Phil Anderton PhD, CEO ADHD360, argues we need to learn from past mistakes to deliver the healthcare of the future
Attributed to Mark Twain, it is frequently stated that “the best predictor of future behaviour is past behaviour”. And so it is with the application of medicine to the human body. But, of course, that isn’t correct. If it were, we would not have medical break throughs, the application of new science and incredible developments to prevent and cure illness.
What if we extended the debate to the best predictor of ‘payors’ future behaviour in healthcare is past behaviour? While accepting that all new breakthrough medical science inventions must be financed to become interventions, we start to argue against our own statement, or do we?
One of the largest challenges to bringing a new way of doing things, or a new product to market, is gaining traction to a sufficient level whereby there is a critical mass, a meaningful future ROI and momentum. That’s just an organisational behavioural fact. When we couple that with the significant challenges of breaking through regulation and ‘red tape’ into medicine, medical devices and service delivery for healthcare, we double the frustration.
When we stray into foreign territories to introduce new ways of doing things, new services or new products, we heighten the hill to be climbed and magnify those issues multi-fold.
But entrepreneurs persist and eventual change can happen.
Changing the mindset
One of the post pandemic ‘breakthrough’ areas of medicine has been the advent of the virtual clinic, utilising new technology to benefit the medical process. It is questionable whether the days of ‘face to face’ clinical contact will continue – in commerce, remote meetings are leading the cultural change and in warfare the use of unmanned aircraft has been dictating the future for a considerable time. To a measured degree some things have changed.
Key tactical questions that inform strategic thinking are found to be:
1. What are the criteria for success for an agent of change?
2. What should change in medicine be measured against?
3. How do we convince the payor to change?
These three seemingly innocuous questions influence our futures, and the answers control progress. If the payor is stuck in the mindset: this is the way we do things because this is the way we have always done this, then the predictable growth curve is to be flattened, if it exists at all.
Unintended consequences
The USA saw a burst of telemedicine companies post-COVID. While perhaps well meant, they drew the attention of the Drugs Enforcement Agency (DEA) due to what was described as ‘doctor shopping’, and an increase in the flow of controlled drugs into the general market, beyond the intended patient market, was claimed. This led to a set of DEA interventions into the American Done clinic, and subsequent charges being brought against executives of the company for distribution of controlled substances and conspiracy. It is claimed that Done Global, through a new and innovative telehealth model, effectively gave access to controlled stimulant medication for ADHD via their telehealth platform when the patients didn’t need them.
The moment those charges were brought, the advances in medicine and treatment for ADHD began to suffer, a suffering that had and for some still is, having a sincere impact on treatment availability.
If we throttle advances in medicine because of what we used to do, we stifle innovation. Returning to the known is a comfort zone, and whilst often an inappropriate place of calm for some, it shouldn’t be the place of calm for innovators and those pushing boundaries forward.
Learning from past mistakes
The UK’s procurement processes, immersed in national state provision of services, have an apparent steadfast resistance to change when engaging progressive services applied to aspects of mental health, such as ADHD, that are at volume and scale. Services of the past were seen as acute, with a focused demand of minor numbers; however, the reality is that many mistakes were made, leading to the current ‘crisis’ of mental health commissioning, so it is hard to believe we can progress without significant change.
Neurodiversity (for this article focussed on ADHD and Autism), is rapidly becoming seen as a drain on limited resources, especially people and financial resources. Services are struggling to commission adequate provision, mainly due to three factors:
• A desire to think as we used to
• A reluctance to challenge self-taught prejudice that stifles change
• A lack of an open mind to truly identify the impact of 1 and 2 on the strategic and tactical thinking that is required to move forward.
As we look to internationalise what is good, maybe great, from UK healthcare, we must also ensure that we correctly identify where failing of thinking has detracted from the overall position of excellence. The NHS badge alone is not a single qualifier of perfection. It is a guide to 75 years of tremendous service delivery, free at the point of need, and often to an unqualified level of clinical excellence. Where I suspect our institution detracts from perfection is in management, procurement and an overall capability to listen and learn from the mistakes of the past.
We should categorically ensure that we do not seek to export everything, but only the best elements of what we proudly have.
The future of treatment for neurodiversity
So where does neurodiversity sit? Historically, ADHD sat with psychiatry; it is to do with the brain and synaptic processes. But does treatment require a psychiatrist? Of course it does, some will say, as it often involves medicine for the brain. These discussion points have validity, but they are also open to challenge. A headache involves the brain, but we treat sometimes with medicine, paracetamol, without the advice of a psychiatrist. And before we cry ‘what about the side effects of ADHD meds, surely they need a trained doctor’, please do go and look at the side effects of paracetamol.
Similarly, should ADHD sit inside psychology as it is hampered and tempered by nurture? But psychology rarely embraces medical intervention, so the fit is one for challenge.
If those deciding on the future shape of services cannot see mistakes of the past, or the errors on judgement that are still heralded as the way forward, or do not have more progressive thinking available to them, then we are very likely to be back into Mark Twain’s world – where the best predictor of future behaviour is past behaviour.
If he were to have written ‘The best predictor of future behaviour is the learning we can take from past behaviour’, we could progress faster and without some of the challenges of our past. Maybe in this context, we should use the information of our past as handrails, not handcuffs, and enjoy a new freedom of interpretation of what will work for the future.
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