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  • Writer's pictureNick Keppel-Palmer

When healthcare is a business....

Updated: Apr 23

The NHS is amazing - but it's not at all normal

I've worked a lot on healthcare over the years. The strategic challenges are complex and meaningful. How to de-stigmatise mental disorders? (Both in the public sphere and within healthcare profession). How to encourage medical students to join the less sexy branches (i.e. not become a surgeon)? How to introduce patient choice into a system where the doctor has always been head honcho.

The role of 'brand' in healthcare is both fascinating and wide ranging. Public discourse on health is shifting all the time, not least because we are all living a lot longer. The pressures on the system are vastly different from those of say 70 years ago - when the health service was pretty much a "stop people dying" service. Polio, smallpox, tuberculosis, diptheria, tetanus, whooping cough, measles, mumps, rubella - and many more - were rife. It is surely a major achievement that for most of us these diseases are no longer a major worry.

Brands in health systems are crucial for shaping how people think not just about their health, but the health of the entire population. With an ageing population expenditure on healthcare has to go up steadily in order to maintain even some kind of status quo in provision.

And of course brands also play a crucial role - or should - on how the people who work in health systems feel about the profession. This - more than most - is a calling not just any job. That vocational pull means staff are inclined to work inhuman hours, often for little money, because they feel it's important.

But now something has broken in the system. We have strikes amongst people who really never want to strike - nurses, ambulance drivers - the people in the frontline.

This isn't just about pay and conditions, it's about whether we value this free-at-the-point-of-delivery health system enough to see the value in continual investment to keep pace with the plethora of new "living longer but necessarily well" health needs.

Healthcare as a business

I spent a lot of 2022 in Georgia working on healthcare. Georgia is interesting in itself given the shadow cast by the Ukraine war, but in a health context you couldn't get further from the NHS model.

It is a different world. We have no idea how lucky we are in the UK to have such a thing as the NHS.

At first contact you would find all the fears that most Brits have about the business-ification of health realised. Dropdown menus and productisation are rife. Everything costs money and you don't get to see anyone until you've paid.

Dig a little deeper and the picture gets even more interesting.

Too many doctors, not enough nurses.

First up, there are loads of doctors. Way, way too many doctors. In a country which should need maybe 12,000 doctors the system was planned around 45,000. This is a legacy of the Soviet era, during which it was assumed that Georgia would be a hotspot should there ever be a conflict with Nato. So the capacity uplift was built for a war that - so far - didn't come.

As a result there are many pretty large scale hospitals dotted around, with low occupancy, and doctors actually competing for patients. That's right - doctors are kind of celebrities (some are anyway) and have their own media profiles. A big hitter doctor can bring a lot of patients with him (normally him) so hospitals compete to attract these 'superstars' as they bring revenue.

There are hardly any nurses. And the profession is so badly paid (not to mention undervalued generally in society) most capable women (normally women) head off to become nannies abroad. (This causes its own social ills - a lot of kids being not-very-well brought up by the husband who stays at home (if they are lucky) whilst their mother is abroad).

Zero trust

One impact of hospitals competing for patients is that there is a lot of advertising of different doctors and services, including (which I still can't get my head around) certain procedures "on discount" for this month only.

When the health system is after you for your money, Georgians (never the most trusting of institutions in the first place) are rightly suspicious. This has two consequences - one is that nobody goes to the doctor until it is an absolute necessity (i.e. you are near death) and second that for the most part you go to someone you know or who your family knows - your cousin. In a country where there are way too many doctors, everyone knows a doctor.

Georgians aren't healthy

This exacerbates the problem that - for the most part - Georgians aren't very health conscious. Tbilisi has astounding traffic, nobody walks anywhere and I haven't seen anyone on a bike, ever. There is a lot of heart disease and also - unsurprising in an economy with no social safety nets at all - a lot of hypertension.

There is no culture of "check up". You don't go to the doctor until you absolutely have to. There's really no functioning primary care system aside from the polyclinics that are a legacy of Soviet times, themselves a business.

It's an unintegrated, highly fragmented, completely opaque, lottery.

It is the spectre of such a commodified health system that lies at the heart of the UK strikes. The vision of what could be.

And yet - barring a couple of specific Georgian idiosyncrasies - health as a business is the norm

Business is fundamental to health (in most places)

Most countries don't have an NHS, and could never afford one if they started now. In Georgia at least, and in most other places where the state provision is non existent or inadequate, the only game in town are health businesses. My client was the biggest health business in Georgia, maybe 20-25% of the totality.

Following the collapse of the Soviet Union healthcare was disorganised for a couple of decades before some semblance of state support came in through insurance schemes in the early 2010s. But these schemes were not universal and funding for them has been frozen since 2013, so in reality state funding of healthcare - such as it is - has been in real terms decline more or less ever since it started.

Which means all of the legwork for developing the system, all of the educational provision, all of the training, all of the infrastructure, all the long term planning falls on the shoulders of the businesses.

This is really uncomfortable. The first thing that the first hospital director I met said to me was:

"I have never got used to the idea that healthcare can be a business"

For the vast majority of vocational, purpose driven, people working in healthcare the idea that it is a "business" is disquieting. Sometimes the influences of "business" insinuate the fundamentals of "health" - when "patients" become "customers" something is wrong.

But.....there is no way that the health system in Georgia is going to improve unless business gets sufficiently organised to invest in its future. Business - the profits from business - are fundamental to the future of healthcare.

This was the heart of the brand shift that was needed - an inversion of the normal fear about business in health.

Instead of thinking about the health system being squeezed for profits, thinking that a healthy commercial enterprise was critical to investing in healthcare.

Subordinating business to health and for health, not subordinating health to business.

Purpose: the power of business in healthcare

There's no doubt that in the Georgian system there are a bunch of people operating who are in it only for the money. But as the sector evolves there is a consolidation towards a small number of significant players whose interests align with those of the population.

This was demonstrated in no small degree by the Covid response that was driven by the business. Only they had the resources, the speed, the sense of purpose and the 'togetherness' to mobilise a response to the pandemic that spanned the country.

Only a business in healthcare had the ability to act universally and for the social good.

This was a demonstration of a way of working that really was the power of business in healthcare - not for profiteering but for getting good things done, fast. It has had a profound impact on the identity of the organisation - it has shown them who they really are.

The trick that's needed to do that for the long term is embedding that universal purpose into the organisation in such a way that the business side and the care side feel integrated and symbiotic. That requires crystal clarity on the difference between customers and patients, and also the ability to develop revenue streams that "pay for" the general provision.

What's fascinating, and why I love healthcare as a strategic challenge, is that the world of "healthcare" offers lots of opportunities to develop revenue streams (cosmetic surgery for example) which can fund "disease fighting" and "disease prevention" provision. The new business will emerge during 2023.

The whole experience has changed some of what I think about healthcare in the UK. We're incredibly lucky to have an NHS, but maybe we shouldn't be so scared about "business in healthcare", after all.

That said, give the flipping nurses the pay rise they deserve.


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