Marlon James' fictional account of the men behind a 1976 attempt to assassinate Bob Marley features a sprawling, gnarly cast of characters. We talk with him about the novel, his approach to writing and what it means to be part of the Caribbean diaspora living in the U.S.
The American health care sector is very different from the National Health Service, the universal, government-run system available to British citizens. But both countries are embracing information technology as a tool to empower patients and improve outcomes. Kojo chats with U.K. Secretary of State for Health Jeremy Hunt about the challenges facing the NHS and why countries around the world are watching the implementation of the Affordable Care Act in the United States.
- Jeremy Hunt Secretary of State for Health, United Kingdom
MR. KOJO NNAMDIFrom WAMU 88.5 at American University in Washington, welcome to "The Kojo Nnamdi Show," connecting your neighborhood with the world. Later in the broadcast, the history of navigation, a new Smithsonian exhibit explores everything from mapping the stars to modern GPS technologies. But first, charting a new course for the United Kingdom's iconic National Health Service.
MR. KOJO NNAMDIOn the surface, the American health care sector bears little resemblance to the one in Britain where the government-run NHS provides universal care to every citizen, but both countries are in the middle of massive efforts to use data and information technology to empower patients, reduce costs and improve outcomes, which is why the United Kingdom's Secretary of State for Health Jeremy Hunt was in Washington earlier this week, attending the 4th Annual Health Datapalooza Conference.
MR. KOJO NNAMDIHe stopped by our studio on Monday to discuss what the data revolution means for health care in Britain and why countries around the world are watching the implementation of the Affordable Care Act in the United States. Jeremy Hunt, thank you so much for joining us.
MR. JEREMY HUNTIt's a pleasure, Kojo.
NNAMDIYour department is responsible for the National Health Service, that sprawling public health network. It's a massive effort that requires vast amounts of often scarce resources, money, brain power, political will, but you were currently managing efforts for the system to take advantage of a resource that is in abundance, data. Why is information such a key element to the future of the NHS?
HUNTWell, it's absolutely fundamental because when you compare the National Health Service with the U.S. health system, we have huge debates in both countries about the future direction, but one thing we have in common is we are both wrecking our brains to think about the issue of affordability, and that's because we have so many more older people, so many people with chronic conditions.
HUNTAnd if we're gonna have an affordable health care system, then we have to embrace the technology revolution, and that means using the power of information to our advantage. And I give you one example which I'm pioneering this summer in the United States, and that is -- in the United Kingdom, and that is publishing the surgery survival rates of every single surgeon throughout the U.K. in 10 major specialties.
HUNTWe've done it for heart surgery, and we've moved our heart surgery survival rates to being one of the best in Europe as a result of that. We're gonna do it for cancer, bariatric, vascular and a whole range of other specialties. And this is a way -- a cost-free way of driving up quality in a way that benefits hundreds of thousands of people.
NNAMDIYou know, in this country and I suspect in the U.K. too, most people would say that's such as a no-brainer. Why didn't it happen before? The health care sector, to many people, seems like a natural place for innovation to occur, doctors, researcher institutions and the like all push the envelope all the time to develop breakthrough technologies, treatments. With that in mind, why is innovating in the health information part of medicine such a slug, so difficult?
HUNTBecause we have had a tradition of a very many years really not -- not just in the U.K. but I think across the world of doctor knows best, and we need to change that to patient knows best. And it's a very, very profound cultural change, which I have to say I think the U.K. medical community is really embracing with great vigor, but it's a big change from what they're used to. I mean when I was growing up, there was an attitude that a patient shouldn't be able to see doctors' notes because the doctor might wanna write things in the notes that they didn't want their own patients to see.
HUNTWe used to have debates. I mean you must remember this too because it wasn't very long ago where you have a debate if someone had a terminal illness as to whether you should actually tell him.
NNAMDIThis is true.
HUNTAnd we wouldn't have that discussion now. I mean, you know, it's, as you said, it's a no-brainer that a patient has to be in control of their own health care. And so that's a very profound change, and I think that's why it's taken a while for people to understand the power of information.
NNAMDIThis is not a new idea in the United States. It's not a new idea in the U.K., but the huge effort to launch a national health database in the U.K. was junked two years ago. What do you feel went wrong during that database effort, and how is your project different?
HUNTWell, it was the right idea. It was just done the wrong way. And I think in technology, we've learned about how you do big technology projects and how you don't do them. And the way that my predecessor government tried to do this was the kinda health service equivalent of building an aircraft carrier. It was an absolutely giant project where you just -- you said, "We're gonna do one absolutely huge national database of everyone's health records, and then we're gonna ask every bit of the system what specifications they want."
