Numerous perspectives on the future of Dutch healthcare have already been published, focusing on topics such as Artificial Intelligence (AI), Virtual Health(care), digital transformation, data interoperability and ’the right care in the right place’.
However, many of the parties involved still seem to struggle with the challenge of bridging the gap between inspiring visions for the potential long-term health(care) landscape and the concrete priorities for the coming years.
I've co-authored this article with John Luijs and Mathieu van Bergen, both partners at Deloitte NL in Life Science and Health, with the help of a lot of others, scroll down to payoff. If this long read is to much for you, you can download a PDF version over here in both English and Dutch.
In this article we aim to add value to the debate on the future of health in the Netherlands in five ways. We start by describing the ‘case for change’ and why, as Dutch society, we can, want and must improve healthcare. We then provide greater focus and coherence to the many and diverse future developments by clustering them in five major shifts. We describe the resulting new health ecosystem and its consequences for traditional and new healthcare providers. We discuss the pace of these changes and the role of COVID-19 as a catalyst. Finally, we attempt to translate this future vision into concrete next steps for the year ahead.
Despite some uncertainty about the shape of the future healthcare and the pace of the shifts described here, there does seem to be clarity with respect to the direction and contours of the changes. Taking the right actions at the right time will offer huge potential and enable leaders to make a significant contribution to even better healthcare in the future.
This article is the first in a Deloitte series on ‘The health(care) future of the Netherlands’, which presents the main themes involved. In subsequent articles, we will elaborate on these themes in more detail, together with the leading parties in the health ecosystem of the future.
What we want to achieve for health in the Netherlands: the four main objectives
Any discussion about possible healthcare improvements must be based on the desired objective. We follow the ‘Quadruple Aim’ in this. The first three objectives (the Triple Aim) are to improve public health, enhance the quality for individual patients and keep per capita healthcare costs affordable. The fourth objective is to reduce the workload and increase job satisfaction for the (increasingly scarce) healthcare professionals who play such a key role in achieving the first three objectives.
Here it is important to note that optimising public health involves more than simply looking after patients. It starts with a healthy lifestyle and prevention of diseases in the population as a whole. It is then followed by the curative aspects of patient diagnosis, treatment and aftercare.
Our current healthcare ecosystem: four types of players, emphasising healthcare for patients
Our current Dutch healthcare ecosystem is still largely a system aimed at healthcare rather than health. A key element is the timely and correct diagnosis of a patient and offering the right treatment, followed by appropriate aftercare and medication at home. Lifestyle and prevention are obviously considered but most resources (time, money and attention) are assigned to interventions and aftercare.
The main players in this healthcare ecosystem therefore focus on healthcare for the patient. We divide them into four categories (the examples per category are a selection and therefore not exhaustive):
Why we can, want and must improve healthcare in the Netherlands. There are three driving forces of change in healthcare. These are technological trends, consumer behaviour trends and demographic & economic trends. To put it more simply: we can, want and must improve Dutch healthcare.
We can improve healthcare, in terms of both costs and quality:
We want to improve healthcare and achieve a better user experience and quality:
We must improve healthcare and provide more effective solutions
It is difficult to predict what the healthcare landscape will look like in the future or when the changes will occur. However, the direction of the changes seems clear. In any event, we believe that five major shifts must be taken into account.
The five shifts will result in a new health ecosystem that is no longer primarily focused on patient healthcare but on improving the health of the population. The four traditional healthcare parties will continue to be part of this ecosystem, but in a different form and role. New entrants will supplement the ‘healthcare chain’, mainly focused on value creation based on personalised health data. This will generate insights into the improvement of wellness, vitality and prevention and will enable them to facilitate Virtual Health(care) solutions. New alliances will emerge between these new and existing parties, with health data being an important binding factor.
New entrants in the health ecosystem: responding to the five shifts. New players in the health ecosystem will respond to the five shifts. They will focus on data and platforms, for example data gathering (collection, connection and security), data analysis, translating analyses in terms of personalised interventions and the necessary underlying infrastructure for data platforms. New entrants will also focus on new solutions relating to vitality and wellness and on secondary prevention with respect to chronic patients through lifestyle interventions (diet and exercise), monitoring and improving compliance with therapy. Further solutions for offering and facilitating Virtual Health(care) will also attract investment.
