the policy cognologist

Posted By policy cognologist on February 1, 2010

News item in the UK: The sector’s funding body, the Higher Education Funding Council for England (HEFCE), announced (on 1 February 2010) that budgets are to be cut by £449 million for 2010/11.  This includes:

* A 1.6 per cent reduction (£215 million) in teaching funding;

* Research budgets will remain the same as last year;

* A 16.9 per cent cut in capital funding;

* A 7 per cent reduction for funding of special programmes and initiatives.

In a letter to vice-chancellors setting out the budgets, HEFCE said it recognised that the reductions will be “challenging” to institutions.

Now what is to be done? Predictably, the higher education sector in the UK is arguing that this will affect perhaps 200,000 students who won’t be able to get a university education. A few weeks ago, the sector argued that the UK’s place as a top tier home of higher learning was at risk — but that came from the elite Russell Group, which represents perhaps the top of the top universities in the UK.

There are a number of possible ways of thinking about this. A few:

1. Universities already get a lot of money, and they perhaps could reduce their running costs — think of the disorganised structure of the academic year, think of teaching loads or confused performance management (is it teaching quality, research or publications??), and pretty good employment contracts. (I had one once.)
2. There are too many universities trying to do too much, and perhaps it would not be a bad thing if some either closed or merged with another institution. The loss of the old polytechnics deprived the higher education system of a sensible alternative. Since comparisons to the US are frequently made, it is worth noting that some of the US’s top institutions are not called “university”, anyway, but ‘institute’ and indeed ‘polytechnic’. One could also look for new innovative institutions to emerge to challenge much that universities do. For instance, research institutions without university links, or which are focused on compelling issues — check out the Santa Fe Institute, for instance. Universities are not the only fruit!
3. Cutting capital funding is not such a bad thing, given the horrendous financing of a state-sponsored capital funding body. Better universities learn how to build collaborative relationships with sources of capital, than expect their funding automatically to come from the state.
4. Perhaps too much inadequate research is done, poor deployment of intellectual effort at reaching wider learning communities, responding to new ways of structuring learning beyond the rather tired full or part time dichotomy, and so on.

But of course, the key dilemma remains, what is to be done?

I take an optimistic view, but I would put the challenge at the door-step of the universities.

Rather than complain, prove that 800 years of public and private investment hasn’t been wasted, and come up with sensible solutions that would establish a sustainable approach going forward.  I doubt 200,000 or 200 students would be disenfranchised as a result, new ideas would emerge.

A recent book review in the Financial Times of Louis Menand’s The Marketplace of Ideas, would be a good place to begin some fresh thinking. The reviewer, Christopher Caldwell, notes:

Starting in the 1970s, professors, newly alert to injustices in society at large, took aim at credentialism and departmentalisation in every nook and cranny of American life – except, Mr Menand notes pointedly, their own. The professorial hierarchy continued to rest on a system of arduous PhDs (raising high barriers to entry), “disciplinarity” (denying the authority of the non-credentialed to teach or even discuss academic subject matter), and tenure (jobs for life). It was a system well-suited to monopolising bureaucratic power, but less well-suited to the free flow of ideas. Menand cites a 2007 study to show that, in the 2004 presidential elections, 95 per cent of the social science and humanities professors at elite US universities voted for John Kerry and 0 per cent (statistically speaking) for George W. Bush. Monopolies produce smugness and sameness in universities, just as they do anywhere else.

The title of this blog entry takes from a line in the film Independence Day, where the President says to the Geoff Goldblum character, ” And we’ll see if you’re as smart as we all hope you are” It is now time for the universities with their massive subsidised top-tier braintrust put on their thinking caps, stop playing victim and take responsibility for the solution.  The university-based economists let us down quite badly with failing models of our economies, and we are all paying for it in one way or other. Let’s not see two in a row.

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Tags: "good idea", Higher education, innovation, reform, Russell Group, UK, universities, USA

Posted By policy cognologist on December 21, 2009

Item in the new: “The manufacturer of a drug which could extend the lives of thousands of people suffering from a rare form of cancer has agreed to pay for further patient treatment as part of a cost-cutting scheme.”  This arises from a decision of the English agency NICE to recommend limited use of this medicine.

We have a situation where the pharma company is going to provide the medicine for free to a certain group of patients (the details aren’t important for this commentary) at a certain point in their treatment — in this case toward the end of that person’s life.

How are we to make sense of this?

Who benefits?: the patients get the medicine which they would otherwise not get it toward the end of their life; indeed, unless they were able to pay for it themselves, they would be deprived of the medicine. NHS gets a medicine, which it would otherwise not pay for, for free, for a group of patients, one might argue they were abandoning.

Who pays?: the pharma company absorbs the cost of doing this for one final application of the medicine if needed; the public sector does not pay anything.

When some derive benefit for free from the actions of others, we call the former free riders; that makes the NHS a free-rider. Indeed, one might view NICE and other HTA agencies as acting to achieve free-ridership for the public system, by rationing public funding according to the HTA assessments. The pharma companies, wanting their medicines to be used (they might actually also want them to be paid for), give them away for this group of patients for their own reasons.

This small group of patients would undoubtedly suffer, a price NICE deems worth the cost, and the NHS in this case, is willing to be bound by a decision which may actually increase suffering. The pharma company has come to the rescue of these few patients and is now doing what one would think the public system should do, alleviate suffering. Had the pharma company put profits before use (which they appear not to be doing otherwise they would have sought payment) no doubt they would have been criticised for their prices, which of course underpins NICE’s cost-benefit analysis in part.

