APPENDIX 6
Memorandum by Alasdair MacDonald (MT 21)
The following report, which is a personal submission,
was written by Alasdair MacDonald and circulated to a number of
colleagues, who are active in the field of e-health, for their
comments and contributions. The document is based on real experience
and understanding of the sector, its component parts, problems
and restrictions. New technologies need new ideas on how to implement
and use them, which in turn demands changes not just to how we
do things, but how we think about how we do things.
Alasdair originally trained as a fast jet pilot
in the Royal Air Force before becoming one of the first IBM authorised
PC dealers in the UK. He is an experienced computer programmer
and systems analyst and has been an innovator in the telemedicine
field for the last 12 years. He is Chief Executive of TeleMedic
Systems Ltd and e-Health Consultants Ltd. A promoter of low bandwidth
real time solutions, Alasdair designed and built the first remote
mobile medical vital signs monitor to send real time ECG, SpO2,
Blood Pressure and Temperature from a commercial aircraft in flight
to a doctor on the ground. With strong, practical, experience
of telemedicine in the most difficult and austere environments,
Alasdair has presented a number of papers at international conferences
and has worked with the WHO and ITU as well as many other individuals
and organisations, including the US special forces.
EXECUTIVE SUMMARY
OF REPORT
IN RESPONSE
TO THE
UK GOVERNMENT SELECT
COMMITTEE ON
HEALTH INQUIRY
INTO—THE
USE OF
NEW MEDICAL
TECHNOLOGIES WITHIN
THE NHS
The following report looks at the use of new
medical technologies from an e-health perspective. e-health, as
with e-commerce and e-government, relates to all aspects of health
that utilise electronic processing, communication, storage etc.
Given the prevalence of such matters in all walks of life, one
would think that this would be a principle concern of any initiative
concerned with new technology. Unfortunately, e-health seems to
be almost an afterthought, as such, new technologies, even now,
are being looked at in isolation, instead as part of an integrated
and interoperable solution.
The report begins with some recommendations
in order to focus the reader with regard to the relevance of the
text that follows. The report then follows with a simplistic overview,
in an attempt to ensure that, as far as this report is concerned,
everyone has at least the same basic information and can, hopefully,
therefore, realise the reasons for the concerns expressed and
recommendations given. The ultimate objective should be the smoother
delivery of, and ubiquitous access to, healthcare through the
use of e-health and new technology.
The report then looks at the four areas specifically
identified.
There is a general lack of understanding of
telemedicine and telecare, both key components of e-health. The
report attempts to explain why there has not been greater success
and uptake in this area and how important it is to establish,
not only an "Innovation Centre", but a real life working
centre of excellence where people can view at first hand what
telemedicine is and how it is an integral part of modern, conventional,
medicine.
A key recommendation is the establishment of
an "accreditation body" for e-health, which will not
only accredit a specific device as being fit for purpose, but
will look at all the people processes, standard operating procedures
and integration issues so that potential users are clear on exactly
how and where something can and should be used and for what purpose.
While the scope of the Healthcare Industries
Task Force (HITF) report goes far beyond e-health related matters,
the content and recommendations are almost exactly those that
the author and a number of colleagues have been trying to draw
the Government's attention to for several years. This report looks
at the key outputs of the HITF report with specific recommendations
of how these need to be modified to elevate e-health to a more
prominent and contributory position.
The key concern relating to the speed of, and
barriers to, the introduction of new technologies is the fragmentation
of the health service in terms of its decision processes. If the
health service were responsible for food, we would never have
cakes because flour is a distinct division, which does not talk
to eggs, sugar etc. In real terms, if an initiative is devised
within primary care that would only really show benefits further
down the line, it is impossible to obtain funding. Primary care
cannot show a benefit and secondary/tertiary care will not fund
something outside their own direct control!
The primary concern with the effectiveness and
cost benefits is one of measurement. How do we measure if something
is a success or not? This section gives a specific example of
an initiative that the participants thought was a great success,
however, an external auditor deemed a failure.
The following report has been prepared as information
for the UK Government Select Committee for Health for its inquiry
into the use of new medical technologies within the NHS. The report
offers useful information towards the understanding of Telemedicine
and e-Health, what it means and some pertinent issues around the
subject. The ultimate objective should be the smoother delivery
of, and ubiquitous access to, healthcare through the use of e-health
and new technology. We will begin with our recommendations in
order that the information that follows can be read with these
in mind, which we hope will bring about a greater relevance and
understanding.