Some major tech parties from outside the healthcare sector are typical foreign examples of entrants to the new health ecosystem: Google, Apple, Amazon and Microsoft. Retailers like Walmart are also investing in healthcare, as are financial parties like Berkshire Hathaway and JP Morgan Chase (in combination with Amazon).
After an initial orientation, we expect leading Dutch companies in the food industry, retail, financial services and telecoms to redouble their efforts to carve out a role for themselves in the new health ecosystem. Alliances with existing parties will be a key success factor here. They will not replace the existing parties but collaborate with them.
Besides the big established companies from other industries which will focus more on healthcare, we expect strong growth in start-ups aimed at healthcare and scale-ups in the health data value chain, particularly in areas like AI.
Traditional healthcare parties: changes in role and form. The existing parties in the health ecosystem will partially adopt a new form and role in the new system. Below we will discuss some initial examples.
Hospitals will take on a different role in the regions. Due to successful prevention, early diagnosis and insights into appropriate care (“Zinnige Zorg”), a significant part of the current care they provide will no longer be required. Some care will still be provided, but in virtual form, so outside the hospital or at other locations in the regions, such as in primary care or long term care institutions. Acute and complex care will be divided among the hospitals in a region, creating more distinctive ‘Centres of Excellence’. Medical staff, including doctors and nursing staff, will be less bound to the physical location of the hospital and their roles will change in response to the growing use of robotisation and AI. This will have a major impact on portfolio choices, infrastructure decisions and discussions about financial stability and business models. Hospitals must also consider the value of the data they generate, how they can valorise this data and with which partners.
Residential care, nursing homes and home care providers will take up some of the volume from the hospitals, requiring close collaboration with these hospitals. Ageing will pose the greatest challenge to these providers in terms of providing long-term complex healthcare despite scarce human resources. They will therefore put more emphasis on implementing major digital transformations. The accelerated introduction of digital healthcare will generate greater demand for more extensive digital capabilities to keep pace with technological changes, both now and in the future.
Primary care providers will start to focus more on prevention, with respect to both physical and mental health. With all the new technological possibilities, the role of GPs could move further towards that of ‘case managers’ for their patients, who can also act as guides to help patients through the many possibilities. Based on a good overview and insight into the data, GPs will also be able to create an even more personalised approach, together with their patients.
Health insurers will play a crucial role in forming a regional vision: the ‘right care in the right place’ in the region, including the shift towards Virtual Health(care). Based on this vision, the funding will be designed to facilitate and support healthcare providers in this transformation. Working with other parties in the ecosystem, they will also use their data more often to improve vitality, prevention and early diagnosis.
For pharmaceutical companies different considerations apply to the local affiliates in the Netherlands than to global headoffices. As our focus is on the future of healthcare in the Netherlands, we explore the role that the local affiliates could play in this. Their main ambition will be to act as partners for hospitals and insurers to facilitate the right care at the right place in their therapeutic focus areas. They will contribute to a healthy population (beyond just providing the medication) by concentrating on lifestyle interventions and education, and investing in prevention, faster recovery and better treatment outcomes. They will also promote value-based healthcare by optimising diagnoses based on testing for a more efficient use of medication for the right type of patient (personalised medicine).
The main issue for the government is how it can play a cohesive, stimulating and facilitating role to ensure that the various stakeholders in the healthcare system can create value together. The top priority here is to amend obstructive regulations, for example relating to data exchange.
New ecosystem alliances: value creation and distribution. Interesting alliances will arise between the new and traditional parties in the ecosystem. New parties bring specific knowledge of data analysis and perhaps large investment budgets. Existing parties provide healthcare knowledge and enjoy the trust of the ‘healthcare consumer’. Recent examples of alliances include Google and health insurer Oscar, or Walmart and health insurer Humana. Many of these alliances are based on creating value by combining and analysing datasets and converting these into interventions that save costs or improve quality and the user experience.
A successful alliance starts by identifying the individual ambitions and knowledge of the parties. In which areas of the healthcare chain can and do we want to add societal value: by improving public health, the quality for patients and/or the costs of healthcare? Or by reducing stress and improving job satisfaction among healthcare professionals? Which part of this societal value can we retain and where does it come from? In other words, who pays for the value-added solution that we offer?