Did NICE shake down the pharma company?

I have argued elsewhere, that public health systems must be the payer of last resort (the so-called Rule of Rescue), which should challenge NICE’s models that would increase suffering, as that cost is something no state should ignore. The unethical conduct of public bodies here is breathtaking.

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Tags: "c'est dommage", ethics, money, UK

Posted By policy cognologist on December 18, 2009

The whatever they are called talks in Copenhagen on climate demonstrate the broken nature of our approach to achieving consensus amongst a diversity of nations, views, and wishes. The circus will soon close and we may have very little to show for it, despite everyone’s hopes and wishes. A room with THAT many people in it could hardly agree what to put on a pizza, let alone work through a complex drafting of such an important document.

A few points are worth noting:

1. Trying to achieve an agreement by having the negotiations stretch throughout the night, so no one gets any sleep is bull-headed, and is hardly evidence of clear and coherent thoughts at 3 in the morning.  Early morning tweets from politicians who have stayed up all night just adds to the impression that these people don’t know what they are doing.
2. The notion that the backroom gang do all the heavy lifting and then the leaders swan in to sign the final draft is well-past its sell-by date. Clearly, neither works.

Savvy negotiators know that getting your opponent to go without sleep is one way to ensure both delay and achievement of your objectives. Tiredness doesn’t just kill on the road, but is a well-established brinkmanship tactic. It is particularly helpful when there is a hard deadline, and great expectations of results; the closer to the deadline with a lack of agreement, the more likely sleep will be deprived and decision-making and clear-thinking begin to fail. Better to add days than nights to negotiations, and drop this adolescent behaviour.

Setting expectations high also creates an opportunity for nay-sayers to bargain their way to a lower level of agreement, giving the impression of failure whereas they may actually have found the spot at which agreement is most likely, but having failed to establish a Plan B, meant that it was Plan A or failure. An existence of a Plan B, though, would have infuriated some advocates for agreement, as it would identify prima facie where compromise would be likely.  The problem in part was that compromise is often seen as failure, rather than agreement by other means. Perhaps it is better to under-promise and over-deliver.

The use of backroom staff is important, but it is evident from Copenhagen that a lot of fundamental bluesky disagreements remained and where solutions lay above the pay grades of the staff involved.  Better than leaders learn to do their own work, and have the backroom staff refine the language, than the other way round.

The problem with Copenhagen appears to be faltering over accountability; this is a re-run of the nuclear arms treaties. One could argue that objections may be well-founded, but we haven’t seen the basis for that. Agreements do need mechanisms to ensure they do what they are intended to do, but we don’t have sufficient vocabulary for what we need as in the past, most agreements were either treaties with broadly equal partners (e.g. Treaty of Rome) or were imposed by victors over vanquished (take your pick here). This seems more like a communitarian process, with considerable inequality. Perhaps some lessons from community development models would have been helpful.

Of course, this is all quite apart from whether a deal is pulled out of the hat, and whether it is a deal or just a political fix.

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Tags: "c'est dommage", fear, opportunity, reform

Posted By policy cognologist on December 17, 2009

Who owns a profession and who should take responsibility for its development?

In the UK, the Prime Minister’s Commission on the Future of Nursing and Midwifery has been working away for awhile to determine the future of these two professions, so lets reflect on this question and look at what this Commission appears to be thinking.

The most obvious observation is that it appears to be thinking of nursing and midwifery within an NHS context. Many nurses work outside of the state-sponsored NHS, such in prisons, nursing homes, private and independent settings and workplaces. The Commission’s focus, therefore, on defining the future role of the profession suffers from a dilemma and in resolving this dilemma in a particular way, may further limit these professions to what the NHS defines as its role. This is particularly worrisome given the dire need for fresh and innovative thinking particularly from such a broad and diverse profession as nurses and midwifes which may indeed need to challenge current political and policy thinking.

I wonder whether, too, it is indeed appropriate for the ’state’ to sponsor this type of work in the first place. The selection of those on the Commission is probably subject to various criteria — one can only hope that these folk are able to address the work of these professions in non-NHS settings in the first place, and secondly can address the dire need for fresh thinking about future demands and innovative approaches to service delivery, however and wherever.

The other concern is the tendency of these sorts of activities to become a restatement of warm words of praise, and in the end fail to move beyond that to address the underlying interconnectedness of clinical work, the interprofessional relationships and clinical responsibility and indeed to more disruptive and potentially more professionally satisfying professional development itself. Regretfully, the so-called “summary vision” is a weak and predictable statement.

There is nothing inherently wrong with addressing the needs of the NHS, but to address it to the exclusion of the legitimacy of the wider and likely future roles is a mistake.  Indeed, the NHS is a stakeholder in the development of these professions, but should not be given too much authority or control over how the professions develop. When the state steps in, as it has in this case, it should do so with the assurance of fairness to the widest possible range of interests, and not just those that fits its current, and probably ideological, preferences.

In the end, the professions own themselves (in an important relationship with their regulator) and should act to ensure that they confront these issues responsibly. Is it a sign of weakness perhaps that this Commission was even needed? Perhaps therein lies a clue to the future of these professions: take responsibility for your profession, as if you don’t others will.

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Tags: "c'est dommage", opportunity, reform, UK

Posted By policy cognologist on December 10, 2009

With public finances in most countries looking pretty challenged these days, what steps can central jurisdictions take to achieve two key health policy goals:

1. reduce the overall healthcare expenditure by bending the cost curve down,
2. improve productivity, value-for-money, health outcomes.

