■ Appendix C United European Gastroenterology Case Study
Shirin Elahi and Rafael Ramírez
Background
United European Gastroenterology, or UEG, is a professional non-profit organization in the health sector. It is actually an association of organizations (what Ahrne and Brunsson (2005) call a meta-organization), comprising all the leading European professional societies concerned with digestive disease, and also includes individual members. In total, UEG represents over 22,000 specialists, who work across medicine, surgery, pediatrics, gastrointestinal (GI) oncology, and endoscopy. This broad reach makes UEG the most comprehensive organization of its kind.1
UEG is therefore uniquely equipped as a platform for collaboration and knowledge sharing, enabling it to further its mission: to advance gastroenterology care and improve the prevention and care of digestive diseases in Europe. UEG acts as the united voice of European gastroenterology, delivering cutting-edge education and training; facilitating and disseminating world-leading research; and working to improve clinical standards and services and reduce health inequalities across Europe. To achieve these goals, UEG collaborates with healthcare professionals, scientists, patients, and the public, and liaises closely with politicians and policymakers.
UEG is funded by membership dues and the scientific activities and events it arranges. These include its annual congress, postgraduate teaching, publication of a scientific journal, and educational programs. It also enjoys sponsorship from industry.
Scenario project work
Current models (as at 2014) for healthcare delivery in Europe are unsustainable, with a rapidly aging population, rising health costs, reduced public budgets, volatile political and economic landscapes, as well as a shrinking workforce and increasing burden of lifestyle diseases. GI diseases contribute significantly to the healthcare burden in Europe, accounting for substantial morbidity, mortality, and cost.
For example, digestive diseases, that is, gastrointestinal and liver disorders, caused more than 500,000 deaths in 2008 in the twenty-eight EU member states, and more than 900,000 deaths in the whole of Europe, including Russia and other non-EU states (UEG 2014). Over one-third of all acute hospital admissions are due to GI diseases, and at least one in three Europeans will visit a gastroenterologist at least once in their lives.
It takes eight years to educate a gastroenterologist, so the UEG leadership considered that in 2040 the students entering medical school in 2014 to study this specialization would be half-way through a professional career that became active in 2022. The UEG wanted to examine how well the profession was educating these incoming colleagues for the conditions they might encounter in their future careers. To better anticipate and prepare for possibly new and very different future contexts, members of UEG’s “Futures Trends Committee” and its then chairman, Professor Michael Farthing (now president of UEG), collaborated with Julia Frauscher from the UEG head office in Vienna, and hired the NormannPartners consultancy to explore how these future contexts might unfold:
“We know that the incidence and prevalence of most major GI disorders are rising across Europe and there is already poor access to care in many countries. Since changing the way we deliver healthcare in the future seems inevitable, we decided to take a bold approach and highlight possible scenarios, inspiring everyone to get involved and play their part in shaping a better future for digestive and liver disease healthcare,” said Prof. Farthing. (UEG 2014)
The UEG scenarios-based strategic planning intervention set out to explore what the European healthcare system might look like in 2040; and to describe the future contexts for health “care” at home, in hospitals, and by oneself in 2040 and beyond.
The scenarios were produced for immediate use by the incoming president and for the members of the Future Trends Committee of the UEG he had chaired. He thought the scenarios would help them, as well as UEG members and stakeholders, in imagining future possibilities. The scenario planning process was thus designed to help these individuals inform UEG members and stakeholders about future possibilities; to challenge current thinking; and to inspire the gastroenterology community to work together to shape a better future for patients. An additional important purpose of the scenarios was to sharpen strategy, enabling UEG, its members, and stakeholders to have more courageous strategic conversations.
The scenario planning project was conceived in 2013 and took over a year to develop. Three scenario workshops were held over a period of several months, with substantial work by the scenario builders in between. The scenario building team comprised a diverse professional group of eighteen people drawn from across the various specialties, age groups, professional levels, and geographic regions of Europe.
The scenarios were built inductively from the eighteen key contextual uncertainties that were identified during the workshops (see Figure C1), and then further researched by the scenario building team. An initial set of eight scenarios were developed during the first day of the second workshop, with four others added in the second day. These twelve candidate sketch scenarios were then discussed, compared, merged, and reduced in plenary to produce three agreed final scenarios. The final set of three were tentatively entitled Meltdown, TechMed, and United States of Europe. The names were discussed and changed during the final workshop to those described in the next section. Following the final workshop, the stories and the formats for comparing the scenarios to each other were refined for sharing in a plenary hour-long session2 in the annual meeting of the UEG held in October 2014. The scenarios were then made public through the UEG’s website.3
The UEG scenarios
Three scenarios describe what the European healthcare system might look like in 2040. The final names were Ice Age, Silicon Age, and Golden Age.
