30 Jan 2014

HRH Princess Haya Calls for Systematic, Programmed Specialization in Healthcare

Your Excellencies,

Distinguished Guests,

Ladies and Gentlemen,

I am honoured to be among so many leaders of the medical community once again. I would like to welcome you to the United Arab Emirates, particularly Dubai.

Since we last met, we have made significant advances in healthcare. The Al Jalila Foundation, a not-for-profit organisation launched in 2013 by His Highness Sheikh Mohammed Bin Rashid Al Maktoum, is mandated with establishing the UAE as a centre of excellence in medical education and research. Additionally, the groundwork for your chosen topic of discussion, specialisation in healthcare, has already been more than strategically paved by the new insurance law which comes into force in Dubai this year and will offer healthcare cover for all our residents. His Highness’ directives are quite simply the most powerful catalyst there could ever be for specialisation in this sector.

We continue to improve the standards of specialist nurses, and our well-advanced plans to establish the University of Medicine and Health Sciences and the University Hospital in Dubai Healthcare City. Also, earlier this month, His Highness Sheikh Mohammed chaired a two-day national brainstorming session to boost the educational and healthcare sectors. They endorsed cancer early detection programs, a national database for all medical records, and several measures tackling obesity and encouraging healthy lifestyles.

These achievements confirm where we are now, but more importantly, underline our commitment to establishing a world-class healthcare system for our people. We remain in the enviable position of learning from our mistakes, building on our solid knowledge base, and on our ability to nurture established partnerships to develop a system we would be proud of.

Before we redesign our healthcare system, we must understand the advantages and risks of specialisation. A specialist is a person who concentrates primarily on a particular subject or activity and becomes highly skilled in a specific and restricted field. In medicine, this translates into a doctor highly trained in a particular branch of medicine, thus possessing detailed knowledge and skill to treat a specific disease or group of diseases.

The main driver for specialisation remains an improved outcome for patients. Although there is a lack of direct evidence, there are observational studies that have shown specialisations leading to a better outcome for patients. For example, treatment in ICUs improve outcomes after head trauma, and specialised paediatric ICUs improve critical care outcomes in patients and lead to a one-day reduction in length of ICU stay. In recent studies, not only has the establishment of London’s Hyperacute Stroke Unit reduced mortality from stroke by 25 per cent at three months, but it also reduced the cost of treating stroke patients by 6 per cent at the same time point.

So, how do we get better outcomes at reduced cost by specialisation? The results we are seeing are not hard to explain.

By building speciality hospitals, healthcare workers are exposed to a large number of patients with the illness in question, which otherwise may rarely be seen by those individuals. With the increased number of treatments comes early recognition of signs and symptoms, the institution of early treatments, better-timed diagnostics and interventions, as well as improved outcomes. The “volume” effect is well recognised in business; similarly, the aggregation of volume by speciality hospitals enable them to benefit from returns to experience that could either reduce cost or improve the quality of care.

By creating specialised centres, the substantial fixed investments required to provide services such as cardiac surgery or orthopaedic procedures have proven economical by consolidating volume that would have otherwise been allocated across multiple diversified facilities.

Concentrating expensive equipment in one location improves utilisation and reduces unit cost. The design of these facilities is such that it is optimal for dealing with a particular disease entity or group of patients; paediatric wards with family accommodation, neurosurgical theatres with intraoperative MRI, and stroke units with rehabilitation facilities on site.

Furthermore, by allowing physicians to share in the efficiency gains through ownership, speciality hospitals may create more powerful incentives to achieve these and other cost and quality improvements.

The concentration of disease and expertise in one area also allows better integration of research, teaching and training. Population studies, basic science and translational research can be conducted efficiently and at a reduced cost. It also allows collaboration with pharmaceutical and other commercial partners to efficiently develop and test new drugs and technologies in this space, saving money, time and most of all lives.

This is of particular significance in rare conditions and even more so when the rare condition is in small populations such as the UAE.

So, how do we fair in the UAE with regard to specialist hospitals?

Most hospitals in the region, especially in the UAE, were established as general hospitals that have become known for a particular speciality over time. These specialities developed because of clinicians driving the agenda at those hospitals, market forces, as well as sometimes simply, profit. Most hospitals were not designed nor structured operationally for the specialities they have become famous for.

To succeed, we must conduct a proper needs assessment for our population, and any other people we think we can attract here for treatment by becoming a centre of excellence for a particular speciality. A detailed needs assessment would identify the most prevalent and highest incidence of diseases in our population, allowing us to concentrate our resources and establishing well-designed, well-staffed, well-equipped, and well-populated specialised centres; such as the intention for the Al Jalila Children’s Specialty Hospital. No project should ever be allowed to proceed, wasting our precious resources without a detailed and proper needs assessment. A project that is allowed to proceed without such an evaluation will have very little chance of success, and when it does, it will be as a result of luck rather than careful planning. We cannot afford to and must not gamble with the health of our nation!

