According to Nassim Nicholas Taleb, predicting what will not change in the future is often much easier than predicting what will. In healthcare, the constant is the patient-caregiver relationship. Regardless of technological advancements, people will always need another person to care for them—this is inherent in our nature. The question is what this “care” will look like in the future and what tools will be used to deliver it. However, there is no doubt that healthcare will continue to require people. At the same time, the biggest shortage we face is precisely in human resources. The World Health Organization (WHO) predicts that by 2030, the global shortage of healthcare workers will reach 15 million. The COVID-19 pandemic has exacerbated this trend, even in developed countries. According to a recent study, up to 20% of primary care physicians and 40% of nurses plan to leave the profession in the near future. Healthcare workers are already among the top five most scarce professionals in the European Union. Moreover, if the years lived in good health do not keep pace with population aging, the demands on healthcare workers will only increase. Reversing this trend requires more than just efforts within the healthcare sector, as approximately 60% of health outcomes depend on the socioeconomic and health behavior factors of the patient. Thus, it is clear that the vision of a sustainable and life-enriching healthcare system must center on people: both healthcare workers and patients, as well as empowering and supporting their daily well-being. The future of healthcare will be shaped by those health systems that can simultaneously offer healthcare workers a developmental and motivating environment while meeting the growing demands and self-awareness of patients, viewing them as part of their own health improvement team. To manage with limited resources, healthcare must make significantly better use of the data generated and the technologies developing in the field. Although it may seem cliché, achieving all of the above is heavily dependent on the better use of existing resources and the management culture we cultivate in healthcare.

From Service-Based to Value-Based

Just a few years ago, policymakers were hesitant to talk about “value-based healthcare.” The concern was that such a concept would not be well received by healthcare workers because no one could adequately measure value. However, in working with healthcare professionals, I see the opposite: frustration stems from the fact that no one measures the value created by healthcare institutions or creates incentives to offer higher-quality services. As the gap between projected healthcare revenues and costs widens, the calls for new funding models that go beyond the ever-increasing costs of individual services grow louder. Value-based funding would help healthcare better keep pace with technological advancements and foster innovation in healthcare services. Over the past decade, investments in biotechnology and digital technology have grown by over 200%—we can only keep up with such developments if all stakeholders think creatively and experiment with new approaches. As long as centrally listed and managed healthcare services are funded, healthcare providers (HCPs) will lack the motivation to experiment with novel solutions that could achieve the same or better outcomes more efficiently. Additionally, the current system lacks sufficient incentives to focus on generally more effective community health maintenance, as treatment is more profitable for HCPs than prevention. Thoughtfully designed funding models that set health outcomes, rather than service volumes, as the goal for HCPs could help break this deadlock. We have seen such a model work well, for example, at Bernhoven Hospital in the Netherlands, where a more value-based funding model allowed the hospital to achieve the same results with 16% less service volume. The clear need to transition to value-based funding in the future puts HCPs that already focus on measuring and continuously improving the value they provide at an advantage. Even in today’s healthcare landscape, where consumers in Estonia and abroad can choose their service provider with their own funds, demonstrable quality is a significant argument for preferring one provider over another. Additionally, HCPs focused on value are in a better position to recruit and retain employees, as moving towards and achieving measurable value satisfies the natural need for increased mastery, which is strongly expressed among healthcare workers.

Generally Personalized, Data-Driven

A study published in the journal Nature demonstrated that the best-selling drugs in the U.S. are effective for only one in four patients (adalimumab) at best, and one in twenty-five (esomeprazole) at worst. This illustrates a well-known but little-discussed fact in medicine: medicine is imprecise. The less data we have about an individual, the harder it is to achieve the desired treatment outcome. The less a person knows about themselves, the more difficult it is to live in optimal health. Such ignorance is demotivating for both the patient and the healthcare provider, as it can give the impression that there is no potential for improvement. Therefore, any vision for future healthcare must consider our ability to make healthcare more precise and individualized. Estonia is an excellent place for such innovation, as our data is not only deep (~20% of our population has been genotyped in the Estonian Biobank) but also broad (socioeconomic status, consumption habits, etc.). The potential of healthcare services built on such data, from prevention to treatment, is still largely untapped. Based on patient consent and strong data science competence—either in-house or in collaboration with universities or relevant companies—these services can be created. Examples can be found worldwide: the Clalit health system in Israel has long-term data on 4.5 million patients and regularly uses it to personalize treatment and develop various data-driven health products, even though they currently lack genetic data. Clalit’s experience also shows that offering more personalized treatment services does not have to be limited to patients who have been genotyped. Nor do data-driven solutions need to be complex. For example, in one Swedish health region, data analysis was used to identify profiles of patients more likely to be hospitalized with COVID-19. By paying preventive attention to these patients (e.g., through home oxygen therapy), hospitalizations were reduced.