Figure C1. Driving forces in UEG’s contextual environment
Used with permission; see <https://ueg.eu>
Ice Age. By 2040 European impoverishment has resulted in a two-tier system of medical treatments, which eventually triggers a collapse of public healthcare systems across Europe.
By 2040 natural resource shortages, climate change impacts, inactive aging, and economic crisis have contributed to the widespread impoverishment of Europe. The European Union no longer exists, most of the population is poor, unemployment is high, and membership of religious groups and alternative “health sects” is high. Environmental hazards, including pollution and increased exposure to potential carcinogens, contribute to this toxic mix.
Silicon Age. By 2040 advances in technology, science, and social interactions have led to extensive automation of diagnoses and treatment and redirected health behaviors, resulting in a shift to preventative health.
In Silicon Age, global trends and crises have led to changes at every level—in individual behavior, social priorities, industrial strategies, and government policies. Population growth has encouraged innovation and there is widespread acceptance of technology. Social media have become highly influential across the healthcare sector.
The European Union still exists and has contributed to the modernization of health legislation across Europe. There is a large non-EU immigrant population relying on social security, draining resources and escalating healthcare expenditure.
Golden Age. By 2040 a strong, well-coordinated, unified Europe has ensured access to high-quality healthcare to all European citizens.
An influx of immigrants and widespread cross-border movement of Europeans has resulted in a more multicultural and united Europe. Here we see a United States of Europe, with no internal borders, homogenized education, taxation, and legislation systems, and universal access to healthcare for all. Economic growth has slowed, environmental issues are being addressed, and preventative health is high on the agenda. The resulting peace and stability denotes a Golden Age for Europe.
Implications for Healthcare and the Roles of Healthcare Professionals
Specific health and healthcare features of each scenario were drawn out, and these are summarized in Table C1. Each scenario also described how the role of the doctor and healthcare specialist might change in each future. In Ice Age, doctors are leaving Europe to seek better conditions and access to the latest technology and treatments elsewhere. In Silicon Age, doctors maintain a traditional role delivering patient-centered care supported by cost-effective e-health platforms. In Golden Age, doctors assist individuals with navigating and understanding their personal electronic patient cloud records.
Project results: uses, outcomes, consequences
These scenarios were made public at UEG Week 2014, an annual professional event that took place in Vienna and was attended by 13,000 delegates from 118 countries. The scenarios were presented at a special UEG Research Symposium, entitled Gastroenterology and Hepatology: Past, Present and Future. Each of the scenarios was presented by the “champion” who had led the particular group of scenario builders who developed that scenario. This presentation triggered a widespread discussion that has subsequently moved online, with each of the scenario presentations described in a detailed video on YouTube.4 At a press conference at UEG Week, the scenarios were also presented to leading medical journalists from all over the world.
In addition to the presentations, the scenarios resources that were prepared and have begun to be shared include a detailed section explaining why the world of healthcare will inevitably change. It argues why and how current models for healthcare delivery in Europe are unsustainable: a rapidly aging population supported by a shrinking workforce with limited public financing presents major challenges and requires new thinking. It describes the eighteen contextual driving forces shaping this transformation of the profession’s transactional environment (see Figure C1).
The purpose of the scenario planning project was to encourage more courageous and informed debate, to support the UEG’s external communications strategy, and to manifest the courageous conversations the scenarios enabled though different social media, particularly Twitter and Facebook.5
A tab on the UEG website called Starting the Conversation6 announced that the scenarios were rendered public. It urged readers to help UEG plan for a better future for people with digestive and liver diseases by visiting the website and casting their vote on which of the three scenarios they thought was the most likely 2040 healthcare scenario; or to post any thoughts and comments on the future of digestive and liver diseases throughout Europe.