Few in government have much experience with reducing healthcare expenditures.  And ministers are rightfully fearful of voter wrath, so one must wonder where the political courage will come from in the first place. Perhaps the key thing is denial is not an option, neither is blame-fixing. The first rule, therefore, is to fix the problem, not the blame.  True statesmanship is now needed, more so than party political rhetoric; that is, of course if we are right that things are in a really bad way.

Few, too, in healthcare management have the necessary experience with substantial changes needed in healthcare delivery systems especially where resource constraints will need to similarly deliver productivity gains.  We’ve had tremendous growth in healthcare expenditure matched with uptake of new technologies, complex treatments, and greater clinical specialisation. We can simply do more, and it costs. But along with this rise in capability, there has been much less reform of the way healthcare is done. Clinical workflows continue to be clogged with unneeded activity; we still use expensive hospitals when less expensive polyclinics or primary care settings would do. We fail to exploit the full potential of the other health professions, such as nurses and pharmacists. The second rule, is that you cannot continue to fund an unreforming health system.

Reform must be a constant feature of healthcare, since it is so dynamic as an area of innovation. If we want to bend the cost curve down, we need to persist in reform, indeed, disruptive reform, creative destruction in healthcare service delivery.  It is not about being nasty as a finance minister, it is all about using the money to unleash creativity to the benefit of all.

The challenge is less how to do that though, than wondering why what is there about healthcare today that seems to keep that from happening in the first place. Now that is really something to wonder about.

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Tags: innovation, money, reform

Posted By policy cognologist on November 12, 2009

THE YEAR 2109, a hundred years from now.

The average life expectancy is around 150 years for most people born in the early part of the 21st century. The life expectancy of a child born in 2109 is in excess of 500 years.

Cars? All electric using ultra-capacitor storage systems.  There are no vehicles with internal combustion engines. Fusion power is the main power source. Broadcast power widespread.

Cities are pedestrianised. People work from home or small community hubs, large corporate office complexes were pretty passée by 2050; the last hospital was built in 2025.

The tallest structure in the world is in Qatar and is a space elevator. There are 10 of them in the world.

The average wage is 800,000 euros (dollars? heard of them but not widely used), but its all e-money anyway, haven’t seen folding money in years and coinage is quaint.  Gold is worth 125,000 euros an ounce (what’s an ounce daddy?)

Robots don’t get paid to work.

More than 95 percent of all births take place at home.

Ninety percent of all doctors are robotic artificial intelligence systems.

The low lying countries have all but disappeared and the massive relocation of whole populations between 2050 and 2070 created whole new countries with renewed economic fortunes. 80 million Bangladeshi were relocated to Northern Canada.  The flooding of the Sahara desert in 2030 to create habitable land was needed to relocate other stranded populations; this also unlocked the resources under the sand.

The population of Nevada in the US is 41 million, having taken on the displaced population of the whole west coast, following both the rising sea level and the Great Quake of 2030. There is some fine beach front property in Idaho. Alberta has a similar population when BC was inundated and the Sunshine Coast disappeared.  Other regions of the world were not spared either.  London was relocated 50 km north, and much of the Netherlands and northern Belgium are gone.

Pneumonia and Influenza, Tuberculosis, Diarrhoea, Heart disease, Stroke used to be big killers, but now through molecular medicine by 2050, organ replication by 2030 and head transplants by 2060 all this has changed. Since 2060, some people have opted to have their brains embedded in robots.

Five leading causes of death are:

1. ?
2. Suicide
3. ?
4. H23N24, equine spider fever
5. B348C90, Martian sand virus

The dominant languages are Chineglish, Spanglish and Arabasque.

There is Mother’s Day, Father’s Day and Children’s day, plus Robot Appreciation Day.  The major global day of reflection is called 350 Day as is held on December 16 (the 350th day of the year), the day that CO2 breached that level and never went below.

Marijuana, heroin, and morphine are all available over the counter at local corner drugstores having been denatured to provide the psychological benefits without the addictive properties. The local medicines dispensary owner said to me, ‘Heroin clears the complexion, gives buoyancy to the mind, regulates the stomach and bowels, and is, in fact, a perfect guardian of health’.   Coca-Cola is still going strong.

Eighteen percent of households have at least one full-time robot servant or domestic help.

Professions that don’t exist anymore: train engineer (robots), mail delivery person (robots for home delivery), bank teller (banks?).

You are receiving this message courtesy of the world wide cog, the cognitive intelligence that links all people through cognitive implants and remote sensors.

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Tags: innovation

Posted By policy cognologist on November 1, 2009

Professor David Nutt, chairman of the UK’s Advisory Council on the Misuse of Drugs, is now a former chairman. He has joined by other scientists (2 so far) resigning in protest as the government’s heavy handed dismissal of Professor Nutt.  The minister, Alan Johnson, has said he had ‘lost confidence’ in the scientist for something he wrote in a scientific article.

The thought police are out in force once again.  But more important is the apparent abuse by this government minister of the whole point of advisors.  They must speak truth to power. In the absence of the speaking of truth, we will have self-censorship, political correctness, and general bowing and scraping to the political powers.  What the politicians don’t get, and Alan Johnson in particular, is that a candid and often challenging relationship is part of this delicate balancing of truth and power.

Indeed, there is clear abuse of power in silencing critics. There is a candle that burns in Canterbury Cathedral, testimony to this very issue (referring to St Thomas Beckett).  Truth is the first casualty of ministerial hubris.

In the end, we, that is taxpayers, and the general well-being of society, suffer when ministers can be so cavalier in dismissing people they don’t agree with.