The next question is how collaboration with an ecosystem partner adds value. Which value do the parties bring and where do the synergies lie? How do we distribute the value that the coalition itself can retain? And how do we ensure a balanced division of the investments and risks?
In discussing what can and must be improved, it is easy to underestimate the results already achieved by the various healthcare parties. Hospitals have made substantial investments in measuring and improving quality. Health insurers have played an important role in targeting higher quality at lower costs and in stimulating efficent care. The pharmaceutical industry has developed medicines that have saved, prolonged and improved many lives. Cooperation in the healthcare chain has also improved in many fields (e.g. in relation to diabetes and COPD) and there are many technological innovations making remote healthcare easier and more accessible.
Nevertheless, many challenges have not been sufficiently overcome yet. The financial pressure on the system is still growing and hospitals are struggling to find sustainable business models and achieve structural financial stability. Developments in prevention, the right care in the right place and digital innovation tend to represent a financial threat rather than an opportunity. There is a shortage of healthcare staff and their workload continues to grow. Innovations (like the provision of remote healthcare) and regional cooperation often shows only slow progress. The right approach, incentives and direction, for example, are still often hard to find. The various ecosystem parties such as health insurers, hospitals and pharmaceutical companies often end up in ‘zero sum’ discussions on prices and do not always manage to create added value together. Meanwhile, people who need healthcare still too often experience our supply-driven system as a bastion of user-unfriendliness, with limited access to information and inefficient logistics.
The healthcare system is sometimes resistant to change, perhaps more so than other sectors. How can we explain this and how do we break through it? And what impact will COVID-19 have, as a potential catalyst of the five major shifts?
Overcoming obstacles to change. To understand why healthcare changes are not always implemented, or not in a timely manner, it is useful to return to the factors of ‘can, want and must’. Even if we can, want and must do something at system level, this may not apply to all the individual stakeholders involved.
To begin with ‘can’: many healthcare professionals still find it difficult to use all the various technological improvements. With an already high workload, they may not always feel they have the time or opportunity to learn about them, deviate from existing methods or experiment with new ones. The capacity and execution power for change is also often limited in healthcare organisations.
The second challenge is ‘want’. A good example is prevention. Improvements in health and cost savings clearly create value for the society. So as an overall system, we do want this. But for the hospitals and the individual medical specialists, prevention is often not an advantage but a disadvantage in financial terms. They lose revenue and receive no returns for this. This is not to say that they do not make any efforts in this direction, because the societal objectives may outweigh the financial disadvantages for them. However, it is important to be aware that this is certainly not always a win-win situation.
This brings us to ‘must’. With fundamental changes, it is not always possible to satisfy everyone. In many cases, embarking on a change process with unanimous consent is a utopian dream. If a majority wants something but a minority does not, a breakthrough can be forced because this is a ‘want’ for the majority and a ‘must’ for the minority. Leaders, such as hospital boards, must weigh up the advantages and disadvantages for the different groups, reaching the right decision for the collective. In healthcare, they do not always appear to have been given that mandate or are not using it as individual doctors have substantial obstructive power.
What is needed to overcome such resistance? For the ‘can’, it is important to invest in the right infrastructure, tooling and training. For the ‘want’, it is important to create and communicate a clear vision on value creation and distribution. The government and insurers and the way they design the funding play a major role here. For the ‘must’, it is important that the leadership teams of the various healthcare parties really demonstrate leadership. The business and medical leaders must join forces to do the right thing for their institutions and the populations that they care for and not be held back by the resistance of a small minority.
The role of COVID-19 as a catalyst. Despite the major short-term impact of the COVID-19 pandemic on our healthcare system (2020 and 2021), we do not expect it to add a significant long-term shift to the five shifts discussed in the preceding chapters. Much of the impact will be temporary (12 to 18 months) until a vaccine is available for the most vulnerable groups, the gap created by delayed healthcare has been closed and the financial damage is divided across the chain.
