PHM-Exch> Climate Change and Tomorrow’s Health Services

[Claudio Schuftan]

From: Sarah Walpole <argotomunky at yahoo.co.uk>


by Martin Hensher

http://www.climateandhealth.org/magazine/read/climate-change-peak-oil-and-tomorrows-health-service-_97.html

*Climate change* is a crucial challenge facing human health and health
systems.  That’s probably why you’re reading this piece in the first place,
and I’m going to assume you’ve given it some thought already.
Unfortunately, it is but one of a family of closely related challenges
which
have the potential to shape humanity’s future in difficult and unpredictable
ways.

While global demand for energy grows apace – with all the consequences for
the planet’s climate this entails – there is growing evidence that key
fossil fuel resources (especially oil and coal) may have reached or be
approaching the point of maximum production (often described as *“peak oil”*
).  After reaching this peak, remaining reserves become increasingly costly
and difficult to extract, total production will begin to fall, and these
energy resources will become ever scarcer.  Sadly, the lag between
CO2emissions and climate changes means that peak oil won’t
 get us off the climate hook – but it is likely to lead to significant
*economic
dislocation* under anything but the rosiest scenarios, dislocations which
may seriously compound the potentially substantial economic impacts of
climate change - and that may hamper efforts to convert the world’s economy
from fossil fuels  to one based on renewable energy sources.   Meanwhile,
global *population growth* will continue, and the effects of *ageing*
and *non-communicable
diseases will* become more significant, even in developing countries.

A great deal of excellent evidence now exists on the likely public health
consequences of climate change, and on how to reduce the climate impacts of
health services.  Less thought has been given to what *kind* of health
services we might need as a result of climate change, and still less to what
the potentially nasty interaction of climate change, resource depletion and
economic dislocation might mean for the nature and functionality of health
services in either rich or poor countries.   I believe it’s high time we put
this right, by beginning the uncomfortable debate about what we need to do
now to secure the best chance of maintaining adequate health care delivery
systems in the future.

As a major industry, health care reflects a number of general economic
trends which have become more pronounced in recent years.  These can be
summarised as:

   - Increasing *specialisation* of services and health professionals
   - Increasing *centralisation* of services and expertise
   - Increasing *globalisation* of supplier markets, and greater reliance on
   “just in time” delivery of key inputs even while their supply lines become
   ever longer

  Whether we like it or not, it would have been hard – perhaps impossible -
to have avoided the pressures that have driven these trends in health care.
 Much evidence exists in many clinical areas that supports a direct link
between specialisation, service centralisation and improved clinical
outcomes; while under the prevailing economic model of our times, these
trends have indeed (when measured by market prices, at least) offered
greater efficiency, economies of scale, and the opportunity to maximise
health care outcomes for a given health budget.  Indeed, they are central to
efforts to improve the productivity of the NHS in England under the QIPP
programme, for example.  But what if these are yesterday’s solutions to
yesterday’s problems?

Above all else, the interaction of climate change and growing resource
scarcity is most likely to lead to considerable unpredictability and
volatility in global, national and regional economies.  Our current health
care systems – in the rich world, at least – have become highly complex
niche inhabitants in a thus far rather predictable economic system.  We need
rapidly to consider how vulnerable health care models might be to an
altogether less predictable world, and how to make them more
resilient. Some examples of the challenges we will need to consider
might include: how
well current models of acute care might work if patients become less able to
travel long distances for care – perhaps due to fuel scarcity or high fuel
prices?  How well might services work if supply chains for key drugs and
consumables became more prone to disruption and interruption?  How safe a
bet is ever greater reliance on IT if energy supplies are scarce or
unpredictable?  How might other risks (such as antibiotic resistance)
interact with resource scarcity?  How can we prepare and train our health
professionals to be more flexible, so they can work not just in ideal
circumstances, but be trained to expect and to thrive in what we now might
consider to be very adverse circumstances, in which they simply cannot offer
everything they might wish to patients?

This debate is hard, and very uncomfortable.  We can enthusiastically
embrace the re-localisation of food production or small-scale manufacturing,
and find great benefits therein.   But “re-localising”  vascular surgery,
say, may not be like that at all – we wouldn’t do it if we had a choice, and
it may well lead to dead patients.  In some of the harsher future scenarios,
it might well be impossible for us to maintain the clinical outcomes that we
achieve today in some areas.  Equally, before we get too carried away with
blueprints for new models of care, we must also remember that something like
“business as usual” may be one of the possible scenarios we must plan for –
if so, we have to be careful, because implementing our plans for the worst
case might sacrifice outcomes and benefits that could have been achieved if
we don’t actually end up in an ecological dystopia.

Engaging people – whether health care workers, the public or politicians –
with debates about what is the least bad option is difficult and
unappealing, when we would all far rather talk about best practice and new
technologies.  It’s awkward when the most useful lessons might come from
poor countries rather than from closer to home.  And it’s even harder when
political debate about health care “reform” focuses on all sides on how best
to tweak the business as usual model, not on how best to keep health systems
functional in very different and unpredictable futures.   But I believe it
is what professionalism requires us to do – and we have a lot of lost time
to make up.
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