Table C1. Health and healthcare features of the UEG scenarios
| Ice Age | Silicon Age | Golden Age |
|---|---|---|
| A two-tier healthcare system has developed and led to the collapse of public healthcare in Europe. An aging population with an increase in age-related chronic diseases like cancer, antibiotic resistance combined with a lack of new drugs, and outbreaks of infectious disease epidemics all threaten the population. Poverty and poor healthcare have led to high rates of morbidity and mortality within the general population. Most individuals have little or no access to healthcare and are also plagued by diseases associated with alcohol, tobacco, and obesity. In desperation, people are turning to alternative medicine and uncontrolled self-medication. For the rich minority, there is excellent healthcare available in the private sector. Science is market-driven, and healthcare services, primarily provided by profit-hungry insurance companies, are only available to those who can pay. Healthcare workers are leaving Europe seeking better conditions and access to the latest technology and treatments. Patients are increasingly seeking healthcare outside Europe or from offshore floating hospitals. |
While inequalities in healthcare still exist, the dominance of technology has provided a means of delivering high-tech, cost-effective care to the majority of Europeans. E-algorithms detailing risk profiles for multiple diseases are developed via genomic screening at birth. Individuals take responsibility for self-monitoring, self-cure, and prevention assisted by comprehensive lifestyle and health data stored in their personal electronic patient cloud record. Automated diagnostics and interventions, including robotics, are readily available by self-referral. With the adoption of e-health, the role of the doctor has fundamentally changed from delivering healthcare to assisting individuals with navigating and understanding their medical e-data. Collaborative ventures as well as innovative public and private partnerships work for the benefit of the patient. Widespread use of social media platforms has helped to integrate significant advances in medical research and data capture. Alongside e-health there has been a shift into an e-economy which includes novel monetary systems that carry the risk of using unofficial currencies and unethical or even criminal activities. Social media and advanced technology bring with them privacy concerns. Some poor-quality health practices as well as complex systems which are hard to navigate have arisen. |
Dictated by a strong, centralized public sector, the private sector has helped implement mandatory prevention programs. Children are formally educated about the importance of health and to encourage all to have a positive attitude toward illness prevention. Consistent Europe-wide prevention-based strategies, policies, and practices are in place. Good quality, cost-effective healthcare is available to all, delivered primarily via e-health initiatives, outpatient clinics, low-cost healthcare centers, and care at home. There is total European cohesion in healthcare with consistent medical education and training across the continent. Doctors continue to play a traditional role and deliver patient-centered care. Patients increasingly use email and dedicated electronic platforms to liaise with their healthcare professional, and travel freely across the United States of Europe to access the best healthcare providers and specialist centers. |
At the time of writing (January 2015), the utilization of these scenarios in UEG is still in its early stages. To date they have opened a dialogue on some pertinent issues about the future of public health. They have enabled UEG’s many constituents to broach a difficult subject, namely, that business as usual is unlikely to continue unimpeded into the future, and consequently that the profession—together with its education and research profiles, and healthcare in general—are bound to change in rather fundamental ways. According to UEG officials, a roadshow has been planned for 2015 and is likely to be taken up again in 2016 to present the scenarios to UEG members and stakeholders.
The scenarios have already begun to be used as a tool for policy engagement. For example, the UEG’s top staff met with policymakers from the European Parliament and the Commission in late 2014 to assess current trends and future challenges in the field of gastrointestinal care for patients, and to discuss how EU health policies should be shaped in order to provide the best possible medical care to citizens.7 The meetings sought to engage stakeholders in a structured debate about the future of public health policies in Europe, the challenges that accompany it, and adequate EU policy responses.
In addition to its Scenarios for the Future, in 2014 UEG also conducted and published a Survey on Digestive Health across Europe. This survey reflected the reality of the profession at that time. It included a detailed assessment of digestive and liver diseases in twenty-eight European countries, examined the clinical and economic burdens of these diseases, and evaluated the organization and delivery of gastroenterology services. It was the first study to compile all available data into a single comprehensive overview of gastrointestinal diseases and treatment in Europe, and identified concrete actions for further research and political action.
Implications
The UEG scenario planning initiative has enabled the organization to further establish its place as a thought leader and key player in the healthcare arena. It has helped it to remind policymakers of the critical role gastroenterology plays in public health. Each of the scenarios envisages very different roles for the patient as well as the doctor. These changing roles would have far-reaching impacts on the relationships among healthcare generalists, specialists, patients and their families, carers, clients/payers, and sources of funding. All of these relationships will require careful consideration.
UEG’s analyses of inevitable change are meant to be a catalyst for further strategic conversations, and seek to help European policymakers to confront what might be unwelcome considerations about the future. The structural changes described in each of the scenarios imply fundamental reorganizations of the prevailing healthcare systems of Europe. In each of the three scenarios, the very nature of health is redefined, as are the actors who operate to provide healthcare in 2040.
In terms of healthcare, these changes impact social dynamics: they highlight the potential for a reinforcing health feedback loop and question the nature of public health. These dynamics also have political implications such as questioning the roles of the EU, how inequality might unfold, and what form the concept of “social solidarity” might take.
In addition to the public engagement, internally the scenarios entail a substantially different role for UEG, requiring it to acquire or develop different capabilities to remain strong and relevant. As such, the uptake of scenario thinking under the newly elected president will require a major rethinking of UEG’s identity, how it relates to professional bodies and individual members, and even how best it can achieve its purpose. This could also include a reassessment of success criteria and ways for it to maintain its desired relevance.