Insights (Essays)

Insights (Essays) October 2017

The Case to Build “Un-Hospitals” in Ontario

Abhi Mukherjee


As the Canadian CFO of a global pharmaceutical company, I had a successful career in the For-Profit world. However, I wanted a more meaningful career – and transitioned to the public healthcare space, where I currently serve as a finance director in Canada’s largest academic and research hospital. I love the work that is done in our hospitals – taking care of our patients and curing them of their ailments. However, over the last few years, I have had this gradual realization – I don’t really work in “healthcare.” I am part of a machinery that tends to sick people – hence I am really in “sick care.” In my worst moments of despair, I visualize this morbid scene where physicians and nurses are waiting in an assembly line for people to fall sick so they can fix them up, clear the beds and wait for the next set of patients to show up. All this because our funding mechanism – whether the Quality Based Procedures (QBPs) or the market share for Health Based Allocation Methodology (HBAM) – are fueled by volumes and the flow of patients.

Which brought me to a crazy hypothetical scenario – what if one day, all the people in our catchment area suddenly became healthy and no one needed to visit any hospital? What if the population did not need so many hospital beds and the huge associated infrastructure? The annual operating budget for my hospital is over $2 Billion – I wonder where is the other side of the ledger? Who is getting incentivized $2 Billion to keep people healthy so that we do not need $2 Billion to fix them?

Greater minds than mine have spoken at length about population health. Policy papers have been tabled and presentations made at numerous fora. So, my idea is not new or innovative. I wonder though if we have aggressively promoted the concept of “proactively keeping people healthy”? I wonder if we need an Un-hospital?

What’s a Un-hospital, you ask? This is my vision of a network of trained (healthcare and allied) professionals working with the community and actively engaged in keeping the population healthy. I have some broad ideas of how this may work.

  • While a hospital is a physical structure, an Un-hospital is a network, collaborating to provide proactive healthcare to residents for early detection of symptoms and prevention of diseases.
  • We could begin a pilot in a somewhat densely populated suburban region of Toronto with a relatively stable resident base. We would need each and every resident by residential unit identified and in the database. This would be a live database that would be updated in real time for additions and deletions.
  • The identified population would be divided along geographical lines to have say 200 families as a unit (“Care Unit”). For instance, if there are 100,000 families in the region, there would be 500 Care Units, (each Care Unit comprising 200 families) numbered from 1 to 500.
  • We would have a “virtual” central command centre where there would be group of analysts and highly trained health informatics professionals collecting data, looking at trends, analyzing reports and feeding valuable information for decision-making throughout the Un-hospital system. The central command centre would be monitoring the activities across all Care Units and could move or coordinate to optimize resources depending upon demand and utilization.
  • Each Care Unit would have a dedicated Wellness Network Team. The Team would comprise family physicians, nurses, PSWs, dentists/ hygienists, eye care teams, physio therapists, psychiatrists, mental health professionals, geriatric professionals, nutritionists, yoga instructors, lab technicians etc. etc. – all certified professionals who would be selected based on the needs of the community.
  • There would be mobile lab units collecting samples at residents’ homes if required and also feeding back vital data (blood pressure, weights, heart rates etc.) to the central command’s database. As well, targeted high-risk residents would be given wearables and mobile apps to constantly feed data to the central command’s database.
  • Residents identified for specific diseases as “medium to high risk” would be specifically coached and monitored. For instance, smokers, people with high Body Mass Index, family histories of diabetes or heart disease, particular ethnic backgrounds etc. would be provided a holistic approach for early detection and prevention of any acute episodes. 
  • There would be a huge emphasis on home care. The Wellness Network Team would coordinate amongst themselves and provide the support and integrated interdisciplinary care for those in need right at their respective homes.
  • Each Wellness Network Team would share relevant data and be collectively accountable for the mental and physical well-being of each family under their care. They would need to proactively manage the well-being – not react to cure illnesses. The idea is not to be there for the residents when they are ill, but to prevent them from having acute episodes.
  • Wellness and good health is not just the responsibility of healthcare professionals. The Wellness Network Team would interact with schools, community centres, local gyms etc. to provide holistic care to the residents.
  • The central command would measure the performances of each Care Unit and be transparent in publishing key performance metrics. Financial metrics would be used for strategic decisions to optimize resources. The Wellness Network Teams would share and learn best practices from each other.
  • The measure of success would be lower acute episodic cases to hospitals from preventable diseases ailments. Care Units would be benchmarked and corrective action taken for negative deviations.      

