Healthcare does not simply equate to hospitals

Imperial College, London, UK Email: p.howitt@imperial.ac. uk The future of healthcare is not, principally, about the hospital. The future is with primary healthcare in the management of chronic disease or, even better, in public health and a drive to reduce the incidence of those diseases. Suzanne Robertson-Malt’s excellent editorial in this edition of Avicenna, sets out the challenge clearly. The Gulf Cooperation Council (GCC) countries rightly aspire to world-class healthcare, but they are in danger of becoming the world leaders in a less desirable area--the prevalence of chronic disease. It may seem strange for one of the authors, as a colorectal surgeon, to be emphasising the importance of primary healthcare and prevention. Yet the evidence is clear that the burden of disease across the world is shifting to chronic disease. Already the majority of global deaths--60% in 2005-are caused by chronic disease [1]. Amongst the relatively affluent GCC states this figure rises further; in Oman, for instance, 75% of deaths are due to non-communicable diseases [2]. Nor is it just deaths that will be driven by chronic disease. It is projected that the two leading contributors to disability-adjusted life years (DALYs) in 2020 will be chronic diseases (heart disease and depression) [3]. Chronic disease should be prevented where possible and managed effectively in the community when it does occur. Hospital treatment of chronic disease--such as emergency amputations carried out on diabetic patients--must be the last resort. However, currently there is a danger that the development of GCC healthcare repeats the experience of Europe, North America and Australasia, where spending has been focussed where it has least impact on the health of the population, as illustrated in Fig. 1. There is no reason why the GCC countries need to repeat the mistakes of Western healthcare systems. Yet to avoid them, there needs to be a fundamental reprioritisation of investment so that healthcare spending is not focused on the construction of huge hospitals. Money would be better spent on state of the art primary care facilities close to where people live. These new facilities need to be staffed by dedicated primary care physicians. Family medicine physicians in the US and General Practitioners in the UK are highly respected doctors whose specialism is recognised. They are also well rewarded financially---In 2007/08 the mean income for a general practitioner in the UK was just under UKP 100,000 compared with a newly qualified hospital consultant who earned just over UKP 70,000 [4]. The status and financial rewards help to ensure that some of the very best medical students go into primary care. Alongside the establishment of an effective primary care system, it is vital that public health and disease prevention are well resourced. Increasing exercise, decreasing obesity, eating a healthy diet and stopping smoking are lifestyle changes that reduce people’s risks of a multitude of chronic disease. The World Health Organisation estimates that if these lifestyle issues were addressed, 80% of heart disease, stroke and type 2 diabetes could be prevented [5]. If lifestyles can be influenced and if primary care can be fully established, then GCC countries will have a sustainable health system. This is not a threat to hospitals, but an opportunity. Instead of dealing with patients who do not need to be there--such as the majority of the 1,500 attendees at Hamad General Hospital’s Emergency Department in Doha--they will be freed up to focus on providing the specialist care to those most in need; the road traffic accident victim suffering multiple trauma or the stroke patient needing rapid CT scan and thrombolysis.