History is littered with many sharp transitions at times when context, conditions and challenges render yesterday’s solutions obsolete. In many of these cases, obsolescence comes through a tumultuous, even spectacular, moment of failure. In the lead-up to these moments, minority voices have often drawn attention to changes in the field of play, but the majority remains invested in the apparent security of proven strategies, technologies and tools.
It would be a tremendous understatement to say that the COVID-19 pandemic has focused attention on our healthcare system. Wealthy and powerful nations scramble to secure simple face masks and enlist resources in disparate sectors to boost the production of ventilators. Governments mandate unprecedented changes in social behaviour to slow the spread of disease so that the finite resources of our hospitals are not overwhelmed. Temporary hospitals are being built in convention halls, parking lots and arenas. It is war, of a kind…
The Super-Hospital: A Billion Dollar Gambit
Until now, much of the modernized world has focused on investments in bigger and more technologically endowed hospitals. These buildings take advantage of economies of scale to deliver a little more care per dollar. They help more patients and caregivers access current tools and knowledge. They do this by concentrating more care into ever larger centres. It is not uncommon to see new hospital projects designed to house over 3000 inpatients and support over 50 operating rooms. In Canada, the past decade has seen ever larger hospital projects with several reaching 1000 beds and floor areas exceeding 200,000m2. These super-hospitals concentrate all forms of diagnostics and treatment under one roof – mothers and children, the elderly, mental health, cancer care, cardio-vascular care, the list goes on. They often include additional facilities for education and laboratories for research. To cater to the needs of large numbers of patients and families, not to mention staff complements in the many thousands, large healthcare facilities are equipped with small shopping malls and food courts. The critical mass offers a manifold of justifiable ancillary services and functions. These are our ‘billion-dollar’ gambits on the delivery of healthcare in the coming decades. Yet it is these vanguard facilities that are besieged by COVID-19.
The Vulnerability of Invincibility
The history of naval vessels tracks a similar slow progression towards larger and larger ships. For many centuries, warship design was limited by propulsion, the practical considerations of wood structures and the range and effectiveness of weaponry. In the 19th century this changed rapidly; first with the application of steam propulsion, then the development of iron hulls and improvements in artillery. Naval strategy revolved around the perceived effectiveness of ever larger ‘ships of the line’ – dreadnoughts and ultimately ‘battleships’. By the mid 20th century, modern navies had invested in the largest ever warships, reaching their climax with the Japanese ‘Yamato’ class battleships which exceeded 850’ in length, could reach 30mph and possessed 18” artillery – the largest ever fitted to a ship. Submarine warfare in WW1 foreshadowed the battleship’s unsuitability for its task. Battleships were too slow and their weaponry ill-adapted to a submerged enemy; their design was adapted in response. Then came another new threat – a small, quick assailant that could attack as a group with speed and stealth from all directions – the airplane. The seemingly invincible Yamato, like all its brethren, made for a very large target. One could argue that the battleship was the ‘billion dollar’ white elephant of the second world war. Many sailors aboard battleships in WW2 died, as did the battleship itself.
Like the unforeseen enemy of the battleship COVID-19, SARS, H1N1 and the next unnamed virus or resistant bacterial pathogen present a fundamentally different challenge to our healthcare system. Our ‘super-hospitals’ are akin to the battleship, packed with the best technologies, sitting low in the water, vulnerable from all sides. In fact, vulnerable to attack from pathogens carried by the very patients they seek to treat and the caregivers who treat them. A very large target indeed! Our emphasis on large singular hospitals places our healthcare systems at the mercy of attack from a nimble, stealthy and pervasive adversary.
The Naval School of Adaptability
At the risk of straining the parallel (and in the process testing its instructiveness), it may be interesting to reflect on how naval strategy responded to the rise of air power. The simple answer is that navies adopted aircraft and autonomous tools (like missiles and drones) together with stealth to replace overt force concentrated in large vessels. Most ships have become smaller, quicker and more focused in their functional roles. With less invested in each component of the strategy, it has given flexibility to add new pieces, adapt exiting ones and re-think inter-functionality on a fluid and ongoing basis as new challenges arise. Secondly, the rules of engagement have changed. Data on the objective and the value of surprise are fundamental. Battle is no longer a ship to ship broadside – it is carried out from great distances with detailed analysis and can be executed with tremendous precision. Of equal importance, this distributed strategy protects from reprisals. No one would argue that today’s great powers are somehow weaker than in the past for lack of battleships.
We are ready for a similar transformation in healthcare. More than ever, our expertise is mobile. Diagnostics can be performed anywhere. Most procedures can be done as day-treatments with no requirement for beds. When was the last time you met a radiologist or pathologist in person? Have you ever actually been in the same geographic location as the lab used to analyze your samples? The system already relies on data collected remotely and fed electronically. It just happens that this data is often moving around departments in a big building. It needn’t be this way. Collaboration is mainly virtual and often sequential among specialties. Technology allows many diagnostic tests to be done at home, at your primary caregiver’s office, or in distributed ambulatory care centres. Emerging services like the “One Minute Clinic” (an autonomous AI-driven kiosk equipped with diagnostic tools and a small pharmacy) currently deployed in Guangxi, China, allow engagement with the primary healthcare system to happen virtually anywhere.
Data-Driven, Resilient + Responsive
Battleship wisdom points to the healthcare system of the future being founded on a distributed network of physical and virtual infrastructure, closer to home. Facilities could be smaller, simpler and more nimble. Exceptional ones will be specialized for specific tasks and care. We will move from intermittent examinations to the use of technology to map trends where anomalies are flagged and scheduled for focused follow-up through a virtual consult or in-person exam. We won’t lose the ‘human touch’, we will just experience it differently. E-medicine will allow us to access all ranges of specialty care. Distributed networks and increased virtual access will strengthen our response to the next ‘COVID-19.’ Visits to venues of care could involve much less cross-exposure as smaller facilities will cater to smaller community units. Unaffected communities might be spared any impacts. Basic care may become completely personal and involve no contact whatsoever.
There is an intellectual laziness associated with doubling down on the next super-hospital – bigger than the last and kitted with better versions of tools and tech. My money isn’t on those majority voices, resistant to change and risk averse, that have prevailed throughout history, but rather on the pioneers, the innovators and from lessons that have repeated throughout history. In the same way that, by necessity, our front-line caregivers have adapted tools to fight COVID-19 and in the same way that large portions of our economy have shifted to new technology and re-defined norms of interaction and exchange, we can create a new, robust and eminently more effective healthcare system. The super-hospital can join the battleship as a curiosity of history and a lesson that big dinosaurs are indeed an evolutionary dead-end.
In the same way that, by necessity, our front-line caregivers have adapted tools to fight COVID-19 and in the same way that large portions of our economy have shifted to new technology and re-defined norms of interaction and exchange, we can create a new, robust and eminently more effective healthcare system.