These are very rudimentary thoughts and need to be fine-tuned. A pilot project could be started for experimenting and learning, and once proven successful, then the model can be scaled across the province. A significant portion of the billions of dollars we spend on sick care can then be channelled towards true healthcare. Building a wellness network system will take initial investments and the payback will happen gradually over time. The question is – do we have the political will and desire to invest in the well-being of Ontarians? Do we have the courage to create the Un-hospital system to keep us healthy and fit?       

About the Author(s)

Abhi Mukherjee is Director of Finance, University Health Network


David Uzan wrote:

Posted 2017/10/16 at 08:28 PM EDT

An excellent article about the direction that the healthcare system needs to head if it is to remain sustainable.


Mike wrote:

Posted 2017/10/18 at 05:47 AM EDT

1. clinical work is assumed to need aggregating into physical locations like hospitals, as that is, as they say, where the brains are, but this creates a self-fulfilling pull toward grouping services and care into these structures (see Foucault's Birth of the Clinic). No doubt we'll see serious disintermediation of expensive hospital infrastructure as precision medicine, AI/prediction models evolve, etc.
2. rich people like to donate money and hospital buildings are a favourite destination. It is said that the official bird of healthcare is the "building crane". Buildings drive a cycle of further service investment leading to service pull to drive further service requirements, without creating any new models of care.


Catherine Butler wrote:

Posted 2017/10/18 at 10:17 AM EDT

Great article with some innovative ideas. I completely agree with the need to redesign the health system based on wellness and health instead of illness and acute care. I also believe there is great opportunity to reorient home care to focus on rehabilitation and a return to wellness as opposed to the last stop before long term care. We could actually build a system of hope alongside a system that treats acute episodes and disease as a brief detour from the wellness journey in a highly specialized and effective way. We also need to build on peoples' and communities' strengths in health care to change behaviours and outcomes. We can only have a sustainable system if we begin treating the root cause of health issues before they begin.


Abhi Mukherjee wrote:

Posted 2017/10/18 at 12:52 PM EDT

@ David Uzan - thanks for your kind words.

@ Mike - well said! Politicians can find votes when they cut ribbons for new hospitals. Building a network for wellness and prevention will not get votes.

@ Catherine Butler - thank you! I think we need people like you and we can start the movement. I would love for this idea to take shape and become a reality. We are a G-7 nation in 2017 - if Elon Musk can dream big and take us to space, we can dream big and create a wellness network that would work alongside acute care, but reduce the number of incidents and the dependency on acute care and emergencies. Your comments mucho appreciated :)


Andre D'Penha wrote:

Posted 2017/10/18 at 04:14 PM EDT

Interesting article that will continue to get people thinking "outside the box."

As healthcare moves in to the digital space of next-generation analytics, predictive modeling, simulation, and precision medicine, and healthcare institutions adopt "hospital at home" approaches, it will be interesting to note how much of this article transforms from vision to reality!


Abhi Mukherjee wrote:

Posted 2017/10/20 at 10:06 AM EDT

@ Andre D'Penha - thank you. You are absolutely correct - there is so much happening in the space of predictive modeling - layered with genetics - imagine how powerful it can be to keep the population healthy!! Is it too much to dream that most of the vision in this article transforms from vision to reality?


Joachim Sturmberg wrote:

Posted 2017/10/20 at 06:45 PM EDT

The time is more than right to change our approaches - we need a "health care" not a "disease management" system.