The Health Journey Begins and Ends at Home

Today, most of a person’s health journey takes place at home. It is in the interests of both patients and the healthcare system for this part to grow over time: more time for family and work, more dignified conditions for patients, fewer hospital-acquired infections, less burden on healthcare workers, especially in emergency medicine, lower construction and maintenance costs for HCPs, etc. There are simpler and more complex solutions to reduce the need for patients to visit healthcare facilities to maintain their health. Simpler, but no less effective, solutions include various remote consultation options, such as reporting symptoms using a home digital solution. In addition to preventing hospitalizations, such a solution extended the lives of cancer patients by nearly 7 months in one study, as disease progression and treatment side effects were detected earlier. The Mental Health Hub at Helsinki University Hospital, which allows patients to improve their mental health independently or in collaboration with a psychologist, has been effective in treating mild to moderate depression while also being cost-effective, allowing one specialist to support up to 20 patients per day. Moderately complex but also high-potential solutions include various algorithmic solutions that enable patients to receive initial treatment advice through a digital assistant, such as a chatbot. The most logistically complex solutions are various “hospital at home” models that allow chronic and some acute patients to be treated in their own homes using a combination of remote monitoring and home visits. Such solutions are feasible for frequently occurring chronic diseases such as heart failure or chronic obstructive pulmonary disease (COPD), and increasingly also during the acute phase of illness (e.g., treatment of erysipelas). In addition to being more patient-friendly, home care solutions can be more effective in some aspects, as seeing the patient in their home environment allows for better health behavior counseling. They are also cost-effective. Studies show that patients treated at home achieve the same treatment outcomes with fewer complications (e.g., infections, falls) and fewer tests. Home care also helps reduce inequality in situations where a patient’s disability, location, or other factors hinder their ability to visit a healthcare facility. Although home care solutions are still relatively uncommon, McKinsey predicts 3-4x growth in the next three years. In healthcare that respects human dignity, these solutions are indispensable: a patient dependent on infusion therapy does not have to tie their life to the hospital, and a terminally ill patient in severe pain can spend their final days at home with loved ones thanks to a pain relief pump.

New Roles in Healthcare

Today’s healthcare worker carries out a variety of roles: diagnostician, healer, caregiver, coordinator, administrator, secretary, counselor, and much more. Understandably, a workforce with such a broad skill set is in short supply. Even in Estonia, with its relatively lenient training requirements, it takes too long to train new doctors and nurses to cope with the already growing workload. By the time the effects of increasing training volumes reach the labor market, the shortage of healthcare workers may be even greater. To better meet the growing demand and workload in healthcare, new roles that do not require licensed healthcare workers need to be introduced.

One “low-hanging fruit” is to examine the daily work of highly qualified workers and remove tasks that others could perform. For example, in the Health Insurance Fund’s pilot projects, nurses with specialized training coordinated patient care pathways. The need for such a coordinating role is evident, yet this work does not require a nursing license or even higher education, as coordination follows a very clear algorithm. It is not unthinkable that, for a more digitally capable patient, such coordination could be handled through a digital application.

In addition to filling existing roles with non-healthcare workers, healthcare also needs new value-creating roles that can be filled by less qualified workers. We know that health behavior affects a person’s health outcomes more than treatment. Primary prevention, which helps people quit harmful habits and establish healthy routines, is key to a sustainable healthcare future. Today, the expectation is often placed on family doctors to motivate patients to change their habits. However, family doctors do not have the time or always the training to do this work during a standard consultation. This role could be filled by health coaches with the necessary skills to help patients achieve their health goals. The goals may be set in collaboration with the attending physician, but the daily support would be provided by coaches, whose training can be significantly faster.

One “role” that healthcare can no longer ignore is that of patients and their relatives. Healthcare has traditionally been seen as something “done” to patients, but this understanding is changing. We can gauge patient proactivity from the complaints where misdocumented cases are described. This is welcome: patients should have a role in their medical documentation, considering that doctors already spend significantly more time on documentation than on clinical work with patients. There are also hospitals where patients play an even more significant role in daily operations, such as serving as quality inspectors.

However, the most important contribution is that of the patient in their own health journey. A common complaint from patients with chronic diseases is that they have acquired a diagnosis-specific mobile application that helps monitor their condition, but healthcare providers do not want to make use of this information. Instead, healthcare providers should thoroughly analyze such solutions, select those that could be beneficial in supporting the patient’s self-management, and “prescribe” them in the same way we prescribe medications today. Both in Estonia and abroad, reliable databases (e.g., ORCHA) have been established to evaluate the evidence base, safety, and other aspects of health applications. Empowered by such applications, patients could play a larger role in their own health journey.

