their turn, reshape today’s system itself a creation of the Gen Ys.

Plus ça change, plus c’est la même chose.

27 December 2047

Note on the Scenario

This scenario is informed by strong and weak signals, including:

Ayers A, Miller K, Park J, Schwartz L, Antcliff R. The Hollywood model: leveraging the capabilities of freelance talent to advance innovation and reduce risk. Research-Technology Management. 2016 Sep 2;59(5):27–37.

Babraham Institute. The zero person biotech company. Drug Baron. http://drugbaron.com/the-zero-person-biotech-company/

Cook D, Thompson JE, Habermann EB, Visscher SL, Dearani JA, Roger VL, et al. From ‘Solution Shop’ Model to ‘Focused Factory’ in hospital surgery: increasing care value and predictability. Health Affairs. 2014 May 1;33(5):746–55.

Cullis P. The personalized medicine revolution: how diagnosing and treating disease are about to change forever. Greystone Books, 2015.

Does machine learning spell the end of the data scientist? Innovation Enterprise. https://channels.theinnovationenterprise.com/articles/does-machine-learning-spell-the-end-of-the-data-scientist

Eberstadt, N. Men without work. Templeton, 2016.

Europe’s robots to become ‘electronic persons’ under draft plan. Reuters. www.reuters.com/article/us-europe-robotics-lawmaking-idUSKCN0Z72AY

First 3D-printed drug just unveiled: welcome to the future of medicine. https://futurism.com/first-3d-printed-drug-just-unveiled-welcome-future-medicine/

Ford M. The rise of the robots: technology and the threat of mass unemployment. Basic Books, 2015.

Frey BC, Osborne MA. The future of employment: how susceptible are jobs to computerisation? Oxford Martin School, Oxford University, 2013.

Generation uphill. The Economist. www.economist.com/news/special-report/21688591-millennials-are-brainiest-best-educated-generation-ever-yet-their-elders-often [accessed December 2016]

Lakdawalla DN, Bhattacharya J, Goldman DP. Are the young becoming more disabled? Health Affairs, 23(1–2004):168–176.

Susskind R, Susskind D. The future of the professions: how technology will transform the work of human experts. Oxford UP, 2015.

Topol E. The creative destruction of medicine: how the digital revolution will create better health care. Basic Books, 2012.

With Samsung’s ‘Bio-Processor,’ wearable health tech is about to get weird. Motherboard. http://motherboard.vice.com/read/with-samsungs-bio-processor-wearable-health-tech-is-about-to-get-weird