HUNTAnd the project got bigger and bigger and more and more unwieldy and more and more expensive, and then it just became unmanageable. And at the same time or just perhaps shortly before this, you know, a miracle was happening with another bit of technology, which is that we -- without really any central planning, we developed a system for your BlackBerry to talk to my iPhone, and it just happened because people said, "Well, we're gonna centrally mandate every single bit of this process. We'll have a few common standards. We'll have interoperability, and we'll allow this to happen from the bottom up."
HUNTSo I want this to happen. I'm totally passionate about it. That's why I'm here in Washington at the moment, but I'm not going to be signing any huge multimillion pound contracts with big IT companies. This is gonna be at the level of hospital, the level of the doctor-surgery. They're gonna be doing the work. We're gonna restrict ourselves to making sure there are common standards in place. And I think that's the same approach that the administration is taking with electronic health records here.
NNAMDIOur guest is Jeremy Hunt. He is the secretary of state for health in the United Kingdom. What's the timeframe for this project? In the U.S., it seems we've been talking about some of the same themes over and over again for years and years, and we're still at the beginning in many ways. What's your timeframe?
HUNTWell, I think the U.S. has actually made some pretty good progress in the last couple of years, and you now I think up to 80 percent of hospitals using electronic health records meaningfully, and that is pretty impressive. We have a timescale for the National Health Service to be completely paperless by 2018. But from next year, all hospital records will have to be electronic. From the year after that, they'll have to be portable so that they can used anywhere in the system whether it's primary care, whether it's social care.
HUNTAnd we have a different structure to our National Health Service, and what people want in a service that's free at the point of use is to be able to go anywhere in the system and with their permission for the doctor to be able to access their entire medical history. For me, it's crazy that you dial in an emergency in the middle of the night for an ambulance to come to your house, and the paramedics arrive, and they don't know the first thing about you.
HUNTThey don't know that you're a diabetic. They don't know that that you might have mild dementia, that you have a heart condition, whatever it is. And that information is really important information. It determines the medicines you can be safely prescribed. It determines the type of treatment that you're gonna get. It determines whether you should be taken to hospital or whether if you're terminally ill and you've expressed a wish to die at home, but actually the right thing to do is for you to be treated by the paramedics at home, not to be taken to hospital. We don't have that information flowing in the U.K. at the moment, and that's what I have to change.
NNAMDIWhen it comes to concerns about privacy and all this information being stored electronically, you've said that people have trusted the banking system to allow for business to move online, so it's possible for the NHS to earn the public's trust to do the same. Why do you feel that's an appropriate analogy, an appropriate comparison?
HUNTWell, I think the reason is because if there's one thing people care about almost as much as their health, it's their money.
NNAMDIThis is true.
HUNTAnd the banks have managed to persuade people that they can be trusted to handle financial transactions online, and there are huge consumer benefits that have happened as a result. There are huge cost savings to the bank. They've reduced the cost of retail banking by about a third as a result of the move online, and that's basically because they make you do all their work for them when you go online, and they don't really have to do anything because we do it all ourselves now.
HUNTSo, you know, they had that barrier to overcome. Now, we have to overcome the same barrier for health care. If people's medical records are gonna be online, then they have to know that that information is gonna be secured. It's not gonna be accessed by people who don't have a right to access it. We said in the U.K. and I think we're the first country to have said this, certainly the first in Europe, that people have an absolute veto.
HUNTIf they don't want their information to be shared, then it won't be. But my experience actually is that the people who say that they want their data to be shared are usually people who are healthy. When people are unwell, if they go into an emergency department, do they want the doctor to see their medical history? Of course, they do, and it's very important information. If people have got cancer, are they happy for their medical history to be used for the benefit of research that could help conquer cancer? Of course, they are. And so this is about getting that relationship of trust for the benefit not just of the individual but of everyone.
NNAMDICouple of questions come to mind. How about people's concern about unauthorized nonmedical personnel being able to access their information? A lot of people will not want their employees, their employers, their co-workers to have any access to their private medical information.
HUNTAbsolutely. And, you know, there are very straightforward ways that you can protect people against that, but perhaps the simplest one of all is to make sure that any access to a medical database is done on a password login system so that the facts that your medical record has been accessed sits on the medical record and can be traced back. Now, when you -- if you use Gmail, you can go into Gmail, and you can see the I.P. address that last accessed your Gmail account, and you can therefore check and see whether there's any unauthorized access to your account. And that's the kind of security we need to build in.
