Squeezing out the doctor

IN A windowless room on a quiet street in Framingham, outside Boston, Rob Goudswaard and his colleagues are trying to unpick the knottiest problem in health care: how to look after an ageing and thus sickening population efficiently. The walls are plastered with photographs of typical patients—here a man who exercises occasionally, there a woman with many chronic ailments. Big sheets of paper chart each patient's course from the hospital back to a comfortable life at home, with divergent lines showing all the problems that might arise and ways to handle them. To map the many paths to health in this way Mr Goudswaard's team interviewed a lot of patients and nurses.

But this “war room” does not belong to a hospital. It belongs to Philips, a Dutch electronics company. Mr Goudswaard, the head of innovation for Philips's home-monitoring business, has no medical training. His speciality is the consumer.

The past 150 years have been a golden age for doctors. In some ways, their job is much as it has been for millennia: they examine patients, diagnose their ailments and try to make them better. Since the mid-19th century, however, they have enjoyed new eminence. The rise of doctors' associations and medical schools helped separate doctors from quacks. Licensing and prescribing laws enshrined their status. And as understanding, technology and technique evolved, doctors became more effective, able to diagnose consistently, treat effectively and advise on public-health interventions—such as hygiene and vaccination—that actually worked.

This has brought rewards. In developed countries, excluding America, doctors with no speciality earn about twice the income of the average worker, according to McKinsey, a consultancy. America's specialist doctors earn ten times America's average wage. A medical degree is a universal badge of respectability. Others make a living. Doctors save lives, too.

With the 21st century certain to see soaring demand for health care, the doctors' star might seem in the ascendant still. By 2030, 22% of people in the OECD club of rich countries will be 65 or older, nearly double the share in 1990. China will catch up just six years later. About half of American adults already have a chronic condition, such as diabetes or hypertension, and as the world becomes richer the diseases of the rich spread farther. In the slums of Calcutta, infectious diseases claim the young; for middle-aged adults, heart disease and cancer are the most common killers. Last year the United Nations held a summit on health (only the second in its history) that gave warning about the rising toll of chronic disease worldwide.

But this demand for health care looks unlikely to be met by doctors in the way the past century's was. For one thing, to treat the 21st century's problems with a 20th-century approach to health care would require an impossible number of doctors. For another, caring for chronic conditions is not what doctors are best at. For both these reasons doctors look set to become much less central to health care—a process which, in some places, has already started.

Make do and mend

Most countries suffer from a simple mismatch: the demand for health care is rising faster than the supply of doctors. The problem is most acute in the developing world, though rich countries are not immune (see article). It does not help that health care is notoriously inefficient. Whereas America's overall labour productivity has increased by 1.8% annually for the past two decades, the figure for health care has declined by 0.6% each year, according to Robert Kocher of the Brookings Institution and Nikhil Sahni, until recently of Harvard University. But it is in poor countries that interest in alternative ways of training doctors and in alternatives to doctors themselves has produced the most innovation.

One approach to making doctors more efficient is to focus what they do. India is home to some of the world's most exciting models along this line, argues Nicolaus Henke of McKinsey, who leads the consultancy's work with health systems. Britain has 27.4 doctors for every 10,000 patients. India has just six. With so few doctors, it is changing the way it uses them.

Your correspondent recently watched Devi Shetty, chief executive of Narayana Hrudayalaya hospital in Bangalore, making careful incisions in a yellowed heart, pulling out clots that resembled tiny octopuses. It looked difficult. Some of the other tasks at Narayana Hrudayalaya hospital do not, and are not. Dr Shetty's goal is to offer as many surgeries as possible, without compromising on quality. To do that, he ensures that his surgeons do only the most complex procedures; an army of other workers do everything else. The result is surgeries that cost less than $2,000 each, about one-fifteenth as much as a similar procedure in America.

The trick is repeated in other areas of health care. India's LifeSpring hospitals slash the price of childbirth by augmenting doctors with less expensive midwives. The costs are about one-sixth of those in a private clinic. The Aravind Eye Care System offers surgery to about 350,000 patients a year. Operating rooms have at least two beds, so surgeons can swivel from one patient to the next. Most important, for every surgeon there are six “eye-care technicians”—young women recruited and trained by Aravind—who perform the myriad tasks in the operating room that do not require a surgeon's training.

Other problems have inspired other solutions, with technology filling gaps in the labour force. The Bill and Melinda Gates Foundation supports a programme that uses mobile phones to deliver advice and reminders to pregnant women in Ghana. In December the foundation and Grand Challenges Canada, a non-profit organisation, announced $32m in grants for new mobile tools that will help health-care workers diagnose various ailments. In Mexico, worried patients can phone Medicall Home, a “telehealth” service. If a patient needs care, Medicall Home can help to arrange a doctor's visit. But about two-thirds of patients' concerns can be addressed over the phone by a doctor (often one only recently qualified).

These programmes are expanding. Medicall Home is rolling out its service in Colombia and plans to be operating in Peru by the end of the year. Aravind has exported its training model to about 30 developing countries. Dr Shetty already has 14 hospitals in India. He plans to add 30,000 hospital beds in big health complexes and small hospitals there over the next seven years, as well as build a hospital in the Cayman Islands.

