Can we de-institutionalise healthcare?

Healthcare has transitioned significantly over the last few decades. This transitioning has been very accurately captured by the tinsel world of ‘Bollywood’. In the ‘black and white’ era of the movies, whenever an ailment befell an individual, it was left to the mercy of ‘God Almighty’ to cure and redeem him/her. Then came the transition in the 1950s and 1960s, when the ‘black and white’ cinema passed through the ‘Eastman’ and ‘Technicolor’ phase on its way to the era of ‘Colour’ cinema. During this transitioning period, an archetypal scene in most melodramatic sequences used to be the elder of the family clutching his chest with an acute coronary event in response to an emotional precedent. Immediately, a doctor would be summoned, who had a quintessential persona of a friend, philosopher and guide, with a ‘Doctor’s bag’ being carried by a family member. Instinctively, a diagnosis of heart attack, colloquially ‘Dil Ka Daura’, would ensue; treatment, essentially oxygen and some jottings on the paper for tablets to be procured, would be administered at home and tender loving care solicited from the relatives. ‘Karma’ performed, the results were left to the almighty ‘God’. This transitioning continued and in synch with the zeitgeist of contemporary times, every single medical emergency nowadays is culminating into an immediate and frenetic transfer to a hospital, with either an intensive care unit (ICU) sojourn or an operating theatre redemption for the individual. Even terminal ailments, like end stage cancer or heart failure—deemed irremediable in previous hospitalisations—take the same course. This, in a way, is a legacy statement of the challenges that contemporary healthcare face across the globe.

Some sane elements have been lamenting for long that healthcare has been medicalised and institutionalised a bit more than what was necessary and desirable. This fact was brought home so very poignantly during the recent coronavirus disease (COVID) pandemic, when all healthcare systems broke down at the very first fall of the hammer. The story was the same worldwide, be it developed or the developing nations, and be it the most heavily funded healthcare system or the most under-served ones—they all collapsed. However, the moment we realised that mild to moderate disease could be treated at home with equal safety and efficacy, the pressure on the hospitals came down. Scenario is no better even in matters of routine healthcare. Those relying more on tertiary care and mechanistic ideologies, like North American and European systems, have done worse than those which are more holistic and centred on primary care, like Japanese. It is intuitive that no matter how many preventive measures be implemented, diseases and disasters—natural or man-made (biological, nuclear, chemical or radiological)—will crop up; and moving forwards, newer forms may take shape, presenting daunting challenges to contemporary ‘Medicare’. These unpleasant ground realities stare in our face calling out for matters not to be left in limbo of status quo. It is time therefore that we have a new look at the way healthcare is delivered and one of them is de-institutionalising healthcare and prioritising domiciliary care.

There is enough evidence that domiciliary care is effective and as safe as hospital-based treatment. A Cochrane review concluded, ‘admission avoidance hospital at home, with the option of transfer to hospital, may provide an effective alternative to inpatient care for a select group of elderly patients requiring hospital admission’ [1]. With the dawning that, across the globe, medical services are stretched, especially for acute care and emergency services, where demand far outstrips the supply, the focus seems to be shifting. Attempts are being made to bridge this demand–supply chasm by delivering emergency-like services at home, including laboratory testing, imaging, and medications, with efficacy and safety [2]. Even acute care of pathologies as sinister as acute myocardial infarction can be safely accomplished at home. A trial in United Kingdom, way back in 1978 summarised, ‘for the majority of patients to whom a general practitioner is called because of suspected infarction, hospital admission confers no clear advantage’ [3].