NNAMDIHow do you see the push to open up data affecting the arc of clinical research, medical innovation, massive projects, like the one underway in the U.K. to sequence hundreds of thousands of genomes?
HUNTWell, I think this is gonna be absolutely extraordinary, and I think it's gonna be a fundamental change that the world hasn't woken up to. But the U.K. was the country that first unlocked the DNA back in 1953, Watson and Crick. And so we have a great tradition in the life sciences industry. And when we're trying to look at the causes of diseases, the causes of rare diseases, if we can match that against people's medical history, we'll be able to unlock a treasure trove of information.
HUNTAnd I think when you look at the misery of conditions like dementia that the world is just waking up to, this is a condition that now affects one in three people over the age of 65 or will affect them at some stage. This offers the potential to find ways to either halt the disease or to help people live at home healthily and happily for much longer and to relieve pressure on families, on careers. So I think it's gonna have a huge impact, and we have to be alive to that and embrace it.
NNAMDIOur guest is Jeremy Hunt. He is the secretary of state for health in the United Kingdom. When it comes to these efforts digitizing your health system, how is your starting position in the U.K. different from ours here in the U.S. What are the advantages and disadvantages from starting this effort in a country with a broad taxpayer funded system like the NHS? You have said you have ambitions to make the U.K. the global hub of health technology.
HUNTWell, I do, and I think we have an opportunity to do that. And I think incidentally, it's something were the U.K. and the U.S. have much more in common than they have that's different because this is an agenda. The open data movement is something that has taken a hold more in the U.K. and the U.S. than any other countries across the world.
HUNTThe difference, I think, really is probably more what we're looking to get out of this because I think in the U.S., the number one concern about health care is the affordability of the health care system going forward. I think it's a fantastic thing that the U.S. is moving to universal coverage. And I was with Secretary Sebelius in Geneva at the World Health Assembly. And I think the fact that the U.S. is now embracing universal coverage is sending a signal to developing countries across the world that this is something that everyone should aspire to as part of their development plans.
HUNTBut in the U.S., affordability has always been an issue, and so I think open data is going to unlock us. Secretary Sebelius said to Datapalooza, which hospitals are charging more for the same procedure as other hospitals that are charging a lot less? In the U.K., we are much more looking at open data as a way of driving quality, of clinical outcomes, of improving surgery survival rates, of making sure that all hospitals are giving acceptable standards of care. And so we are very much looking at it from the health outcomes perspective.
NNAMDIWhen you say that universal care here in the United States can serve as an example and objective for people in different countries around the world, I'm fascinated because that has not been a part of the debate here at all even as we have had a great deal of controversy in over what's known as Obamacare or the Affordable Care Act. One of the aspects of it that was not widely discussed is the impact that this might happen on countries around world. It's clearly something that you and the U.K. have been thinking about a great deal.
HUNTWell, we do. And, of course, you know, we were one of the first countries in the world, if not, the first country in the world to embrace universal coverage through the founding of the National Health Service in 1948. And I would, by no means, say that our system is perfect, and we have huge challenges just as you have huge challenges. But, perhaps, America is such a huge country that it's difficult to realize the impact of what happens here in other countries.
HUNTBut I think if you're a developing country in Africa or South America or Asia and you're thinking about the development of your country and you're thinking, what is it that we're aspiring to as a country, the fact that up till now America has not embraced universal health care coverage has meant that that's really a choice you have to make. But I think that now that America has embraced it, it's become one of those things that everyone aspires to just like universal primary education. And I think that's a wonderful thing and a big step forward for humanity.
NNAMDII was fascinated by the example you gave earlier about the patient who needs emergency care and the ambulance personnel now being able to know exactly who that person is because the way it is now, they don't have a clue exactly who they're coming to see. Emergency room images were very much a part of our recent debate about health care reform here in the U.S.
NNAMDIWe talked a lot about the problems created by uninsured patients who avoid care until they end up in emergency rooms or retreat emergency rooms as their sole entry point into the system. There's a political debate in your country right now about emergency services, A&E, accident in emergency department. Some say there's a crisis right now in the NHS with wait times and whether ambulances are being turned away from hospitals.
NNAMDIYou've asserted that this is not a crisis, and that many of the problems are related to a contract that general practitioner sign some eight years ago and how it applies to their after-hours work. What do you see going on?
HUNTWell, there's a lot of different things going on. But when you have a health services we have in the U.K., which is free at the point of use, when you have pressures building up, then those pressures tend to focus on emergency departments. So if people are finding it difficult to access their doctor who they would normally see for primary care, if they are in a residential care home and something goes wrong on a Friday night, normally the problems tend to emerge first in accidents and emergency departments.