Distinguishing between giving advice based on science, and political commentary is difficult navigation, as both scientists hold political views, which ministers may not like, while ministers may express scientific commentary with little grasp of its meaning.  Both can get it wrong, and much nonsense has come out of the mouths of both scientists and politicians.  But rather than shoot the messenger, politicians need to remember that they are in the main wholly dependent on right-minded scientists for advice, ones who will often hold dissenting views from the ’spin’ that ministers seek to put on science itself. Einstein and colleagues understood this when they wrote to Roosevelt about atomic energy in 1939. It is worth noting that the US government dragged its feet on this letter until at least 1941, and it was not until 1942 that the Manhatten project began.

It is worth listening, even if you don’t like what you are being told. If scientists and advisors must speak truth to power, so power must listen to truth.

Such is the politician’s duty. Pity such duty is so poorly observed.

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Tags: "c'est dommage", Europe, reform, UK

Posted By policy cognologist on October 31, 2009

For all the reform and protestations that the public deserves a health system for the 21st century, the ongoing saga of health reform in Britain continues to amaze.  The Secretary of State for Health for England, Andy Burnham, has decided that NHS providers get to try twice to prove they are worthy of continuing public confidence.  As he has put it, the NHS is the “preferred provider”, apparently for itself.

Those not familiar with the reform of the NHS, and indeed those who are, must be wondering why mediocrity should be rewarded, and in these difficult times, why the taxpayer or the government should countenance circumstances that public public money at risk.

The NHS commissioners (purchasers in real world speak) are the surrogates for consumer choice, as while NHS patients do have some choice, commissioners in the end are deciding in which directions that choice can be exercised.  A bit like Henry Ford’s model T car: you can have it in any colour as long as it is black.

Why should this matter? The Minister has said that the NHS should not be agnostic about who provides healthcare service delivery but instead favour NHS providers.  But as a monopoly supplier of services, the NHS and the English Department of Health must be mindful of abuse of a dominant position and in particular favouring institutions that are in effect emanations of the state, on the one hand, and forcing the public to experience second-rate service on the other.

Favouring a failing provider strikes me as looking a lot like state aid.  It also does not appear to be a service contract either, as the reason for awarding the contract seems to depend on the ownership of the provider (and protecting their status) and not whether they can deliver the service to a quality standard (which is the purpose of the contract).  The clue that this is a policy fudge is that a failing provider gets another chance to be a preferred provider over a potentially more competent and higher quality provider.  Can you legally enter into a contract for a service to a quality standard, knowing in advance that the provider is unlikely to be able to deliver to the terms of the contract?

Hmm. So much for value for money and healthcare fit for the 21st century.  Do I hear the auditors stirring?

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Tags: "bad idea", money, reform, UK

Posted By policy cognologist on October 12, 2009

There is trouble in e-health land, at least in Ontario’s funny notion of what they might mean.  EHealth Ontario has been subject to an emergency audit of its procurement or not of an electronic health record [EHR] by the Auditor General of the province.  Apparently, somewhere approaching C$1 billion has been spent with virtually nothing to show for it.  The problems lie in a bad ehealth strategy, and inappropriate use of consultants.

There are lessons here for other jurisdictions, as they seek to embrace the benefits of EHRs, and ehealth more widely, in particular. Of course, what is an EHR for, is the core question.

One of my alma maters, McMaster University, has sprung into the fray saying it has an EHR called OSCAR that could be implemented for perhaps 2% of the estimated cost of a provincial EHR.  Their argument being that a lot of doctors are using it.

EHRs are not a tool for doctors, though.

EHRs are an integrated information repository to facilitate better healthcare.  Doctors are not the only oranges, and nurses, physios, social workers, pharmacists, OTs, oh, yes patients and parents, informal carers, too, need access to health records. In my view, patients should own and hold their own health record, to ensure high audit standards (would you let an error remain on your health record if you knew about it?).

Servicing the specific needs of doctors alone is not an EHR strategy worth having, and doctors themselves should be the first to say this. It is time they showed leadership within the wider healthcare system, and rejected self-serving models, such as McMaster’s, which automate obsolete information models. McMaster, too, should have known better.

The Ontario Ministry of Health has wisely rejected OSCAR’s offer, but for the wrong reasons.  Citing the need for doctors to choose their own systems, just shows their continuing logic of catering to the needs of a particular health profession, rather than addressing the systematic provision of patient information within an integrated decision-support system.

All this is being driven by beleagured officials who really need to think again about their priorities and why they really need an EHR.  Perhaps they are afraid to admit to having made a mistake.  Such hubris.

Clearly more work is needed to define the purpose of the EHR and the goals for an ehealth strategy in Ontario (and other jurisdictions of course), before more taxpayers’ money is spent on ehealth.

Oh yes, apparently Ontario are going for a tender on a diabetes registry. NYC has one. I fear the worst.

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Tags: "c'est dommage", Canada, e-health, innovation, technology

Posted By policy cognologist on October 12, 2009

The elephant in the room in healthcare is the hospital, about which I have suggested that we will build the last one in 2025.  What will “smart hospitals” look like, and why should we care?

Why should we care?

Hospitals are expensive and complex labour intensive organisations originating in industrial era thinking.  Little has been done to modernise the institution itself, although much has been done of course to improve what hospitals do. We also know that hospitals account for a considerable carbon burden and consume a huge amount of energy since they operate 24 hours a day. We know that as labour intensive institutions they suffer from the challenges all such organisations face as they try to improve operating practices and reduce running costs. Healthcare delivery is characterised by regulated cartels, which serve both to protect the public, and protect professional practice from incursion by other health professionals.  A bit like an early 20th century factory with craft guilds.