We must consider that there will be diseases that are too rare for us to treat alone. We need local, and on occasions, international partners, to help us deliver the best possible care. We must not dilute our expertise by establishing competing facilities when the demand is low, as this will reduce expertise, increase the cost of healthcare delivery and most drastic of all, worsen outcome. That would be tragic and at odds with our mission and our beliefs.

Another challenge for our region is identifying how many specialised centres are required to serve our important but relatively small populations. As neighbours in the middle east, we must accept that we cannot all have specialised centres treating every rare disease. The notion of several cancer centres, several paediatric centres, several transplant centres, and several cardiac centres is simply naive. We must ensure we have the need for certain specialities before we needlessly build centres that see no significant volume of patients; in healthcare, both volume and experience are equally important!

Even countries with advanced healthcare systems such as the UK and USA limit the number of speciality centres in order to concentrate expertise, reduce cost and improve outcomes. We must work together to limit the senseless expansion of facilities that dilute our expertise, waste our money, and end up failing our patients. We must work together to identify the opportunities and decide on how best to share the work, risks and benefits of centralised specialist services. We must avoid making specialisation an instrument looking for an illness to treat, rather than keeping our people healthy.

At the same time, we need to be mindful that specialisation does not mean lowering our standards when it comes to “general health care”. Healthcare professionals (doctors and nurses) have become so much specialised in certain areas that they have neglected the basics of general care.

One of the areas often neglected is rehabilitation. Patients suffering from a prolonged illness, a life-changing event, often receive excellent acute care but limited rehabilitation. All that hard work getting the patient over the acute injury is almost wasted if the patient is not rehabilitated and integrated back into society where they can then live a normal life and contribute to the country.

Many experts argue the need for centres specialised in rehabilitation, physical and mental! Specialisation is of no benefit if basic healthcare, including rehabilitation, is inadequate. Good doctors treat disease; great doctors treat patients!

We need to stay alert to the potential outbreaks of infectious diseases, to ensure continuing investment in public health and to be prepared to respond to emergencies. We must insist that all healthcare providers in the UAE continue to provide safe, up to date, and free from harm general medical care. They must maintain basic skills as well as the ability to recognise when specialist help is required, from within the region, and occasionally, further afield.

Recognising our limitations is not a sign of weakness, but a sign of maturity and an admission that the needs of our patients always exceed our desire for fame and glory.

We live in a world driven by competition, for better or worse. Dubai understands first hand its importance, as, without it, there would be no firsts in its history of achievements.

It is this competitive hunger that helps us drive forward faster, harder and with a vengeance. We can take advantage of having a competitive mind-set; however, we do not have the luxury of time. We must be vigilant and plan far ahead. We thrive on competition, as it can spearhead us to new heights.

Having a competitive edge is optimised through smart synergies. If we are not careful, it could also derail foundations built based on trust and strategic alignment. It could waste valuable resources and distance us from fighting for what is right, planning beyond our own needs.

We can lose sight of what is important and seek out success selfishly.  It is time to face the truth that this cannot be done alone. Our local efforts must be utilised effectively before we can look to the outside because we have to be in shape before opening up to collaborating with anyone who can see what we have to offer more than we can see it in ourselves.

We are primed, too, for advancement. Technology is at our fingertips, and we have endless opportunities in the healthcare sphere to maximise its benefits. Technology pushes boundaries, forces us to think differently, and remember our capacity for creativity. It is our responsibility to make it happen. It is also our responsibility to implement the vision of His Highness Sheikh Mohammed to become mobile by 2015. Healthcare must keep up.

A network of capabilities must be in place for successful execution, and it starts with refining the infrastructure already underway, not by rebuilding it or ignoring the systems that must be in place to support it. The IT infrastructure healthcare required cannot be built without synchronising local, federal and private entities just as specialisation cannot exist without general care.  We must start with the basics in order to go beyond.

His Highness Sheikh Mohammed has always reminded us that the health of our nation will always be more important than the wealth of our nation. His desire is to build a sustainable healthcare system that serves the needs of our growing population. Therefore, let us all commit to working together to make good on His Highness Sheikh Mohammed’s promise.

My final message to you is that our healthcare systems need to respond to the growing need for specialised centres in order to serve our current and future population needs. These specialised centres should be designed and built based on solid evidence from a macro level assessment of our current and likely future needs. We must seek help by establishing good partnerships with local and international partners who have set up specialised centres before us so that we can avoid pitfalls. Above all, we must not compete with each other, diluting our workload, expertise and worsening our outcomes.

To go back to my introduction on specialisation and the insurance law introduced by His Highness Sheikh Mohammed, ironically, it ticks both boxes – while it is the catalyst for specialisation, it also will simply not allow you all to neglect general care either!

One of my favourite stories that His Highness Sheikh Mohammad tells is about the lion and the gazelle. Each new day in Africa a gazelle wakes up knowing he must outrun the fastest lion or perish. At the same time, a lion stirs and stretches knowing he must outrun the quickest gazelle or starve. It is not different for the human race. Whether you consider yourself a gazelle or a lion, you simply have to run faster than others to survive.

With this in mind, I welcome you all to Dubai, and as we say in Dubai, start running because each and every one of you has to go that extra mile to save our patients travelling several thousand miles.

Thank you.