PI Brief Update

What History tells us about Collapsing Health Systems 2019 - Dr Mark Burgin

30/01/19. Dr Mark Burgin BM BCh (oxon) MRCGP looks to history for clues of what it means for a health system to collapse and how to describe the pattern mathematically.

There is a discrepancy between what professionals say about their health system and how the politicians describe the problems that health systems face.

Typically professionals will describe problems facing the NHS using words like frustrating, too late, tsunami, shortage, accusations, inflexibility, unfeasible and tragic.

Politicians use different words - record numbers, brightest and best, concerns, workload and risk, review, introduce, reinvigorate, transformation, models, support, sustainable.

Neither give a reliable picture of the stability and effectiveness of the health system and the figures give similarly conflicting messages.

A new mathematical measure is needed to measure the effectiveness of a health system for individual diseases and to compare across different health systems.

The HIV crisis in New York 1981 (1)

The descriptions of practicing medicine at a time of when there were large numbers of young men who were presenting very ill with unusual diseases is chilling.

The doctors working at that time describe how the senior doctors took a step back leaving the junior staff to do what they could to help the desperate patients delay death.

The fear both in the patients and doctors meant that for this group the health system had collapsed, there was no political will to provide for this stigmatised group.

The same pattern of inadequate response is seen in the treatment of drugs and alcohol and obesity where effective treatments are rationed.

Where the numbers being diagnosed are high but their life expectancy is reduced the health system is failing to address the issue.

Alcohol and heart disease Russia 1995 -2005 (2)

The soviet centrally funded health system was replaced by a patient payment system leading to lack of medication and equipment.

The rates of mental health problems increased with increasing risky behaviours involving drug, alcohol and sexual activities leading to HIV spread and termination of pregnancy.

Cardiovascular disease increased both as a failure of the prevention programmes and due to increased smoking and alcohol consumption.

The fall in the population was associated with increasing violent death and a male life expectancy 59 years compared with female of 72 years.

Russia’s experience gives the clearest view of the effects of a collapsing health system and shows the same pattern of more people getting ill and dying quickly.

Burnout in Japan 1980 to present (3)

The Japanese had one of the most efficient and effective health systems in the world with integrated health system, high life expectancies, low disease burden on funding less than the UK.

The Japanese have a high rate of medical attendance of about 14 times a year (compare UK 6) and rely upon their doctors to work long hours (average 66 to 77 per week) to provide the care.

There is increasing ‘tachisarigata’ (staff leaving) and the emergency services are overloaded so hospitals refuse to take patients leaving inexperienced staff managing complex patients.

The Japanese describe the phenomena of a ‘monster patient’ who makes unreasonable demands and increases the cost of running the health system.

Loss of skilled staff in Japan due to burnout started in 1980 and is now being repeated in the USA and UK but even Japan struggles to show worsening health care.

Conclusions

Any system that does not prevent illness in the whole population finds that the cost of treating complications is more expensive to health and society in general.

There is a significant lag from localised or generalised failure in a health system until the costs from increasing health burden work their way through the bottom line.

A perfect system would have a low incidence of new disease (from prevention) and a high prevalence of disease in the population (from effective treatment).

The ratio between disease prevalence and incidence takes the lessons from history and counter intuitively offers a measure of the success (or failure) of a health system.

Doctor Mark Burgin, BM BCh (oxon) MRCGP is on the General Practitioner Specialist Register.

Dr. Burgin can be contacted This email address is being protected from spambots. You need JavaScript enabled to view it. and 0845 331 3304 website drmarkburgin.co.uk

1. Zuger (1995) Strong Shadows: Scenes from An Inner City AIDS Clinic W.H. Freeman & Co Ltd

2. Danton (2007) The Health Crisis in Russia Topical Research Digest

3. Suzuki (2008) The Imminent Healthcare and Emergency Care Crisis in Japan West J Emerg Med. 2008 May; 9(2): 91–96.

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