Of course, healthcare cannot be developed solely based on the needs of self-sufficient, digitally literate patients. The Joint Commission International’s Patient-Centered Care standard describes that every healthcare facility should assess a patient’s ability to cope with their illness and involve relatives if this ability is low. The readiness of relatives to participate in the care journey is an underutilized resource. Better involvement of relatives in patient care gives them a sense of control during anxious times and can also help alleviate the burden on healthcare workers in the long term.

Networked General Practice

One of the paradoxes of future healthcare is that we expect greater personalization and precision, while also requiring broad general knowledge and holistic treatment of people as the proportion of multimorbid patients grows. We want highly specialized competence centers and, at the same time, integrated care pathways where people do not fall through the cracks of the system. Competence centers are a source of tension in a small country like Estonia, where low service volumes make high specialization difficult. At the same time, Estonia’s small size should not be a limitation for patients who genuinely need highly specialized care. In my view, the way out of this paradox is threefold: greater appreciation and teaching of general medical knowledge (including the competencies of family doctors), empowerment of general practice with clinical decision support, and the networking of highly specialized care. According to the Pareto principle, we need better capability to address the selected health conditions that cause the majority of our disease burden. The healthcare system also felt the lack of universal general knowledge during the COVID-19 crisis when the system desperately needed flexible workers who could substitute for each other in situations where they fell ill or were quarantined. Advancing general knowledge requires a paradigm shift in a world where only a specialized doctor is considered the “right” doctor. In a developing world where clinical decision supports that process large amounts of data play an increasingly important role in diagnosing and treating rare diseases, a digitally empowered and competent general practice could take on a much larger share of patient care, allowing a few specialists to better focus on highly specialized care in relevant competence centers. These top specialists do not necessarily have to be located in the same country. It is already natural that in the case of very rare diseases, which may only affect 50 patients in Estonia, close collaboration with European centers of excellence, for example, through European Reference Networks, is essential. Establishing good collaboration and technical interoperability with such centers of excellence allows even a healthcare facility focused primarily on general practice to offer top-notch care to its patients.

Innovation in Support Processes

When talking about innovation in healthcare, most media attention is focused on solutions directly related to medical work: 3D-printed organs, clinical decision supports based on mass analysis of scientific publications and treatment data, AI-powered imaging diagnostics, and so on. All of these are significant advancements in healthcare, but they are also difficult to implement due to the high evidence standards required for healthcare services. Novel solutions require thorough testing, which is a motivating challenge for healthcare workers but also demands time, which is scarce alongside their primary work. At the same time, there is much that technological advancement could achieve in the “back-office” of healthcare, where implementation can begin immediately. Humber River Hospital in Toronto is a good example of innovation in hospital support services: among other things, hospital supply transport, medication administration, laboratory analyses, and more have been automated. Everyday support processes in healthcare facilities are full of examples of wasted resources and avoidable errors where newer technologies could help save time, lives, and resources—support processes account for up to 25% of hospital costs. This includes the need to update documentation systems, in which healthcare workers spend a significant portion of their time. Today’s systems are developed with a paper-based mindset, which means the time saved over paper systems is minimal. A modern documentation system would be integrated with decision support, where documentation would be an extension of the healthcare worker’s natural thought process. By freeing up healthcare workers’ time through innovation in support processes, we open the door for them to experiment more and implement novel patient-centered solutions, such as AI-based diagnostics and treatment, in an evidence-based manner.

The Future of Healthcare Requires Professional Management

A few years ago, a study in Estonia garnered much attention, suggesting that hospitals led by doctors achieve better treatment outcomes. This study is easy to misinterpret, as if simply being a doctor gives someone an advantage in leading a healthcare facility. In reality, the study indicated that when a doctor has received management training and takes on the role of leading a healthcare facility, the institution they lead is likely to achieve better results. The key here is management training, which is unfortunately very rare in medicine. At the same time, management plays a crucial role in achieving all of the above, helping to overcome the apparent paradoxes in healthcare where we should achieve more with less, be both generally competent and highly specialized, and simultaneously be more digital and patient-centered. In my view, the lack of professional management is one of the root causes of healthcare workers’ burnout, even when the immediate cause cited is an increasing workload. Professional managers can harness the full potential of healthcare teams in overcoming daily challenges, large and small, including better coping with workload. Healthcare is too complex for a “club of the wise”: true innovation happens on the front lines, which sees the nuances and obstacles of every medical service. Unfortunately, the same frontline has been relegated to the role of mere implementers of medical work at any cost, under outdated management models and rigid hierarchies. The inability to influence one’s working conditions is one of the well-documented bases for burnout in any industry. In a professionally managed healthcare facility, the frontline has every opportunity to raise issues, propose solutions, experiment with new technologies, and create new work processes. Achieving such management requires immediate attention to the development of future healthcare leaders. Here, too, a shift in our thinking may be needed, where the primary criterion for selecting a leader is not necessarily their medical degree or long experience as a healthcare worker, but rather their management potential and philosophy.