We should care because these institutions need to become smarter in the use of modern technologies and practices, but this process is slow and cumbersome, and while they evolve, the taxpayer is faced with paying the costs of institutions which in many cases should be replaced. This is not to say that those who lead hospitals are not focused on these issues, but only to say that their job is not easy and with the many vested interests around, challenged.

What would be refreshing would be leadership for clinical workflow change to come from the professions themselves, due recognition of their need to evolve and reform rather than simply protect the status quo.  We need these groups to drive change in healthcare, rather than waiting for politicians or Ministries of Health to set the agenda. Of course, informed and empowered patients will eventually not put up with much of the nonsense that confronts them when they seek healthcare, but that is another story.

What will they look like?

We are left with wondering how to improve how they do what they do.  Enter ’smarts’. This brings together a constellation of forces currently abroad in the world, ranging from automated building management systems, smart grids, energy recovery systems, to wireless technologies in hospitals to remove the wires.

Coupling smart systems together creates networks that can link patients in their home to monitoring facilities and first-responder capabilities. With the added advantage of wireless, we have untethered remote monitoring.  In the end, we have real-time healthcare.

Smart hospitals will not need to define themselves in terms of their geography or location, that is in terms of buildings. They will define themselves in terms of two factors:

1. their capabilities and
2. how they deliver these capabilities.

Indeed, the organising logic of the modern hospital will be replaced with one akin to a dating agency — it will link people with needs to capabilities to meet those needs — built on a sea of clinical, and patient information, and connectivity to various organisations that can deliver the services (healthcare) that is needed.  This breaks the current approach to vertical integration (based on the industrial conglomerate model) and replaces it with the virtual hospital, a network of focused and tasked organisations.

I had scoped such an approach to a redesign effort for a teaching hospital, which would have replaced a campus model (mainly an old building and some attached add-ons) with a distributed and electronically-linked (ehealth stuff here)  network of perhaps 24 centres scattered across a city of a million or so.  But industrial era logic prevailed and they went with the single building.

I guess we won’t get smart hospitals until we have smart planning.

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Tags: e-health, Europe, foresight, hospitals, innovation, opportunity, technology, UK, USA

Posted By policy cognologist on October 7, 2009

We have had years of reform efforts in healthcare, and despite what country one picks, the themes are depressingly familiar: cost-containment, more health professionals, patient empowerment, more primary care, value for money, and so on.  These types of reforms are rarely revolutionary, despite the claims, and the benefits not as readily forthcoming as forecast. For instance, we have had perhaps 20 years of integrated care pathways, yet such simple knitting together of care is still elusive.  What is clear, though, is that you can’t continue to spend good taxpayers’ money on unreformed health systems.

Reform models reflect the history of our healthcare (and other) systems, deriving from organisational and service delivery models of the industrial age.  Hospitals are really just 1030s conglomerates, and the claims that vertical integration likely to improve care and drive down costs, are simply copying the corporate models of General Motors, General Electric, GEC, Westinghouse, some of which are no more.  We don’t really live in that sort of world anymore, and despite the vast amount of money spent on healthcare, it is still the least information-enabled of all sectors of our economy, even though healthcare floats on an ever-changing sea of knowledge and clinical/patient information.  Our current notion of healthcare is wedded to the brains of individuals (i.e. health professionals), not the collective intelligence of many people working together (dare I call this cloud cognition, hive minds, or distributed cognitive systems…?).

I think we need to take a different look at reform models, and embrace a new terminology, one built on disruption.  Disruptive technologies in particular are game-changing, they alter our modes of interaction with other people, change how we manage information, make decisions, perhaps even think. They, of course, produce winners and losers, as these sorts of changes often are zero-sum. Keep in mind that health reform has tended to be non-zero-sum; there has been a fear of creating losers while at the same time trying to reward winners, so-called protection of legacy providers, and we see this in the most recent UK Department of Health plans to allow failing NHS providers two tries to improve performance before alternative providers will be allowed to take over the work. Disruption says enough is enough, and we must do things differently.

We don’t know that much about disruption except by what its effect is on us, but there are efforts to understand  disruption.  But this work has been weakly connected to both the policy space in which these insights can achieve some measure of meaning, and the real-world.  Healthcare systems can go to great lengths to frustrate innovation and change.  It is, therefore, timely and pleasing to see efforts of understand disruption, and the forthcoming report on disruptive forecasting from the US Committee on Forecasting Disruptive Technologies, National Research Council, may offer a renewed impetus not just to the forecasting work, but to its utility.

I like disruptive technologies for their ability to shift our thinking away from industrial age paradigms to information age paradigms.  In this way, we break the logic of physicality that defines, for instance, hospitals, and leads to new approaches anchored around the health information value chain, which unites patients and all actors in health systems (payers, providers, industry, academe).  Ehealth is one of these potentially disruptive technologies, as it achieves a couple of key disruptions, in terms of decoupling patients from physical location, and of the potential pooling of knowledge in distributed cognitive systems with machine intelligences through smart/remote diagnostics, predictive modelling and in time physical models of disease.

But disruptions are a much harder sell, but it seems to me that difficult public finances does offer an opportunity for rethinking: one should not waste a perfectly good crisis as it is an opportunity to evolve. (with apologies to Rahm Emanual who said “never waste a good crisis”.