RECOMMENDATIONS
Our most important recommendation is that the
Government establish a single body to coordinate all e-health
activities across any and all boundaries. This body needs to be
completely autonomous reporting directly to the Department of
Health, it could, perhaps, be a special health authority.
For new ideas, technologies, systems and services
to be tested effectively, they must work in a real environment
and integrate and interoperate with existing processes. There
must, therefore, be an active medical centre using these new systems
and services on a day to day basis. In this way, the clinicians
with first hand experience of e-health systems would be able to
evaluate and appraise new technologies based on experience and
their relative value as part of a wider, overall, solution. Other
clinicians would be able to come and see for themselves how things
work and the benefits that can be gained.
Systems also need proper technical evaluation
and accreditation. There is, therefore, a need for high quality
medical technicians and IT specialists, to evaluate the technical
capabilities of new technologies and systems. That they have passed
regulatory approval and are safe does not mean that they will
be useful, they need to be appraised against existing systems
for compatibility and interoperability. Clear and practical information
needs to be produced on the capabilities and limitations of each
system in different environments, how and where they could be
used, possible interference with other systems and so on.
e-health solutions also need to be regulated
by some form of standardisation agency. There needs to be a separate
team to look at the people and process aspects. Technologies need
to be assessed in terms of their role and the manner in which
they should be used. Because not all elements of an e-health solution
will be under the control of any one given body, all participants
in any specific area of e-health must operate to clear and specific
"standard operating procedures". These standards are
not those already defined and managed by any other body or agency,
these are the people processes and best practice procedures that
must be undertaken to ensure the seamless integration and interoperation
of a specific device, system or service, irrespective of its place
of use or place of service delivery.
Finally, there is the need to inform and instruct
everyone as to the relevance and value of e-health services as
well as training those who will train people within their own
organisation.
We recommend that all these functions be put
together in a single centre, which we have called an "Incubation
Centre". This is a place where, once started, initiatives
are developed and matured before fully defining, standardising
and releasing into the wider healthcare market as fully developed
and replicable systems and services.
The standardisation group, although acting independently,
will work within this centre with both clinicians and technicians
to establish how they each see a particular device, system or
service working. They will then look at appropriate models of
best practice, medical efficacy and any other regulatory aspect
before presenting a prospective blue print back to the clinicians
and technicians. After any fine tuning, the result will be a clearly
documented definition of how this specific device, system or service
should be implemented.
Furthermore, by having a clear reference document
to work to, not only can other health facilities easily implement
their own instance of this system or service, they also have a
measure against which to be assessed for accreditation purposes.
This standards group will also, therefore, have a role in the
accreditation of e-health systems and services. Any accredited
system or service should be able to integrate and interoperate
with any other accredited system or service anywhere else in the
country.
Finally, the centre would be able to train those
people responsible for training within their own organisations.
Training is, after all just another service and would be subject
to the same accreditation as any other service. This means that
the training is consistent, irrespective of location.
A full description of the Incubation Centre
and its various functions and responsibilities is available on
request.
Before reading this report further, we would
like to offer readers a common understanding of a number of key
issues. In particular, where we are today and what certain expressions
and phrases actually mean. In this instance, jargon is not the
biggest inhibitor, however, there is such a range of understanding
about different aspects that without a short overview it would
be no better than trying to explain a "Stealth Fighter"
to the Wright brothers. Indeed, for those "within" telemedicine
circles, the term "telemedicine" has been dropped in
favour of the term "e-health". People seem to be more
able to relate to the "e" aspect and its broad scope
while "telemedicine" is often only seen as having very
limited application, usually being limited to a particular example
that an individual has been exposed to in some way, such as Teleradiology.
New technology within medicine is a subject
as old as medicine itself and as in any walk of life, is always
looked on with scepticism and introduced with reservation. The
stethoscope being a particularly good example. It is, however,
in the area of computerisation that the biggest problems arise.
This is best understood by looking at the history of computers
in health. Initially computers delivered little or no clinical
benefit but did increase the workload on clinicians and were a
long way from being "user friendly". The advent of the
PC and more specifically, the Windows operating system, helped
dramatically by being more useable and offering easier access
to information. However, a whole plethora of dissimilar competing
systems popped up with individual clinicians having personal preferences
for this or that system. They did not (and still don't) integrate
or interoperate with one another and they do not necessarily collect
the same data. While much of this is the responsibility of the
National Program for IT (NPfIT) there are important aspects that
are not covered and it is these that we will look at now.
