Healthcare for the future

Nearly two-thirds of 10 common causes of hospital admissions could be treated at home by 2035.

Hospitals all over the world are facing growing demand for healthcare due to population ageing, increase in chronic pathologies, and prolonged life expectancy. That is why their capacity is getting more and more saturated and expenditure for healthcare continues to increase. Meanwhile governments are under continuous pressure to contain healthcare costs due to limited budgets.

It is no different in Malta.  Budget 2024 provided for a record-breaking €1.6 billion expenditure in the health field.  The projects in the pipeline include the imminent opening of the Vincent Moran Regional Health Centre in Paola at a cost of €40 million (of which 80% came from EU Funds); and work on the new outpatient facility at Mater Dei, which includes a new cardiac suite, at a cost of €170 million.  Then there is the announced new mental health hospital at a projected cost of €150 million, though this was promised five years ago and nobody really knows its fate.

On top of that, there was the statement by Health Minister Jo Etienne Abela that he believes that Malta needs a second national hospital to keep up with its growing population.  Abela believes the Gwardamangia area, that includes St Luke’s and Karin Grech hospitals, is ideally placed to serve that function, as part of a broader “health village”.  This would provide non-clinical services, including the medical school.  The announcement has already provoked controversy, not least because of the association with the fraudulent Vitals and Steward Health agreements on the site.

We have a healthcare problem

Do we have a healthcare problem?   Undoubtedly.  After the initial years of the Labour government installed in 2013, we witnessed great progress, not least by the near elimination of queues for tests and operations.  But now we are back to the bad old days, with long waiting tests and deteriorating conditions caused by the big increase in the population.

Also, consider that currently 19.3% of the population is aged 65 or older, a percentage that will rise to 22.5% in 2050 and further to 34.6% in 2075, according to Europol baseline projections.   Then consider that, according to the World Health Organisation, health spending per person accelerates after 60 in most developed countries.  Further, consider that, according to the Organisation for Economic Cooperation and Development (OECD), ageing tends to increase the dependency ratio and dampen the productivity growth that can help finance that spending.  And finally, note that the shortage of doctors and nurses in Malta   ̶   like in many other countries   ̶   has become an issue and could get even worse.

Life expectancy at birth in Malta is two years higher than the EU average and could rise even further, thus contributing to high health expenditure. Circulatory diseases and cancer accounted for more than half of all deaths in Malta in 2020.  On the other hand, the proportion of people with chronic conditions and activity limitations after age 65 is much lower in Malta than the EU average.

Behavioural and environmental risk factors account for one-third of all deaths   ̶   a proportion similar to the EU average (39.0%). Some 18% of all deaths were attributed to dietary risks (including low fruit and vegetable intake, and high sugar and salt consumption), while 16.0% of deaths related to tobacco smoking (including direct and second-hand smoking) – again proportions similar to the EU averages.  About 5.0% of all deaths were related to low physical activity, which is a much greater share than the EU average (2.0%). Air pollution in the form of fine particulate matter (PM2.5) and ozone exposure alone accounted for about 4.0% of deaths.

Compared to other EU countries, Malta’s share of spending on health in 2020 was about 10.7% of the GDP   ̶   similar to the EU’s.  But if one limits the spending to that of the Government, then the percentage of 67.0% is considerably lower than the 81.0% in the EU.  Health spending in Malta has grown at the highest rate in the EU in real terms over the last decade   ̶   from 5.4% in 2010-2011, it rose to 14.7% in 2018-19.  Nevertheless, per capita health expenditure was €3,055 in 2020   ̶   below the EU average of €3,719 for that year.

One of the great challenges our health system faces is that avoidable hospital admissions for ambulatory-sensitive conditions are among the highest in Europe. At 274 per 100,000 population in 2017 (the latest year for which data are available), admissions for asthma and chronic obstructive pulmonary disease (COPD) were above the EU average of 114 per 100,000 in 2021.