READ an interview I gave on ehealth here: [LINK to Euractiv ehealth interview]

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Tags: disruption, Europe, fear, foresight, innovation, opportunity, reform, technology

Posted By policy cognologist on September 4, 2009

The leaked McKinsey report on the NHS, which endeavoured to provide a review of areas where efficiencies can be achieved in the face of declining public finances does not really offer anything we don’t or at least shouldn’t already know.

NOTE: This post does endorse the McKinsey’s report findings — only to express some surprise that it was not more insightful.  Of course, I have only read the leaked documents, and cannot comment more fully, but then if the Department of Health did want a proper (adult) debate, they would put it in the public domain for all to see.  Perhaps McKinsey would, as supposedly insightful strategy consultants, suggest to the Department the value of a wider social debate on the NHS priorities — but this isn’t their style.  The wisdom of crowds, or the madness of experts?

So on with the commentary.

As if at least 20 years of NHS reform meant nothing, OECD countries together are grappling with rising healthcare expenditure coupled with demand that seems insatiable.  The recession and its consequences has for many offered a useful policy window through which to drive changes that under more benign economic circumstances would be untenable.  Health, as always, is the last to face the music.

What actually is the NHS?  In the UK, it is 4 devolved publicly (tax) funded universal health systems (England, Scotland, Wales, Northern Ireland run their own show); McKinsey is writing about the English NHS.  The “NHS” is often described as one of the largest employers in the world, but then healthcare systems are generally large employers, usually about 5% of a country’s workforce, consuming around 9% of GDP.  The whole health industry is usually about 15% of GDP, employing perhaps 7-8% of the workforce.  So they are all big.  What characterises the UK’s fascination with the NHS is the tendency to speak of the NHS as though it were ‘one thing’, whereas it is more likened, perhaps more accurately, to a confederation.  Regretfully, policy makers have failed to really make sense of the role of private and non-profit providers so there is really only weak integration of services across all providers.  This constrains policy and service delivery somewhat in England as there is always the fears of privatisation and so on.  It is worth keeping in mind though that general practitioners are private sub-contractors, while the acute sector is increasingly run by autonomous arm’s length hospital ‘foundations’ (a weak attempt at copying a hospital arrangement from Spain).

So the NHS is an acute service provider, a contractor for primary care from service providers, and a buyer of services from acute providers.  That it is characterised by a purchaser/provider split is helpful in understanding the constraints under which the system works, as the purchasers (primary care trusts) are in the main general practitioners commissioning (English jargon for buying) care from acute providers.  This engenders some confusion in the public domain between who is responsible for the planning and problems that get thrown up.  The McKinsey report can be seen either as a message to acute providers to reduce their overheads, or a message to purchasing organisations to set contracts with tighter cost controls for the value received (i.e. for the care provided at what level of quality to their patients).

The politicians are indeed running around in a bit of a frenzy because the NHS is seen as a sacrosanct public sector organisation, and that cutting the budget would be equivalent to committing treason.  Of course, this adds to the problem and increases the denial.  This strengthens the hands of those who oppose reforming healthcare, and makes the case for increasing efficiency and productivity, and in general ensuring that the public receives good value for the tax money spent on healthcare more difficult.

Yes, healthcare is a hands-on activity, and yes we need hospitals (at least for now).  But it is hubris to suggest that the acute hospitals are as productive and efficient as they could be, or that the distribution of clinical work across the health professions is a well done as it might be.  Hospitals by and large still draw on industrial age models of organisation — they are little different from commercial conglomerates.  Efficiencies in McKinsey’s report comes from things such as:

• vertical integration (hospitals into community care, for instance)
• integrated care pathways (something healthcare has been up to for at least 20 years)
• reduction of waste and duplication (no surprise there)
• role clarification of clinical work (yes, professional cartels called Royal Colleges)
• elimination of clinically ineffective or doubtful work (the tough call but is a natural consequence of evidence-based medicine).

Criticisms of the report are right to the extent that McKinsey has done what they are generally good at: stating the obvious.  Any of these items should be on any hospital CEO’s to-do list, and subject of Board level discussions.  Unfortunately, where McKinsey is less good is in looking at the NHS and assessing the underlying logic and meaning of its organisational structure, its clinical care paradigm, and how it can evolve, as a dynamic entity, into a better care system (they would surely argue that that wasn’t their brief, but good consultants work with, not just for, their clients).

But salaries and infrastructure (buildings) are the costs to look at: perhaps 80% of a hospital’s budget.  Choices here require a different logic, and include:

• using e-health, telehealth technologies to replace both staff and infrastructure (home telecare monitoring, for instance)
• use of supportive clinical decision-support technologies (from robotic vision systems to work with radiologists to scan mammograms, thus doubling the number of radiologists, to artificial intelligence systems to data-mine health records to identify patients are risk of A/E readmission to a COPD exacerbation)
• using medicines to replace hospital stays, surgical interventions
• using best-imaging-technology first to diagnose (the best technology to diagnose a problem is not generally used in initial diagnosis, an x-ray might be used, then CT, then MRI.  Just use the best first.)
• and so on.

These all address the possibility of labour (clinical work) substitution, (which might improve the quality of the jobs clinical and support staff actually do), greater patient empowerment (as they take greater control of their healthcare, direct resources to achieve their own healthcare goals), and a real use, slowly being addressed by the Connecting for Health initiative, for information for clinical and patient decision-making.  This emerging information value-chain will produce improved measurement of clinical outcomes, and thus inform better in-hospital decision-making and resource allocation.