Most measurements of physiological data by clinicians,
such as blood pressure, are done manually or by stand-alone devices.
Transcribing this information into a patient's record is also
done manually, even when using a computerised electronic patient
record system. These electronic devices are obviously more prevalent
in hospitals and ambulances. Some even have a data port, which
will allow them to connect to another electronic device or link
them into a larger, proprietary system. There are two significant
problems with this, firstly, they are designed as stand alone
systems not as components of an integrated information system
and secondly, there is much confusion about what they can or cannot
do.
Let us consider an illustration. The Government
has recently made money available to ambulance services to purchase
"telemedicine" enabled 12 lead Electrocardiograph (ECG)
units (An ECG unit is a device for producing a graph of the electrical
activity of the heart. The term "lead" refers to a view
of the heart through a particular axis, not as most of us would
think, the number of wires connected to the patient). Now, let
us start by asking, what is a 12 lead ECG? Do we really need a
12 lead or would a three lead do? (A 12 lead is used routinely
in hospital because (1) it is available and (2) it usually gives
diagnostic details without the need for a cardiologist.) If we
do need a 12 lead, do we need all 12 leads simultaneously or one
at a time? If one at a time should they all be of the same time
interval, sent sequentially, or a representation of the time interval
over which they are being sent? How are we going to send it? Who
is going to receive it and what will happen to it then? While
the reader may not know what is or is not the right answer, they
should at least realise that there are quite a few questions that
need asking and a simple "that's how it has always been done"
is insufficient.
As we will discuss later, devices themselves
are not a solution, in fact most devices on their own have little
diagnostic value, there are other components necessary to ensure
that they work as part of a solution that at least allows access
to an appropriately qualified person to use/interpret the data
received.
It is also important to realise that because
a 12 lead ECG unit has a data port and is "communications
enabled" that does not make it a telemedicine unit. Telemedicine
requires appropriate data communication and trained personnel.
And what does "communications enabled" mean? Often it
means that it can communicate with a computer, this is also potentially
very misleading. Those with PC experience you will know that even
if everything works correctly now, if you try and install a new
program or device, while it may or may not work, other applications
and systems that were previously working may now not work! This
is not an acceptable outcome for a medical device! There is a
serious lack of understanding, outside the regulatory bodies,
about the use of computers in the medical field and about what
is and what is not a medical device and where responsibility for
failure lies.
This brings us back to the first point, companies
that produce these devices, sometimes also produce a range of
other devices that link together to make a total "solution".
While this negates the point that the device is entirely stand-alone,
it does create an additional problem that you have to use their
components, their terminals, their software etc. This is how the
computer market was before the advent of the IBM Personal Computer
(PC) 25 years ago. To fully appreciate what this means think about
your PC. It doesn't matter what make it is, it has the same look
and feel (through the assumed operating system, Microsoft Windows)
as every other PC. You can buy any PC software and it will run,
any hardware and it will connect. You can take data off your PC
and run it on someone elses!
We take this interconnectivity for granted,
businesses have grown up that only make certain bits of computer
hardware. Perhaps less well known but more technically interesting,
is the fact that specialist programmers write pieces of code which
are used by other programmers to incorporate into their own offerings.
Before the "PC" this did not happen, it could not be
done. Not only could you not take a floppy disk from one computer
and run it on another, the disk probably wouldn't even fit. Programmers
not only had to write programs for your specific computer but
they had to know or restrict you to a set of known printers and
other peripherals.
Just as the PC market changed, so too must the
medical market. For the PC this was brought about by an open hardware
platform (the IBM Personal Computer or "PC") and a common
operating system or user interface. The medical market must change
in a similar way but with one important additional item, the adoption
of common practices and standard clinical procedures on a national
basis. This is nothing to do with clinical or regulatory standards,
which are already well catered for, but a clear set of "Standard
Operating Procedures" to ensure different people in separate
locations know what is going on, where in a process things are
and what comes next.
Most professions have clearly defined rules
and procedures, as circumstances change then the rules change.
Medicine is practised by highly qualified professionals but, and
this is really serious, they practice medicine in their own particular
way. Imagine if this was how air traffic control was handled.
