Futures from past to present
In our EHFF Newsletter, posted October 23rd, I promised a review of EHFF’s changing view of the future over the 15 years or so that EHFF has identified as a futures organisation. Here’s the fourth of the levers for change in the process of healthcare transformation that we had identified.
Transforming healthcare education:
Healthcare staff have always tended to behave like tribes. Repel all borders, keep knowledge in-house etc. The medical fraternity represent the most extreme version of this, perpetuating what we might call a guild mentality: “an inward-looking mindset, often associated with professional or trade groups, that prioritizes protecting the interests of its members, maintaining exclusive control over skills, and resisting outside competition or innovation. It draws its name from historical medieval guilds which regulated their trades, controlled quality, and limited membership.”
The characteristics described represent a clear enough explanation for one major barrier to progress in this area: resistance to change, in particular unwillingness to hand over some aspects of the autonomy granted via guild membership. It mirrors the anxiety induced in many medical if not other health professionals by the idea of citizens having access to data about themselves or indeed medical information itself, via digital means.
Given our basic premise, that the current healthcare model is not sustainable, the education of healthcare staff would also require transformation. This was highlighted ten years ago when EHFF was part of a work package on futures, in a European Commission Joint Action on workforce planning. The need for new, additional roles was clearly identified, as was the likelihood of strong resistance from the established professions (https://ja-archive.healthworkforce.eu/wp-content/uploads/2016/07/JAHWF_WP6_D062-Future-skills-and-competences-of-the-health-workforce-in-Europe-Final-May-2016.pdf ).
Manpower planning has been recognised over the last twenty years as being a vulnerable area for health systems. Obvious gaps appeared, representing the failure of planning to adjust to demographic change in the population served, such as the relative lack of expertise in managing multi-morbidity or persistent shortfalls in the availability of adolescent psychiatrists, just to give two examples. The threat has accelerated since the COVID epidemic, and it is widely acknowledged that there is now a European crisis in nurse recruitment, with other healthcare professions also affected, where the age of the present workforce has also created a problem. The overall situation was well summarised by Andrzej Rys, then a DG Director at the Commission in his closing address for the above-mentioned Joint Action, in May 2016: ‘Building the Knowledge and Sharing Expertise for a sustainable health workforce’ (his talk can be Googled) but what was noticeable was his side-stepping of the challenge of creating new roles, despite his constructive suggestions to support the present workforce.
Rys promoted digital literacy as an essential element of workforce futures, which has been widely accepted. What we do know is that in the UK, for example, digital skills training is available in most medical schools now, and similarly the Royal College of Nursing provides a wide range of courses. What is heartening is the growth of interest in health literacy training, with the establishment of IHLA from 2016 and CEmPaC from 2020.
Competence in the digital world doesn’t however compensate for the evident current need to ration time with professionals, as exemplified by increasing waiting lists and greater difficulty in accessing primary care appointments in many European countries despite the use of digital booking and eConsult tools.
We would argue that apart from the overarching need to transform our ideas about what a health service (in the holistic sense) would look like, and how to implement that, the discomfort that health professionals show about creating new job descriptions, with lesser training requirements, to compliment the current roles is, as previously noted, a huge barrier to progress. There have been small steps forward. Examples would be nurse specialists carrying out outpatient gastroscopy clinics or pharmacists having greater leeway in prescribing certain medications without direct medical oversight (something that less than ten years ago, CPME, the European doctors association, fought energetically to prevent). As far as we can tell the crucial development of new roles just isn’t happening yet on any scale, and services are failing as a result.
The other major issue revolves around the skills of trainers in medical, nursing and other professional schools. As identified in our section on patient empowerment, trainees won’t be enlightened by a vision of a more holistic and humane delivery of care if their trainers aren’t. The biggest danger regarding the education of professionals is ‘same old, same old’, that is, a curriculum that isn’t updated to embrace new perspectives on pedagogy and doesn’t challenge some of the traditional frameworks, particularly the so-called ‘medical model’ .
Future of healthcare education
If constructive progress is to be made, notwithstanding the amazing things that can be accomplished now, compared to twenty or thirty years ago in the way of detecting and treating medical conditions, it must require a move away from silo thinking (as has already been observed in relation to most of the areas already discussed). There will always be a need for specialist expertise in treating acute or managing chronic conditions but leaving public health staff to advocate for sickness prevention or the maintenance of good health is dysfunctional and ultimately ineffective. Integration is needed.
We have to find a way of reconciling these approaches within our training and also systemically, so that the health professional as health coach can be identified separately from the super-specialist as one of an number of alternative roles that then need to be integrated into the overall model of service delivery. At the same time, a common set of values needs to be built into these diverse roles, so that humane, mutually respectful and person-centred attitudes can be inculcated during training for all. These ideas are evidently not new ones, what is highlighted for the future is discovering much more effective means of ensuring that such ideas really are embedded and are not adopted as some form of lip-service. This takes us back to the thorny issue of the competence and attitudes of the educators themselves and indeed to their own training.
Finally, still within the framework of breaking free of silo thinking, and as a necessary complement to better education of professionals, is the task of providing effective education for the public throughout the lifecycle. Who takes responsibility for this? Looked at holistically, surely this is not simply something that health professionals should have sole responsibility for (apart from the historical truth that it doesn’t work!). How best to achieve a more effective and productive approach here? The obvious answer is health and education services working in tandem, but this unfortunately is a rarely done. The biggest barrier here is culture; familiar difficulties in health and social care services working effectively together exemplifies this.
There are always green shoots that can be detected, but these are not so much about reprofiling roles so much as more sophisticated attempts at health education, such as gamification to help young diabetics learn to manage their condition or teaching mental health resilience in schools. For the general public, apart from the introduction of wellness apps and the sale of better home fitness equipment, which are commercially driven, what seems like a spontaneous increase in public awareness of the importance of exercise is shown by the growth of ‘park run’ as a communal activity in many countries.
Should we, as health futurists, also look to negative or unwelcome scenarios? These would represent for example, opportunity costs for not addressing change that has to be made if systems are to remain sustainable or where barriers to change are realistically unsurmountable. COVID provided uncomfortable examples of botched impromptu solutions where there had been inadequate preparation for what was a fairly predictable crisis. Again, there is an inevitable parallel between the response of governments to global warming and the lack of an effective response to the current manpower crisis.