Technology does not just allow diagnosis at a distance—it allows surgery at a distance, too. In 2001 doctors in New York used robotic instruments under remote control to remove the gall bladder of a brave woman in Strasbourg. Robots allow doctors to be more precise, as well as more omnipresent, making incisions more neatly than human hands can. As yet they are enhancements for surgeons more than they are replacements, but that may change in time. Military drones started off being flown by officers who had gone through the expensive rigours of flight school; these days other ranks with far less exhaustive training can take the controls.

Team effort

Less flashy technology, though, could make the biggest difference by reducing the number of crises which require a doctor's intervention. Marta Pettit works on a programme to manage chronic conditions that is run from Montefiore Medical Centre, the largest hospital system in the Bronx, a New York borough. Ms Pettit and a squadron of other “care co-ordinators” examine a stream of data gathered from health records and devices in patients' homes, such as the Health Buddy. Made by Bosch, a German engineering company, the Health Buddy asks patients questions about their symptoms each day. If a diabetic's blood sugar jumps, or a patient with congestive heart failure shows a sudden weight gain, Ms Pettit calls the patient and, if necessary, alerts her superior, a nurse.

Other tasks are simpler, but no less important. Montefiore noticed that one old woman was not seeing her doctor because she was scared of crossing the Grand Concourse, a busy road in the Bronx. So Montefiore found a new doctor on her side of the Concourse. Together, such measures make a difference. Diabetics' trips to hospital plunged by 30% between 2006 and 2010; their costs dropped by 12%.

Similar programmes will become even more sophisticated as monitors evolve. Patients are much happier to monitor themselves at home with gadgets bought online than they used to be, and gadget-makers think there is a huge potential for growth in taking the trend further. Philips, General Electric (GE) and others are all upping their investments in home health, and widening the markets in which they sell their existing products (Philips is trying to crack Japan with emergency-alert devices for the elderly). GE's design gurus predict that a patient's overall condition will soon be measured as easily as a thermometer measures his temperature.

Such technologies have long seemed promising; recently the promise has begun to be borne out. Britain has completed the world's biggest randomised trial of telehealth technology, including gizmos from Philips. The study examined 6,000 patients with chronic diseases. According to preliminary results of a study by Britain's health department in December 2011, admissions to the emergency room dropped by 20% and mortality plummeted by 45%.

Nursed back to health

Changing health systems is tortuous. Reformers are stymied by medical lobbies, nervous patients and heaps of regulations about who may do what and where. But there is movement, particularly in the lower ranks of the labour market. India's health ministry has proposed a new three-and-a-half-year degree that would let graduates deliver basic primary care in rural areas. Dr Shetty thinks his hospitals could benefit from a broader range of training programmes, to create workers with a wider array of skills.

Workers with a lot less training than doctors can still be highly effective. Physician assistants in America can do about 85% of the work of a general practitioner, according to James Cawley of George Washington University. A pilot programme of rural health-care workers in India—the type that the health ministry wants to expand—found that the workers were perfectly able to diagnose basic ailments and prescribe appropriate drugs. In some areas non-doctors actually look preferable. A review of studies of nurse practitioners in Britain, South Africa, America, Japan, Israel and Australia, published in the British Medical Journal, determined that patients treated by nurses were more satisfied and no less healthy than those treated by doctors.

But expanding the supply of non-doctors is not, in itself, enough. America has led the world in developing the roles of nurse practitioners and physician assistants. Other, less trained workers are proliferating there too. The number of “diagnostic medical sonographers”, who have two years of training, is expected to jump by 44% between 2010 and 2020, according to the Bureau of Labour Statistics. Yet productivity still falls. This seems to be because new ways of doing things, and of managing health teams, have not kept pace—and are still under the control of doctors.

The doctors' power rests on their professional prestige rather than managerial acumen, for which they are neither selected nor trained. But it is a power that they wish to keep. The Confederation of Medical Associations in Asia and Oceania, a regional group of doctors' lobbies, wants “task-shifting” limited to emergencies. Japan's medical lobby has vehemently opposed the creation of nurse practitioners. India's proposal for a rural cadre outraged the country's medical establishment, and legislation to create the three-and-a-half-year degree has gone nowhere.

In 2010 America's respected Institute of Medicine (IOM) called for nurses to play a greater role in primary care. Among other barriers, nurses face wildly different constraints from one state to another. But any change will first require swaying the doctors. The American Medical Association, the main doctors' lobby, greeted the IOM's report with a veiled snarl. “Nurses are critical to the health-care team, but there is no substitute for education and training,” the group said in a statement.

As doctors become scarcer and health costs continue to rise, more and more systems will seek to innovate, and the successes they have will become ever more widely known. Already, programmes such as Montefiore's are becoming the paradigm for keeping patients healthy. In December America's health department chose Montefiore for a pilot to improve care and lower costs for the old.

All this should be cause for excitement. Resources are slowly being reallocated. Nurses and other health workers will put their training to better use. Devices will bolster care in ways previously unthinkable. Doctors, meanwhile, will devote their skill to the complex tasks worthy of their highly trained abilities. Doctors may thus lose some of their old standing. But patients will clearly win.