Of course this ignores the actual physical unbundling of hospitals themselves.  The organisational logic that requires the aggregation of clinical skills in the modern hospital is dated under many service scenarios.

So where are we?  We are at the point of knowing that much can be done to improve the patient’s experience of healthcare, by driving out dated clinical and organisational practices, adopting new practices and technologies, procedures and methods.  It should not be inconceivable for any healthcare system to achieve 20% savings.  Fear of alienating clinicians is less the issue than engaging them in service improvement, to which they should be committed.  This will in the end ensure the high-touch requirements of healthcare where it is needed, without protecting sacred cows and vested interest groups.  In the end, it will come down to political will, managerial commitment, and clinical professionalism to ensure, in a publicly funded healthcare system, that the public gets what it thinks it is already paying for.  Otherwise, resistance looks a lot like protectionism.

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Tags: "bad idea", money, UK

Posted By policy cognologist on August 25, 2009

Informed research leads us to the conclusion that ageing is expensive for healthcare systems.  Indeed, it is widely tossed around that the bulk of healthcare costs incurred by individuals throughout their entire life time, are incurred in the last 6 months of life.  This is in part why policy makers and ministers of finance worry about the costs of healthcare.

But the problem we have is determining when we are in the last 6 months of life.

The somewhat awkward yet timely debate in the US about how to deal with health costs at the ‘end of life’ stage of our existence  has illustrated the fear we all have of the final moment, and what we will do to push it off.  It has been said that in the US, death is an option on the insurance application form.  From the debates characterising health reform today, one could think that was the case.

• Is end-of-life an issue for policy?  If so, does that mean we revisit not just German National Socialism of the 1930s but similar euthanasia movements in other ‘civilised’ countries at that time?  Does it lead to death squads?).
• Is it an issue just for doctors? No, we are now well past the time when doctors make these final choices for their patient.
• Is some other option of voluntary euthanasia lurking on the fringes of our moral sensibilities?  This has been explored by Harry Harrison in his “Make Room, Make Room”, for instance, and the rather less satisfying movie, “Soylent Green”.
• Will we live forever?  The transhumanists think so, and read through Kurzweil’s “The Singularity is Near” is road that takes us in part to Singularity University, happily located on some un-used NASA property in California.

However we try to square this circle, as I’ve said before, it is important to distinguish between prolonging life and delaying death.  Most of what medicine does prolongs life.  But some healthcare is really only buying time and thus delaying death.  How are we to tell the difference?

Moral argument will take us toward social values. The healthcare space will take us to a discussion between an individual and their family.  A policy debate will ask what interest does society have in the answer, what are the social costs (not necessarily meaning money here) and are these ones associated with a society we want to live in.

The answer to the question is dependent on who is asking the question, and that is different from those who are trying to answer the question.  We need to be clear about the difference.

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Tags: ethics, innovation

Posted By policy cognologist on August 13, 2009

In an earlier post, I raised the ideological differences that may underpin much of the political rhetoric.

Of course, many informed commentators understand the problems and challenges facing US healthcare, which can be the best in the world.  And much good learning about how to make a health system better come from the US.  The NHS has learned much from the US, too.

But the NHS is like any system, built on assumptions and reflects a view of healthcare delivery that may not be shared by everyone.  However, many do share the underlying principles of universal healthcare, just not the organising principles that the UK used in designing the NHS.  There are other systems of healthcare organisation, and there is evidence that Bismarckian systems (non tax-funded systems) may actually produce better outcomes and care.  On that basis, the NHS is vulnerable to structural criticism, but not for trying to deliver a universal healthcare system that decouples the need for healthcare from the ability to pay.  The Americans in particular would not argue that people need healthcare, but they would debate how best to pay for it.  Hence the debate.

But the NHS does have vulnerabilities.  Let’s summarise a few:

1. NICE is seen by many as establishing a value for a human life based on quality adjusted life years, general affordability of a medicine based on a blend of clinical effectiveness and cost.  While NICE lacks statutory authority to enforce its decisions, its role from a US perspective would support the conclusion that within the NHS is a decision process that indeed does value human lives.

2. Overseas observers may be forgiven for not following the daily reform of the NHS, and on that basis, cursory searches of the health literature will produce historical documentation that supports the view that the NHS has been known to cause considerable personal suffering through the persistence of waiting lists.  For many US commentators, this equates to a form of rationing, which in their view is unacceptable.  Granted that people wait in all health systems; but in the past, the NHS can be accused of having used administrative procedures, like waiting lists, to queue patient care on the basis of clinical need, but with fewer deployed resources per capita than other countries, patients did in fact  suffer health consequences from waiting.

3. As a cash-limited system, the NHS is open to greater criticism from American commentators, who are more comfortable with co-payment systems, and systems which in effect enable people to buy their way to the front of the queue.  Since it is deemed unacceptable to use co-payment as a mainstream payment mechanism in the NHS (unlike the health systems in other European countries such as France, where co-payments are the norm, coupled with supplementary insurance), other commentators would naturally wonder why resource constraints that penalise people seeking greater healthcare cannot be overcome through personal discretionary payments.  The Canadian healthcare system comes under very similar US criticisms here.  That the NHS as a purchaser fails to fully integrate the provider infrastructure would seem odd to Americans and many Europeans, more accustomed to receiving care from a system that is largely agnostic over who owns the provider (public, private, voluntary, profit, not-for-profit).  More generally, the ability to pay more would be seen by some as not necessarily penalising others who might pay less or nothing — there is no moral contradiction for some here — as both types of patients will in the end get seen; the consumption of healthcare by the rich does not necessarily reduce the availability of healthcare for the poor, some would argue.  But it is important to keep in mind Titmus’s point, that a welfare system that only services the poor will lack support of the middle class, and in the end fail in its social welfare objectives, and also be financially unviable.  This is one argument for community risk rating and pooling.