With the advent of e-health, many clinical interventions will
be done out of the physical presence of a clinician, or by a less
qualified clinician remotely supported, for this to work smoothly
there need to be clearly defined operational procedures and processes.
As already stated, we are not referring to aspects already adequately
covered by existing standards bodies and agencies but the specific
elements that pertain to remote use and the interaction and interoperability
of people and systems when connected electronically.
Given the global economy in which we now live,
these procedures and processes must be International. For example,
most airlines now use a company called MedAire in Phoenix, Arizona
to handle medical emergencies in the air. As new technologies,
such as remote medical monitors, allow the MedAire physicians
to obtain qualitative information on the patient's physiological
parameters, clear international standards and procedures need
to be in place to allow, or deny as appropriate, access to patient
information and the forwarding of this to the next people in the
process chain
THE UTILISATION
OF TELEMEDICINE
(INCLUDING TELECARE)
AND ITS
FUTURE POTENTIAL
FOR IMPROVING
SERVICES
As has already been mentioned, the term "Telemedicine"
now comes under the broader banner of e-health, along with Telecare.
However, the intended use for this inquiry is presumed to be the
use of e-health systems and services to deliver remote medical
interventions (telemedicine) and ongoing remote care at home or
other non-medical facilities (telecare). The key word here is
"remote", which simply means that one or more elements
of the solution are not at the same locality as the patient. Remote
can, therefore, be as diverse as the care of an airline passenger
by a doctor on the ground or a patient receiving care at home
from a community nurse with remote access to patient records,
hospital booking systems etc. Large distances are NOT a prerequisite!
At the moment, instances of telemedicine and
telecare tend to be looked at in isolation, a bit like looking
at flour, eggs, sugar etc as the end product without looking to
see how these things can be put together to make something that
is more than the sum of the parts! Indeed, very little consideration
is given to telemedicine despite the huge cost being incurred
in building NPfIT, which will enable telemedicine and turn it
into a major form of medical intervention. This could be likened
to the use of aircraft by the military at the outbreak of World
War One, the powers that be saw them as little more than observation
platforms, by the end of the war they had their own service and
now "air supremacy" is seen as a pre-requisite of any
land or sea intervention!
NHS Direct is telemedicine, the initial activity
is telephone based, however, despite doing a reasonable job for
many, it does a less than adequate job for most long term or repeat
illness patients. In these cases the call centre operative deals
with them in exactly the same way as someone who calls in with
a stomach ache, these people need an enhanced system where they
reach a clinician with direct access to their notes and, in the
case of longer term illness, perhaps even real time medical parameters,
blood pressure, ECG etc. It is not that the capability does not
exist; it is that there is no high level support for such initiatives.
Instances of telemedicine and telecare are currently
run as local "pilots" where there is a clinical lead
that is willing to support the initiative. Often funding for such
"pilots" dries up or the clinical lead moves on. This
lack of high-level support means that the same initiatives are
piloted again and again all over the country, the outcomes of
previous pilots being completely unknown to anyone other than
those intimately involved in the project. This lack of understanding
also means that people with little or no experience of telemedicine
are able to pass themselves off as experts, if you are ignorant
of something, someone who knows a little is, in your eyes, an
expert!
There is also a sense that telemedicine systems,
because they connect to computer systems, which are getting cheaper
and cheaper, should also be significantly cheaper than hospital
systems. An over the counter blood pressure unit from Boots can
cost you less than a hundred pounds, a hospital unit often costs
ten times this. The answer is clearly one of quality, but as more
and more of these systems are produced their unit cost will reduce.
What we shouldn't do, but is happening, is to compare telemedicine
systems based on low quality components, with the equivalent high
quality hospital based system.
Once we make this change of attitude, the potential
for telemedicine far exceeds our imagination. Care homes are,
by their very nature, places that tend to have a greater need
for home visits and out of hours care. By putting telemedicine
equipment into these locations and connecting them to a "virtual
GP" system, much of this need could be addressed remotely.
Community nurses should also be equipped with appropriate systems
both in terms of monitoring and remote access to electronic patient
records, decision support tools and so on. Once established, with
the staff and patients both conversant with the systems, it will
be possible for regular, routine monitoring to take place, not
just knee jerk emergency intervention. Regular monitoring combined
with other pieces of relevant information can be used for early
intervention and ultimately prevention.