HUNTAnd that's what's been happening in the U.K. And we had a very difficult winter. We had a cold winter. And we have a target that 95 percent of people who go to accident and emergency departments should be seen within four hours and indeed a lot quicker.
NNAMDIIt averages about 53 minutes now as my understanding.
HUNTYes. And that's our national objective, and we've reached that target for several weeks over winter. And so my job really as health secretary is to look at what you can do in the short term because we need to make sure people are getting the care they need quickly, but also, what are the underlying causes? And of the underlying causes is some contractual changes that were made to the general practice doctors, which meant that they were no longer responsible for 24/7 provision of -- out of our services.
HUNTAnd so I think that has created a sense in the public that it's more difficult to see your doctor if it's an evening or if it's a weekend. And that's added pressure in emergency departments. It's not the only reason, but it's one of the things that I think we need to look at.
NNAMDIThat he or she is only your family doctor a part of the time. You've proposed rewriting the contracts of those GPs, and you've said the current situation does not reward doctors for putting patients first. What do you feel needs to change?
HUNTI think we need a system that properly understands the changing demographics. And in fact, for example, in my country -- and I'm sure the picture is very similar here in the U.S. -- within the next three years, there'll be three million people who have not one chronic condition, not two chronic conditions, but three or more chronic conditions. And these people are not gonna use health care or they're not going to use health providers in the traditional way where you have a problem, maybe you need a new knee.
HUNTYou go into a hospital. The knee is replaced. You come out better. That's the old model. The new model is of people who have a series of complex conditions that are not gonna be cured, and they're gonna be frequent flyers in the health care system. They're gonna be going in and out of doctor surgeries in hospitals several times a year and maybe several times a month. And we need to embrace different models to deal with those people.
HUNTAnd I think what that means is for those people, you need to have a clinician, a doctor, who is accountable for their care even when they're not in the hospital. And when you go to a hospital, there's a consultant who's responsible for you from the day you arrive to the day you leave. And that consultant doesn't do everything. That consultant doesn't necessarily feed you or wash you, but they're responsible.
HUNTI think we need to have that same sense of responsibility for people outside the hospital when there are older people who have these complex long-term conditions.
NNAMDIHere in the States, so much about political debate about health care has been about changing the fee-for-service system of health care and finding ways to reward providers for outcomes and for quality rather than for quantity of care. How would you compare the challenges you're facing to those we're facing here in that regard?
HUNTWell, they're more similar, actually, than you might think because we, too, have a system of fee for services. We call it payment by results. And the result is that we have had a focus on quantity rather than quality. And a hospital -- if a hospital manages to do 2,000 knees rather than 1,500 knees, then they get paid extra money. And so their priority is to do more knees. But, actually, sometimes what gets overlooked there is the knees of the patient.
HUNTAnd the patient might need their knees doing, but they might have some other needs as well. And they want to be looked at as a whole person. And we don't have a system that is as good as it should be at looking at the patient as a whole person. And that's what we have to change.
NNAMDIWhat goes through your mind as you observe the current political atmosphere here in the United States when it comes to health care? Here, we're locked into many of the same debates about austerity, about improving the quality of health care. The health care systems in the middle of those conversations are very different. But the political dynamics do have some similarities, do they not?
HUNTWell, I think that the debate about health care in both countries is more partisan than it needs to be. I think that it is an incredible privilege to work in health care -- for any one to work in health care. And I think that the vast majority of people go into health care because, you know, they have altruistic motives. It's an incredibly honorable profession. You know, it's one of the oldest professions, and it's a wonderful thing to do. And I think sometimes the kind of partisan sides to it actually have more heat than light. And that's something we definitely have in common.
NNAMDIYou may have already answered my final question. It was going to be, given the political partisanship that accompanies these debates over health care, whether in your country or mine, what got into your head to cause you to accept the position of being secretary of state for health?
HUNTWell, the job I was doing before that was responsibility for the Olympics, and that came to an end. And I think, probably the job I'm doing now is a bit like doing the Olympics but every week and perhaps without the glamour. But actually, you know, I wouldn't swap it for the world. It's an incredible privilege to do anything associated with health care. The one very simple reason which is that people's health care matters to them more than anything else in the whole world, and that's why it's so important to get it right.
NNAMDIAnd that, I guess, is why you decided to take this on. Jeremy Hunt is the secretary of state for health in the United Kingdom. Thank you so much for joining us.
NNAMDIWhen we come back, from following the North Star at sea to following the GPS device in your car, The Smithsonian goes behind the history of navigation. I'm Kojo Nnamdi.
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