4. The NHS can be criticised for confusing the politics of the NHS and the politics of healthcare, itself.  To external commentators, this mixes the essential relationship between the doctor and patient, with a state-mandated intermediary.  US commentary in part is predicated on avoiding any government intermediary between doctor and patient.  The NHS is a system for delivering care, while healthcare itself is essentially a private matter between doctor and patient, as many would argue.  You can always change the system, but the relationship remains.  Tinkering with the former in ways that alters the latter for many is unacceptable.

It is worth keeping in mind that the UK is not the only health system that American critics could attack; it is probably one of the easier to learn about and which offers an extreme view from their perspective.  Critics for years have attacked Canada’s health system as ’socialised’, but have failed to target Italy’s.  They have generally ignored insurance-based or Bismarckian systems perhaps because of the insurance approach, which is closer to their view of how risk should be managed — buy insurance, don’t buy the risk itself.

The NHS itself, is a particular way of organising and paying for a universal health system, and there are separate debates in the UK about whether the NHS should become an insurance-based model, and so and so forth.  But in the end, few Americans are actually inconvenienced by their healthcare system, and perhaps think very little about it, in much the same way as UK citizens enjoy the benefits of the NHS, without necessarily being concerned exactly how it is financed.

Universal health systems do work well and apportion risk across the whole population in most cases without a lot of public hand-wringing.  UK politics is perhaps overly sensitive given the past problems with NHS waiting lists and apparent rationing, and dysfunctional separation of public and private providers adding delay to access to treatment.  These problems are largely absent from Bismarckian health systems of France, Germany etc, and so there is always the general public accountability to be had about whether the UK is making appropriate evidence-based decisions about the financing system it uses.  But that is quite apart from the fact of universal coverage.

In the end, the US doesn’t want an NHS style healthcare system.  In fact, very few countries actually copy the form the NHS form of financing (tax funded), preferring to use insurance, and of those that are tax funded they tend not to copy the organisational style of the NHS (state-run/owned hospitals for instance). This is keeping in mind that there are four NHS’s — one in each UK country, with the English NHS being the most progressively reformed (with some US ideas, too).

There is much to learn from looking at other health systems, and the US clearly isn’t having that sort of reform debate.  Something perhaps for the US to think about again.

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Tags: reform, UK, USA

Posted By policy cognologist on August 13, 2009

So various US publications have waded into the health reform debate with comparing the US with the UK’s NHS.  These commentary, as many other bloggers and those on Twitter, are of varying degrees of stupidity, ignorance and general lack of insight.

It is worth keeping in mind that for decades, there have been comparisons between Canada’s healthcare system (very similar to the UK’s NHS, but there are very important differences, too) and the US.  The Americans have these debates constantly and the various lobby groups are well-equipped to flood the ether with their rhetoric. There is a deep-seated concern about ’socialised’ medicine, about the role the state usurping individual responsibility, and about power and control.

And the spirited defence of the NHS will no doubt continue apace.

But underlying the debate is the unanswered question of why does the US have so much trouble with reforming its healthcare system in the first place.

One reasons is that Americans seem have a lot of trouble with what are called free-riders.  Because their system is insurance based, those who do not take out/cannot afford health insurance, get a ‘free ride’ on the taxpayer, through the federally funded Medicare/Medicaid programmes for instance.

By and large, Americans philosophically are liberal in their outlook, and believe that individuals should make the most of their gifts, so the system rewards, and celebrates success, and while not necessarily punishing failure, ignores it as long you pick yourself up and get on with improving your life.  Ideologically, that means that it is hard to grasp that everyone may have an interest in the general welfare of individuals, AND that the responsibility for the general welfare is the responsibility of government. Practically that translates into a political ideological debate about the role of the state.

Why does that matter?

The US politically is a different system from parliamentary democracies. In the latter, political parties stake out ideological territory (left, right, socialist, whatever) and the electorate chooses.  In the US, the United States itself IS the ideology.  The political parties are interpreters of this founding ideology and the electorate chooses within that ideology from the political parties.  That explains in part why there is a narrow range of political choice on offer in US elections, and why, under the skin, all political beliefs flow back to the founding ideology of the US Constitution, and its revolutionary roots.  The US believes it is the definition of democracy, so why would one have varying degrees of political persuasion if you’ve already solved the hard problem.

That means that the health reform debate is predicated on historical consensus about the political objectives of the US as a democratic entity. One of these principles challenges the role of government, another principle addresses individual liberty and third focuses on how the US interprets the public interest and general welfare.  The third principle is NOT interpreted by the state (as in the US, the state is a creation of the people), as it is parliamentary systems (where the state exists independently of the people — read Hobbes).  In the US, the resolution of a political debate amongst competing interests determines the public interest as the state does not have an independent existence and so cannot have its own guiding principles.

Why should this matter?

Because in the US, these debates nourish the democracy itself. The discussion is not esoteric but fundamental to the concept that Americans have of their country.  Such debate in UK, France, Germany, Canada, etc, with universal health systems, will invariably invoke principles to resolve the issue, that can not work in the US political arena.  The difference, of course, is that while the Americans will have the debate, other countries will sit complacently by while their governments pursue reform policies which should be challenged and debated outside the government.  The differences are subtle, but important.

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Tags: "c'est dommage", innovation, reform, USA