Intuitively speaking too, home care may not only be non-inferior to hospital-based treatment, but in some respects, it may turn out superior. The World Health Organization estimates that nearly 1/6th (15%) of patients in acute care hospitals are likely to contract a hospital-based infection and approximately one in ten patients die from these infections. Domiciliary care will virtually eliminate this major drawback of hospital-based treatment in one stroke. The Centers for Medicare and Medicaid Services (CMS) proposed, ‘more than 60 different acute conditions, such as asthma, congestive heart failure, pneumonia and chronic obstructive pulmonary disease care, can be treated appropriately and safely in home settings with proper monitoring and treatment protocols’ [4]. In fact, after the initial reverses and disasters during the COVID pandemic, especially in the New York state, CMS in USA announced a programme labelled ‘Hospital without Walls’. This was followed by another programme labelled ‘Acute Hospital Care at Home’ (AHCaH). These programmes were launched under the ‘Public Health Emergency’ provisions of the federal government and were therefore time bound to sunset in May 2023. Later, one-and-a-half-year extension was granted and the provisions of AHCaH were extended till end of 2024. However, there is currently a huge clamour that they should be made a permanent feature and this demand has found traction with the public also.

To some extent, this transition is happening in India too. According to NATHEALTH’s Indian home healthcare 2.0 report, Indian home care market is growing at a compound annual growth rate (CAGR) of 19%. It is likely to grow from US $ 5.4 billion in 2021 to US $ 19.9 billion by 2025 [5]. Though currently it is mainly to respond to senior citizens without adequate family support, it can be easily transitioned and metamorphosed into a system to provide even acute care at home for certain other subset of patients. Partly it was the COVID epidemic which fuelled this sudden surge, but it also reflects the demand of the society, and of an individual, to be treated in the comforts of a familiar, and more reassuring, surroundings of home. We, in India, are in a pole position to implement and benefit from this concept. With digitisation of health, ubiquitous availability of 5G telecom services, deep penetration of mobile telephony and remote monitoring capabilities, this sounds a very promising and holistic trajectory that the healthcare can take moving forwards. This arrangement will be in synch with our Indian psyche and culture, which is still seeped in a family-based, strong support system. In most households, parents would like to be with their loved ones around and most youngsters are still willing to take care of the senior citizens in the family, even though some readers may see in it a ‘tongue-in-cheek’ assertion. It will be a win–win situation for all stakeholders and Adashi et al.’s assertion, ‘the popular sentiments will have it no other way’ [6] appertains to India too.

Moving forwards

Disruptive models ….. needing validation and certification

Pulling a leaf out of online, revenue-sharing, aggregator models, medical teams can be on wheels, with an app-based model just like Uber and Ola. For any acute emergency, the nearest team of mobile unit can be directed to provide first responder services to the patients at home. This can be complemented, and strengthened, by tertiary care hospitals developing a wheel and spoke model involving the family physicians of a particular area under their jurisdiction, who can visit the patient once or twice a day, and keep in touch with tertiary care specialists in hospitals, seeking their advice and intervention as and when needed. In fact, hospitals should take these homecare beds as extended bed capacity, and ‘artificial intelligence’ and ‘machine learning’ can be reined in to provide customised and protocolised home-based care, with the provision of human over-ride, to take this concept to the next level. Needless to say, there should be a provision for quick, efficient and safe transfer of an occasional patient, who may need an intervention or hospital-based care.

Uncoupling of healthcare from hospitals is the likely panacea to many of the ills that it currently faces. It will help deliver seamless, personalised and sustainable healthcare to the last mile of India’s vast geography and at scales to meet the demands of our 1.4 billion, and growing, population. Obviously, such a disruptive thought would face headwinds from the private sector, especially the big corporates. Those pressures will have to be neutralised and soaked in. Even the insurance companies will have to come on board and make the expenditure reimbursable. Moreover, to have this concept come to fruition, there will need to be a strong political will to implement it. This would require a lot of advocacy, with not only the puissant and contumacious bureaucracy, but also with our political masters, so that it passes the floor test in the parliament for enactment of necessary legislations to govern and regulate home-based healthcare in an ethical manner.

In a single liner, to the nay-sayers, I yield—Yes, it is a thought experiment; but one, I truly believe and hope, worth putting on the anvil.

Will political sagacity and rectitude show up to redeem the day? …. Time will tell.

Funding

None.

Data availability

All data is already in public domain.

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Informed consent

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Conflict of interest

Nil.