It is great to see the notion of "health" being brought to the foreground, my own contemplations have led me to understand health as a "personal complex-adaptive state", conceptualised by the somato-psycho-socio-semiotic model of health.

Making "personal health" the centre of the "health care system" would result in a very different health and social (and for that matter economic) system - in short a redesign (I have written a book on this which will be published in January). Reform is no longer going to work, reform means "tinkering at the edges" within the prevailing framework.

Thank you for promoting this discourse which ultimately needs to be a "whole of society" one.


SP wrote:

Posted 2017/10/23 at 08:41 AM EDT

Un-hospitalizing is the way to go, without a doubt! And I think we are, ever so slowly, trying to move toward this type of preventative medicine. But we are not moving fast, or on a scale that is large enough.

Our hospitals are responding to a global economy driven by the profitability of hospitalizing its people. The Wellness Network Team must include more than our conventional health care providers, because the social determinants of health are impacted by a broader group. It is going to need to involve the individuals of every industry, to ensure the responsibility for "wellness" belongs to everyone.

This a great article, and such food for thought. To all the professors out there, constructing a model for un-hospitalization would be a very neat assignment.


Hugh MacLeod wrote:

Posted 2017/10/25 at 07:21 PM EDT

A great essay and a must read for all. Health and wellness is far greater than independent ambitions or election votes. As your essay suggests, true transformation requires a new and revolutionary mindset and strategy. It is imperative that health care moves well beyond its current standing of; stale protocols, outmoded agendas, incomplete strategies, forceful top down mandates, self-serving ambitions, and political quick fixes. I have witnessed and been part these insertions for a number of decades, and they fail to work.

Your essay calls for healthcare leaders to be gritty and to stand up against outdated systems and relationship patterns. They need to use their voice, influence and energy to break down and remove each and every component that obstructs health and wellness change.


Abhi Mukherjee wrote:

Posted 2017/10/27 at 07:45 PM EDT

Thank you all for your comments and support.

@ Joachim Sturmberg, S P and Hugh MacLeod : Your comments are very apt. I hope you will champion this change and continue the dialogue. Thank you!


Josh Williams wrote:

Posted 2018/02/01 at 03:19 PM EST

This sounds a lot like the work CityBlock is beginning to undertake in NYC and may spillover into Toronto with the awarding of the Quayside development to Sidewalk Labs. An opportunity there to take your thoughts off of the paper and into a real life model.


Karen Waite wrote:

Posted 2018/02/01 at 04:40 PM EST

Abhi - you're 'right on the money' - we definitely need to move more aggressively in this direction! We've been slowly chipping away at this through the introduction of digital health tools but we need policy and political will to realize this vision. Let's use the ringing in of 2018 to dig deep and get the momentum goes beyond health care leaders...we need leadership in all spaces. Financial security, housing, we need a coalition to move this forward.


Abhi Mukherjee wrote:

Posted 2018/03/01 at 10:07 PM EST

@ Josh Williams: Thanks! I would love to take my thoughts into the real world. The Quayside is a good idea- but may have its challenges. I was thinking more of a defined geographical area with a stable population to begin as a pilot and plan to succeed. If we have good (timely & accurate) data on each and every person in that area and use the data to monitor the individuals for good health and wellness - may be we can build a case to scale this model across Canada. I know I am a dreamer, but reading the comments, I believe I am not the only one! Thank you for your feedback and encouragement.


Abhi Mukherjee wrote:

Posted 2018/03/01 at 10:14 PM EST

@ Karen Waite: Thank you for your insight. You are absolutely correct in your assessment that healthcare is a component of mental, physical, emotional and economic factors and "goes beyond health care leaders..." We are blessed to live in Canada where we can contemplate having a holistic approach to wellness. We need champions like you Karen, so please help keep the conversation going on this.


Gillian Kernaghan wrote:

Posted 2018/08/28 at 10:27 AM EDT

We need to think of hospitals less about the building rather the coalition of expertise. The hospital of the future will be less about people coming to the hospital and more about the expertise going to people enabled by technology.


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