What is the purpose of Denmark’s healthcare system? A very general answer could be to ensure that as many people as possible are healthy and thereby not sick. A more operational answer could be that the healthcare system should provide the best treatment at the lowest price to as many people as possible. Seen from inside a tax-funded healthcare system, most people would likely agree. Are we accomplishing this? And do our research and development models promote this?
Denmark’s healthcare system is very efficient using the measure that more and more patients are treated. This is the natural consequence of decades of financial reimbursements based on throughput rather than quality. Whether the healthcare system treats patients optimally is therefore difficult to say. But evidence clearly indicates that many treatments have uncertain benefits for patients and the healthcare system. More than half of all treatments are based on low-quality evidence, even in major medical specialties such as cardiology and oncology.
In many specialties, low-quality evidence is the current state. This also applies to high-risk patients regardless of diagnosis: the very sick, those with multiple illnesses, the very old, children and pregnant women. Thus, so many treatments have uncertain benefits for patients and the healthcare system that “no” is the obvious answer to the question of whether we provide the best treatment at the lowest price.
We are not providing optimal treatment
Danish Patients (the umbrella organization for 102 associations for patients and their relatives in Denmark), Danish Regions and the Organization of Danish Medical Societies have all accepted the premise of the Choosing Wisely (Vælg Klogt) joint project that 20–30% of all activities in Denmark’s healthcare system is wasted. This not only directly and indirectly harms existing patients but also future patients.
This is most evident for antibiotics, which poses an obvious analogy to climate change. We use excessive antibiotics now so that they cannot be used for future patients. We do this based on uncertainty, since we lack good clinical trials showing that using less antibiotics and those with a narrower spectrum is safe.
Choosing Wisely, the Danish Medicines Council and the Danish Treatment Council all represent initiatives that show increasing understanding that some treatments do not provide benefits to patients and the healthcare system despite being used or being approved for use.
The realization therefore seems to be dawning that Denmark’s healthcare system does not provide the best treatment at the lowest price. Choosing Wisely, the Danish Medicines Council and the Danish Treatment Council are extremely important tools, but they are band-aid solutions to a fundamental problem.
If all treatments and procedures, or at least the new ones, were properly validated before or during implementation, these organizations’ scrutiny would not be needed. And then we have reached the answer to the second question: do our research and development models promote the goals?
The COVID-19 pandemic has shown a way
The research and development model for the health sector strongly depends on commercial partners in the final stages of development. In contrast, the healthcare system has not established its own model for systematically testing the benefits of treatments and processes during implementation or for assuring the quality and thereby the benefits of existing treatments. The current research and development model therefore does not support the goal of providing the best treatment at the lowest price to as many people as possible.
Staying with the climate change analogy, we need a development model that ensures a sustainable healthcare system, especially because the number of older people is increasing in Denmark, and more people with acute and chronic illness will therefore need treatment. We cannot expect our commercial partners to carry out the clinical trials showing that it is safe for the individual and better for the society to use less antibiotics, less chemotherapy and less blood, to perform surgery later or not at all and to prevent disease and promote health.
These clinical trials should be given priority and performed by the healthcare system, together with the patients in order to maximize the benefits and minimize the inequality for the money spent on health.
Does this sound utopian? The COVID-19 pandemic has also here shown the way. The treatment breakthroughs – what we should do and especially not do – have emerged from publicly funded and driven clinical trials, which were finalized extremely rapidly. The results have had enormous benefits for patients, improving survival and minimizing side-effects, and for the healthcare system, reducing the pressure on intensive care units and enabling shorter hospital stays.
A very modest public investment in clinical trials has therefore had immediate benefits, and most importantly, these trials have saved patients’ lives. The COVID-19 pandemic has shown how to achieve a sustainable healthcare system – and now we need to continue these efforts.