Reflecting the high preventable mortality rates for cardiovascular diseases and diabetes, avoidable admissions were also considerably higher than the averages for the EU countries with available data for chronic heart failure (429 per 100,000 population in Malta in 2017; 226 per 100.000 across the EU in 2021) and diabetes (226 per 100,000 in Malta in 2017; 105 per 100,000 across the EU in 2021).

What about home healthcare?

So, what do we need to do?  I am not an expert in health planning, but one trend from other countries that has come to my attention is that of home healthcare.  It is already being offered as an alternative to classical hospitalisation designed to shorten or avoid hospital stays by providing care to patients at home. It is claimed by practitioners to be comparable, in terms of nature and intensity, to the one delivered during a traditional hospitalisation. It has a double benefit: reducing costs for regional and national healthcare systems and increasing patients’ quality of life as they continue to live in a familiar environment.

There are two primary types of home healthcare.   One is medical care proper, which is provided by a medical professional such as a physician, registered nurse, or physical therapist. Services they could provide include wound care and physical, occupational, and speech therapy. Other potential services include patient and caregiver education, injections, and nutrition therapy. Medical home healthcare is prescribed by a doctor.  The other is non-medical care, where assistance is provided for activities of daily living   ̶   things like bathing, dressing, meal preparation, transportation to and from physician appointments, running errands, shopping, and housekeeping.

The rapid expansion of telehealth is proving that organisations can also deploy remote technologies quickly. Consumers and clinicians alike have grown more comfortable with virtual care, which is even more sophisticated than normal home healthcare. 

Virtual health consists of digital tools and software programmes for a healthcare service provider to improve patient care quality and can be accessed through digital devices such as smartphones, tablets, laptops, or desktop computers. It also provides a bridge between patients and physicians regardless of their geographic location. Consumers can video-chat with a physician or specialist instead of physically going to the doctor’s office.

The market for digital health in Europe was estimated to be worth $45.3 billion in 2022 and is anticipated to increase at a compound annual rate of 16% in the next three years, reaching $80.4 billion by 2027.  The UK and France are the top two investors in health tech products.

Clinicians say virtual care will be more common than in-person visits by 2027. The consultancy firm Oliver Wyman predicts point-of-care devices and at-home testing kits will provide quick and accurate results for a wide range of conditions. Patients will be able to conduct the basics of a physical exam at home using thermometers, otoscopes, stethoscopes, and scales that send real-time information to care teams via an app.  Oliver Wyman projects that, on average, nearly two-thirds of 10 common causes of hospital admissions could be treated at home by 2035.

Several factors may increase the complexity of home care, such as the nature of the delivered care; the number, needs, and diversity of assisted patients; resource synchronisation and skill requirements; and the supply of necessary devices and materials.

What is also driving the demand for home healthcare is that some research suggests nearly 90% of people over 65 want to age in place   ̶   to live at home as long as possible.  But to make it happen, additional care is often necessary, which is why some families turn to home health care services.

The challenges of virtual healthcare

Healthcare providers   ̶   both public and private  ̶  are moving to address the challenges of virtual health.  They are embracing artificial intelligence (AI) and other digital tools to sharpen how diseases are diagnosed and treated, use remote technologies to treat more patients at home rather than in hospitals, and lean into consumers’ desire to play a bigger role in their own health decisions, among other things.

Generative AI, meanwhile, can streamline some of the bureaucracy and paperwork that drives up the cost of healthcare. With smart implementation, organisations can automate tasks such as obtaining prior authorisations for treatment, developing care plans, and ordering consultations based on fresh assessments. Such gains could help fill the gaps of an ageing healthcare workforce.  According to some estimates, Generative AI could save doctors up to three hours a day by 2030 and enable them to serve an additional 500 million patients.

Our Health Ministry already has a telemedicine service running, but my understanding of it is that it is pretty basic.  There is no doubt that the challenges of healthcare in the future can only be adequately met if we join other countries in developing virtual medicine and home healthcare.

Photo: Getty Images

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