As has already been mentioned, however, telemedicine
is not simply about technology, it requires the adoption of common
practices and processes. This cannot be achieved by individual
"pilots" run by local enthusiasts, this must be done,
first in a specific area (where it is evaluated and problems ironed
out) and then systematically on a wider and wider basis until
adopted nationwide. This requires support at the highest level
within government and, on an international basis, through cooperation
and mutual development with other countries.
Telemedicine will also enable a strong interaction
between the private sector and NHS. There is a diving company,
based in Aberdeen, which provides telemedicine support for their
divers, even while still in hyperbaric chambers. A doctor, also
in Aberdeen, is able to monitor a diver, under pressure in a hyperbaric
chamber, on board the company's diving vessels, wherever they
may be, anywhere in the world. Under the NPfIT, these divers will
all have an electronic patient record; the private doctor in Aberdeen
should be allowed appropriate access to this record to be able
to properly manage the current medical situation. Likewise, on
returning to shore, the diver's GP should be able to see what
action was taken by the doctor in Aberdeen and by any medic on
the ship. This is just one example of how companies and even individuals
will pay for medical services, the outcome of which is available
to NHS doctors, thereby simplifying and streamlining the interventions
and care given and ultimately reducing costs through cutting out
duplication of tests etc.
Ultimately, people will be able to receive hospital
grade monitoring in their workplace, at the gym, on board an aircraft
on holiday and so on. These cease to be isolated incidents but
part of the complete picture of a person's long-term health.
THE RECOMMENDATIONS
OF THE
HEALTHCARE INDUSTRIES
TASK FORCE
(HITF) REPORT, PUBLISHED
17 NOVEMBER 2004
The main recommendations of the HITF report
were contained in nine key outputs; however, these are primarily
concerned with medicine as we know it, not e-health, which is
seen as a new technology in itself. It is our belief that, within
a very short time frame, all aspects of health will, in some way,
integrate with a wider "e" component, even if they are
not themselves part of an overall e-health solution. To that end,
this report emphasises the additional aspects needed for this
to happen.
The HITF report seeks to "inform procurement
decisions and encourage the support and uptake of useful, safe,
innovative products and procedures". For this to happen,
there must be some system of evaluation and assessment that has
also been proven in real life scenarios. Unfortunately, unless
these recommendations are followed through, nothing changes. There
is also the need to "train the trainers" with regard
to the wider benefits of e-health. While the outputs of the HITF
are being considered and the follow-on actions devised, e-health
implications must be built in. Otherwise technology will only
be an add-on to existing practices, not an integral part of healthcare
delivery, the folly of which has been well illustrated in earlier
examples.
The report also seeks to "Stimulate more
innovation and encourage a more entrepreneurial culture in industry
and the NHS". The only part of this that needs serious action
is that part involving the NHS and even here it is not a lack
of desire on the part of those involved, simply those in decision
making positions. The UK leads the world in the development of
innovative medical technology; the problem is not one of innovation
but one of innovative leadership. The author and a number of colleagues
have been trying to bring a number of things to the attention
of the "powers that be" for, in some cases, almost 10
years.
The HITF report calls for a new Innovation Centre,
while this is a good idea in principle, what we really need is
an "Incubation Centre" (as recommended at the beginning
of this report) where innovations are used and tested in real,
working situations. Within such a centre the relevance to and
capabilities of integration and interoperation with other systems
can be evaluated and an appropriate blue print of how they should
be used in other real world situations defined. The "Incubation
Centre" would not be just a showcase but a model of how innovative
technologies can be used. Nurses need to see other nurses working
with something to understand the true potential and value; the
same is true of all professionals, not just in healthcare. Such
a centre would also fulfil a large number of other recommendations
of the HITF report, with the exception of introducing an "innovation
fund". However, the output of the "Incubation Centre"
will do this and the need therefore is not for a "fund"
but to fund the "Incubation Centre".
One aspect looked at in the HITF report is procurement.
It is not for us to make recommendations outside our sphere of
expertise. However, common sense would suggest that if an "Incubation
Centre" is established and it delivers clear guidelines on
not only how to use a specific piece of technology for a particular
function, but defines best practice procedures and processes,
then healthcare agencies within the NHS should, subject to their
own budgetary constraints, be able to purchase said technology
for use in this manner. Those involved in the procurement process
should actively work with the "Incubation Centre" to
ensure that "cost effectiveness" is a major consideration
and provide details of how this is evaluated.
e-health also has a serious role to play in
providing the evidence base in support of R&D activities.
