Dr Erica Whineray Kell

Investment in clicks not bricks is key to New Zealand in overcoming health sector challenges

Friday , 17 May 2024 by Dr. Erica Whineray Kelly

Southern Cross Healthcare’s Chief Medical Officer Dr. Erica Whineray Kelly, a breast cancer surgeon, doctor and women’s health advocate, writes of challenges in the New Zealand health sector including in biological sex and ethnicity, and the role that technology plays in helping to overcome them. These views are her own.

The World Health Organisation’s (WHO) definition of health; being the ability to adapt and self-manage in the face of social, physical and emotional challenges.

What a challenge we have to reach this goal. Health is much bigger than the individual, and much bigger than the legacy system of hospitals, medical clinics, pharmacy, and allied health. Health is where we live, work, play, pray, shop and learn.

It won’t come as a surprise to those of us who work in the health sector, but medical care obtained through health services alone is estimated to account for just 10 to 20 per cent of a person’s health outcome.

The rest, 80 to 90 per cent, is determined by social and commercial factors.

Social factors include housing, education, clear air and drinking water, food, employment, income, family situations and the community you live contributing to 50 per cent of health outcomes while the rest, 30 to 40 percent, are commercial determinants, that is, private industry that impacts health, often by large multinational commercial entities, and often negatively. If we consider that, then the health system alone cannot ‘fix’ health.

So many of the social factors are determined by the public allocation of resources. And what we know from OECD data, is that life expectancy correlates with the percentage of the GDP allocated to social spending and not healthcare spending. This is seen best if you look at the US: the highest per capita health spend and lowest social spend, they are the first generation in the history of civilisation where the life expectancy of the next generation is lower. It has dropped 7.5 years and this impacts everyone, wealth is not protective so the wealthiest American will have a similar life expectancy to the poorest Continental European. Equity is good for all.

Not only is there a problem with equity according to ethnicity, but there is also a health gap for women. By women, I mean wāhine plus: cisgender women, transgender and non-binary individuals, and others whose healthcare needs relate to those of cisgender women. Women live longer but they are unwell or disabled for more of their life. In diseases that are shared with men, women do worse. Women are 50 per cent more likely to die from an acute cardiac event than men, women will be slower to receive analgesia in emergency departments and the dose will be smaller. If you compare Aotearoa’s excess cancer deaths to Australia, there are three times more for women than men.

Why is this? For decades women were excluded from clinical trials and research as it was considered difficult to study with monthly hormone cycles. More than that, trials were also performed on male animals and the cell lines in a petri-dish? Also, male. It wasn’t until 1993 that it became mandatory for women to be included in trials, and researchers have not gone back to re-do the same trials in women. Consequently, it is thought that women are under-diagnosed and under-treated in up to 700 pathologies. If you consider an acute cardiac event, men will describe crushing left sided chest pain, down their arm and into their neck, while data in New Zealand has women complaining their bra was a bit tight that day. In cardiac disease, women often do not have the same pathology as men, and they have different risk factors. Risk factors that are not listed in standard cardiac risk calculators.

When people talk about women’s health, people think of so-called bikini medicine. That is disease of organs you find under a bikini. Whilst breast cancer does come in the top five causes of mortality, the most common cause of death for women is cardio- and cerebrovascular disease. Gynaecological cancers whilst aggressive are rare, and with the rollout of the HPV vaccination, in 15 years’ time, cervical cancer will be an historic disease.

So yes, a health gap exists for women, and it is worse if you are Māori, Pasifika or a person of non-European descent. That is why in Aotearoa New Zealand today, there is a Women’s Health Pae Ora Strategy, and a focus on improving outcomes over the next 10 years.

Now to turn to the role of the digital world in health. As we live our lives today, it’s difficult to not see the significance the digital world plays in achieving the WHO goal of health, especially when it comes to access to health information.

As a society, we want informed health citizens and not ‘worried well’. There is of course a careful balance in getting right the information that people can access digitally, the ownership of one’s own care is having enough knowledge to empower but not overwhelm.

A key solution to decrease clinical demand without raising costs and rationing care is embracing technologies. And women should be a focus: Women make 80 per cent of the health purchasing and health decisions for their families, 60 per cent of single women make health decisions for someone else.

What the system does not need is over-medicalisation and excessive, unnecessary screening. Our first binding principle of medicine is to do no harm; sometimes it may be better not to do something, or even to do nothing, than to risk causing more harm than good.

Prevention can extend your life expectancy. However, screening does not extend the length of life- it aims to make sure you do not die earlier than your trajectory, so more screening, over-diagnosis and over-treatment are a harm. As a third of screen detected prostate and breast cancers will not cause death over a person’s lifetime, we should be cautious developing technology that detects subclinical disease or disease that would never lead to sickness. An example from my practice was a patient with no cancer symptoms wanting a whole-body scan to reassure that ‘there is nothing there’. The imaging is so good now that we will find the solitary three mm lesion in your lung which could well have been from inhaling a grass seed as a child. This would likely be benign or likely to remain so for life, yet the resulting report will say it ‘cannot rule out malignancy, clinical correlation required, repeat CT chest required in three months. Along with the unnecessary anxiety the patient will now face, we start a diagnostic journey to prove that something is benign. We have not helped the patient and we have added stress on to the health system. It is extremely difficult to reassure people that they don’t require treatment once they ‘know it is there’.

What we do need in the industry is to share ideas early with clinicians, so we can work together to create solutions to problems we have, rather than solutions that are looking for a problem. But to do this we need to be taught. Many of us in the health sector need support to increase our tech literacy.

We need design for the pathways in healthcare in real time. My enduring electronic records were with a provider which was co-founded with a plastic surgeon, and it made sense.

A goal is to see a transition from health consumer to health citizen where patients own their health records and are offered technology which empowers them to better look after themselves. Like we have seen in travel and stock trading, technology gives citizens direct access to options and information. Whilst concerning and exciting at the same time, generative AI has the potential to empower individuals and improve medical outcomes.

Keeping all of this in mind, I see a future in New Zealand with coordinated virtual healthcare, with in-person visits making up a smaller proportion. More remote health monitoring, hospitals-at-home care, investment in ‘clicks not bricks’, non-clinical patient navigators and kaiāwhina, and technology allowing healthcare workers to work at the top of their scope. There needs to be a focus on preventative medicine supporting the individual to do so by social investment in the determinants of health. Technology that supports and educates people to look after their own health with people becoming the lead in their health team.

While there are many challenges in achieving globally recognised health ideals, we must remember that everywhere around us opportunities, especially digital ones, also exist.