Joyously replete with war stories lost and won, Lönnberg, a combative diabetic and social democratic politician has spent the past thirty years fighting for change in health care. Roles included the national coordinator for Life Science issues. He was also a political expert in the Ministry of Social Affairs 1983–1987 and Secretary of State 1987–1990 as well as a Stockholm county councillor for 25 years. So what has he learnt about how health care works? And what is the solution?
A fairly unfit 65, Lonnberg has embraced the idea of moving fast and breaking things. Although he admits that he rarely got the chance to do either in his 40 years stint in health care.
He loves the advent of digital health. “Doctors have lost the knowledge monopoly and they are finally having to accept technical change. Look at telehealth in Sweden. In three years it has reduced the cost of a doctor visit from 2,500 SEK to 500 SEK. Three years ago we had 15,000 doctor visits through telehealth and I forecast that within three years telehealth in all its forms would make up a majority. And it has happened. That is incredible.”
I suggest the Swedish system is good and he snorts. “In a year the average doctor sees 705 patients against an average of 2,145 a year in Europe. Productivity is low but medical quality is high.” That is partly why he was behind the push to enable any doctor to set up a for-profit primary care unit in Stockholm, a move which saw huge improvements in access and availability.
He is alive to the problems of pushing through reform and illustrates this with a hundred anecdotes such as this:
“A decade ago someone came up with digital spirometer for COPD patients. They blow down a straw and the results go straight to the hospital. So the patients don’t need to visit the day clinic. You can see exacerbation within 2-4 days and so save three-week hospital trips which cost €30,000.
The patients were mostly older men, smokers who like beer and football and don’t like nurses, so we got nurses to call them every day and they started blowing down the straws to get rid of the bloody nurses. Adherence rose from 9pc to 32pc.
So then we asked all the lung units these guys used to visit to implement digital. None of them did. We did some digging and there were three reasons:
- The clinics were paid per patient visit. We said ‘OK you can have a separate price for the digital patients’ and they said that was too complicated. I said: ‘your local grocer handles thousands of prices, why do you think two is too difficult?’
- If it works, staff could drop from 120 to 80 in each clinic. That shows that treatment accords to budgets, not patients needs. The clinics just saw a lot of problems: union negotiations, media reporting cuts rather than higher efficiency etc
- You will damage my status which depends on how many people the clinic employs.”
So what happened?
“Nothing. Stockholm still hasn’t adopted digital spirometers. We lost.”
Unsurprisingly, he remains profoundly sceptical about much of the medical profession and health care institutions. “When people talk about patient-centric health they are talking bullshit. Healthcare is always budget-centric.”
“I asked the heads of 89 clinics whether they worked out their budgets. and it was all about whether it should be a 2% rise or 4%. There was no discussion around the budget about what new methods they were introducing or how they were going to measure improvements. Stockholm has 40 foot amputations for diabetics every year. You could set a goal of zero. But nobody does.”
Enough of the negative, Anders! What then is the answer?
For Lonnberg, it is embracing data in all its forms and nuances and then following a policy of gradual year-by-year improvement.
This should be pragmatic. “Patients and health care systems can’t afford to wait 10 or 15 years to see if a particular course of action works.”
He is alive to just how stupid most of the data in the healthcare system is. “I’m a diabetic and there have been tonnes of clinical trials on diabetes. Almost all of them stipulate that the patient should be suffering only from diabetes. In other words, they eradicate 90pc of all diabetic patients. And then they base science on that. It is mad. 80% of the costs of treating diabetes are in treating the complications, not the core condition!
He says that you need to look at data very widely. “We had some diabetic treatments which were aggressively lowering HD1C and measuring outcomes based on that. And then we noticed an increase in traffic accidents because diabetics were going into hypoglycemia.”
So you need to look very widely for your data. You need to agree on a set of values which will lower incidences year on year and then you have to track it in real terms to see if it has that effect.”
“It is a social game. You have to make deals. The value chain in healthcare look like this: make deadly diseases into chronic diseases and then move them to acute diseases and then move them to prevention.”
He is also angry that it takes so long for research to become practice. “I was at a conference recently of diabetic doctors and there is some recent research showing that diabetes 2 is five conditions, not one. So I said ‘You are mistreating 80pc of all patients, aren’t you.’ They didn’t like that much.”
He recognises the importance of payment methods. “15 years ago in Stockholm, it was more profitable to operate on the wrong hip because the outcomes would be better and then you got to operate on the other hip. Then we launched DRG plus where the operator was paid extra depending upon patient recorded outcomes and had to fix errors in the first 24 months. Suddenly prices fell 40pc and quality rose 28%.”
But he agrees that using value health on complex co-morbidities is too complex. “Michael Porters value-based healthcare is trivial, of course, we should base improvement on patient outcomes rather than budget outcomes.
He is also a big advocate of patient power. “More staff! That is always the answer in a health care system. But it isn’t. What a new diabetic needs isn’t a nurse but a mentor, the person who got what they have now five years ago.”
“Health care is better and more efficient if it is run by patients. So is medtech. Many new inventions come from parents of patients.”
Stockholm has done this with skin ailments like psoriasis. “We put the patients in charge and gave them their own facility where they distribute the lotion. It is five times cheaper and ten times better. We’ve measured it.”
He also points to rheumatology as an example of patient and doctor working together more closely. Today the patient can log their experience and symptoms online before seeing the doctor thus integrating patient and medical data and leading to better joint decisions.
Like many Swedish Social Democrats, he is agnostic about the for-profit sector. He sees it as an innovator but he doesn’t like doctors splitting their time between the public and private sectors as this creates false incentives. Nor does he like legal tax avoidance involving artificial debt and exotic offshore owners.
He thinks the argument that longer, better lives will cost less or create economic benefits is false. The better prevention the longer and better life: but you also live many more years with disease. So it is a paradox: more and better prevention also leads to the need for more healthcare later in life. It is good in itself, but can never be a way to finance healthcare
“When I started a quarter of the population had a chronic disease, now it is 50%, that is a great human success, but it has to be financed.” He adds: Longer lives will cost more. To avoid that you have to increase the retirement age that is the biggest economic benefit that is achievable. People have this view that disease affects the young. It doesn’t. 80% of healthcare costs are related to the elderly and that will cost more.”We would welcome your thoughts on this story. Email your views to Max Hotopf or call 0207 183 3779.