Regular monitoring of everyone, by using e-health tools as part
of an overall e-health programme, will provide a greater understanding
of factors leading to ill health. At the moment people only really
enter an evidence-based program once they are already sick. e-health
offers the first real chance of monitoring people, both well and
sick, from before birth until death and should, therefore, be
embraced as a common thread to any R&D programme.
The author is aware of a number of initiatives
involving different academic centres of excellence, which are
looking to be "the recognised academic body" within
a specific area or aspect of health. The problem here is one of
status, rather than have one official academic centre, which will
not stop other centres from trying to out-do them to show that
they should have been the "official centre", the academics
should work with the "Incubation Centre", as outlined
above, to ensure that all are working to the same goals.
The establishment of an "Incubation Centre"
would also provide a platform from which to address communications
with and between patients/the public and clinical bodies/government
agencies in all aspects relating to e-health. A working centre
that is open to public scrutiny and which would actively encourage
the participation of patient and healthcare groups, including
Royal Colleges, Unions and other interested parties, would provide
an open forum that would actively encourage communication. This,
in turn leads to education and training.
"Knowledge dispels fear" is an apt
phrase because the converse is also true. People are afraid of
what they do not understand. When PCs were first introduced, people
from all walks of life became concerned about their jobs and a
myriad of other completely unrelated things. Training and education
removes this barrier of fear and people move on.
The HITF report suggests "Maximising UK
influence in regulatory matters in the EU and other international
forums". We agree with this wholeheartedly, the UK already
leads the world in many aspects of e-health and to apply best
practice and standard operating procedures to this at a time when
they simply do not exist would be to secure our long-term influence.
This is also a major cost factor as, if other standards are adopted
in preference to ours, then in order to operate on an international
basis, our systems will have to be changed or adapted to meet
these different standards.
THE SPEED
OF, AND
BARRIERS TO,
THE INTRODUCTION
ON NEW
TECHNOLOGIES
It is fair to say that most e-health "pilots"
have not moved beyond the initial "pilot" stage. The
reasons for this have been well documented above, principally
they have been driven by a single, local, sponsor with no ongoing
funding and no "place" for a full blown service within
the current healthcare structure.
Healthcare is broken up into very distinct compartments
and if an initiative crosses boundaries, or worse if the benefits
of an initiative are seen in a different segment, there is no
funding. Sources of funding also change, and even when funding
has been obtained, it is not unknown for this to be used somewhere
else within an organisation, not for or even by the department
that applied.
There is little to no long term planning, with
short-term goals taking precedence over long term objectives that
bring accumulating benefits.
There is a lack of trust by clinicians in IT
systems, which have, in the past, been purely administrative tools.
There needs to be a place where people from all sectors of healthcare
can go and see new technology being used in real situations by
ordinary people.
THE EFFECTIVENESS
AND COST
BENEFIT OF
NEW TECHNOLOGIES
As new technologies, practices and processes
are adopted, there will be the initial benefits for which they
were intended, but there will then come additional benefits, many
of which will remain unknown until they actually happen. What
we have to be wary of, however, is a simplified comparison against
some arbitrary factor.
There was a dermatology pilot conducted between
GPs in rural practices and a remote consultant dermatologist.
When the GPs were faced with a skin problem they could not identify,
an appointment would be made for the patient to return to the
practice at a time when the doctor could have a live link to the
remote dermatologist. The skin would be photographed using an
appropriate digital camera and the image sent to the dermatologist.
He would discuss this with the patient in the presence of the
GP.
At the end of the project it was reported to
be a failure, not by the doctors, patients or dermatologist but
by a third party auditor. The reason for the failure, after an
initial period of regular use, the system was used less and less.
On questioning the doctors, they deemed it a huge success. Why
the drop in usage? Each time they referred a patient, they were,
in effect, receiving ongoing training. Once a condition had been
seen on a number of occasions, the doctors no longer needed to
refer the patient but were able to deal with the situation themselves!
Healthcare will never cost less, however, it
will be possible to do more for the same amount. As new technologies
emerge, when a patient is screened for one particular aspect,
it will probably be possible to simultaneously screen for many
other things at the same time. Medicine will start to move from
only dealing with people once they are sick, to managing them
while they are well and intervening at the fist sign of "preconditions"
to act in a preventative manner. Once this happens, healthcare
in the UK will move to a truly National HEALTH Service.
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