The main question then is which shifts will be accelerated by COVID-19 and which will be delayed. We mainly expect the COVID-19 pandemic to have an accelerating impact on Virtual Health(care). This drove the rise in phone- and video-consultations, as well as the adoption of remote testing and diagnosis and data analysis generated by coronavirus apps. A small reversal will follow when physical appointments are possible again. A virtual consultation is not always a good alternative to a physical appointment, for example if an explanation of a complicated diagnosis or treatment is needed.
Meanwhile the logistical and cost benefits are evident and some factors slowing the adoption (such as resistance from doctors and financial fees) will remain lower. We do expect hospitals and other parties in the healthcare ecosystem to seize the momentum for Virtual Health(care). They will do this firstly by creating a sequence: which types of care processes and patient groups qualify first for a shift towards Virtual Health(care)? Secondly, investments will also be required in the right technological infrastructure and appropriate training of medical professionals to enable them to use these technologies properly. Good structural agreements on a sustainable business model must also be reached with health insurers and capacity planning must be tailored accordingly.
A frequently heard statement by healthcare professionals is that the Virtual Health(care) ‘genie is now truly out of the bottle’ as a result of the COVID-19 pandemic. If this is true, it is one of the most positive changes that will emerge from this serious crisis.
It is important for leaders in the current healthcare ecosystem and leaders of companies wishing to play a role in the health ecosystem of the future to develop a strategic vision of future Dutch health(care) and of the role that their organisations can and want to play in this. Of course, it is also possible to wait and see what the future brings. However, to play a leading role and keep control over our own future, it is important to anticipate the shifts described in this article now.
Firstly, this means developing their vision of how the health requirements will change in the coming years for the specific population (e.g. the population of a region, or specific groups of patients or healthcare consumers) on which the organisation is focusing. Which needs will increase and which will diminish? What is the best way and the best location to meet those needs, given the developments in Virtual Health(care), value-driven healthcare, data-driven personalised interventions, and a growing focus on prevention and early diagnosis? What role will our own organisation then play in that network of care (and healthcare) providers around the individual? How do we become a leading, excellent party in that role? What are our specialist fields and skills? Who are the best partners to work with in these fields, what value is created with those partnerships and how should that value be divided? What does this all mean for our investments in infrastructure and employees? How do we ensure a sustainable business model that is consistent with this future vision? How do we ensure that all internal stakeholders are on board and that as an organisation, we have a shared vision of what we can, want and must do in relation to the future?
We hope that this article has helped by providing an initial overview and hence a mirror for the future vision based on how the various players now operate and a good basis for the continued evolution of that vision. We would be happy to embark on a dialogue to elaborate on that future vision and make it more concrete together.
As we mentioned, this article is the first in a Deloitte series about the health(care) future of the Netherlands. Subsequent articles will develop these themes in more detail, together with leading parties in the health ecosystem of the future.
Deloitte wants to play an active role in the health ecosystem and to strengthen and accelerate the improvements described in this article. We will do this through multiple events: hackathons, roundtable discussions and C-level dialogues. The aim is to bring together the various parties in the new health ecosystem and explore which alliances can create value.
We look forward to an interesting journey together towards the health(care) future of the Netherlands.
We are more than happy to start a conversation with you, supported by this visual, about what you can, want and must do to improve.
John Luijs, Mathieu van Bergen and Lucien Engelen
This article would not have been possible without the help of with the help of many others like Nicole Lentink , Marly Kiewik, Matthijs Boom, Merik Seven, Rogier van Hulten, Martijn Ludwig and Bastiaan Walenkamp)
It is at the intersection of technology and patient empowerment, which is where Lucien Engelen (1962), director of the Radboud University Nijmegen Medical Centre REshape Center and advisor to the Board of Directors (since 2007) feels most at home. The two worlds combined into the Radboud University Nijmegen Medical Centre and Singularity University in Silicon Valley & the Netherlands and in the Nordics, his modus operandi is always challenging, sometimes provocative but always techno-realistic. Writing on a new book that will be titled "Augmented Health(care)™ : The end of the beginning" (May 2018, Barcelone Spain) as he thinks we're at the end of an era of creating awareness, pilots, proof of concepts etc in the digital transformation of health(care). More on that on, his Linkedin Page has over 750.000 followers. He is Faculty Global Health(care) & Medecine since 2011 at Singularity University's Exponential Medicine in the US and in the Netherlands.