Visualising Influence

The Policy Cognologist also maintains a European policy blog, Euro-Sante/Euro-Health. Waggener-Edstrom Worldwide conducted a study of the most influential policy oriented blogs in Europe and I am delighted that my blog was rated amongst the most influential specialist blogs.

There is also activity on Twitter about the influence of the blogs in the study in the EU at #bbs10. You can also request a copy of the report with ratings of all the blogs, specialist and general at Waggener-Edstrom.

The report makes for interesting reading. One observation is the relative greater influence of generalist policy blogs over specialist ones; the highest rated is written by someone from the BBC. Others by folk with less illustrious affiliations, but no less important things to say.

I am pleased though to be counted amongst such company.

Overall, the blogs represent efforts by many people across Europe to put ideas forward with varying degrees of success or recognition. The world wide web creates amazing opportunities for fresh ideas to be presented in easy and accessible forms. Blogs can be updated quickly and with RSS feeds, interested individuals can receive notifications of new posts. Whether internet search engines effectively identify blog entries is another matter. Blogs operate in the real world in real time and with rankings such as Waggener-Edstrom’s, the task is much easier for bloggers with important things to say to be heard.

On a cautionary note, policy processes within the EU and government depend on having accessing to fresh ideas and knowledgable people. But in my experience, they can fail to engage with emerging influencers, as well as with individuals who lack official, recognised or organisational positions to give them ‘organisational cover’ as it were. Influence and quality of thinking depends more on the cogency of the writer’s knowledge and ability to craft succinct argument, than the reputation of their employer (and perhaps the EU puts too much emphasis on the latter).

A herd of leaders charging an outcome

What is this loud thundering I hear across  England as people begin to adopt the new thinking on the English NHS from the coalition government?  Not a year ago many of those same people were saying quite different things. What has changed?

Golly, but now they are all trumpeting the appropriateness of outcome measurement in the NHS, something that should have been the case decades ago, but got hi-jacked by bureaucracy.  As I have said elsewhere, the patient is the most disruptive force in healthcare, and as the ‘auditor of one’ can drive quality and service integration in ways that top-down monster plans never could.

I’ve worked on developing outcome measures, and perhaps the one thing that is important to realise they are best developed as emergent measures from within the delivery of care as much as designed by a room full of experts and some evidence base.  My preference is to develop a system using something simple like a balanced scorecard, (with perhaps 4 to 6 critical measures under each of these four headings, so around 16-24 measures), something like this:

1. Measures about how well the healthcare commissiong process interprets healthcare requirements, and how well a provider responds to manifest demand for its services. [Measures here focus on the ability to interpret the dynamic nature of the healthcare environment.]
2. Measures about how efficient a healthcare provider is in organising care, including interconnectedness with other providers (handling referrals across institutional boundaries). Also measures of how effective commissioning processes are. [Measures here focus on efficiency, doing things well.]
3. Measures about how effective a healthcare provider is in delivering outcomes, including with other providers (integration of capabilities linked to specific desired results). Also, measures of how effective commissioners are in what they do. [Measure here focus on effectiveness, doing the right thing, mindful that the right thing has always been about outcomes, not outputs.]
4. Measures of how well the various health system actors such as commissioning bodies, consortia, providers, professionals, patient groups, etc. learn how to improve what they do, including driving forward change, introducing innovation, learning from mistakes, and developing solutions. [Measures here focus on ability to evolve, innovate, learn, change.]

None of these require central thinking and with properly strategically managed organisations would have been the norm, but for the various distractions over the years). They can be developed into an hierarchical performance model to tie together what individuals do, what processes are used, and how organisations institutionalise practices to achieve outcomes. (There is a cognitive model at work here by the way.)  This puts the measurement focus onto individual organisations, and not onto arbitrary aggregates (such as regions); the focus also requires much stronger strategic abilities within the leadership of system actors, and greater operational attentiveness by everyone. Hospitals, GP Consortia will need much improved analytical and operational research capacity within their institutions in order to more accurately interpret their local environment and respond in a timely manner; this important capacity has been held higher up in the NHS (in all its devolved parts) and indeed important operational research capacity and mathematical modelling seems the preserve of the Department of Health, whereas the problems are at the front-line. Shifting resources to where they are needed removes top-down performance management as the focus is now measuring performance in terms of delivery, not activity. Keep in mind, too, that as a complex adaptive system, there are no ‘strings to pull’, and that does change the nature of any information that is reported.

Change always requires that individuals learn to behave differently. Organisations are how we group together the behaviours of people to achieve certain goals. It is importnat to understand that:

1. Some people have trouble altering their behaviour, especially if it requires initiative and originality which in the past was not rewarded — so they may need either help or perhaps counselled out, particularly if they are in leadership positions (and beware the recycling of failed leaders);
2. Some goals may not require some organisational arrangements that are currently used, and may need to be changed (think of the potential disruptive potential of e-health); but people have a great deal of difficulty with ‘creative destruction’ of publicly funded institutions, which is why public service institutional renewal can be so difficult.

No one said all this would be easy, but it should be done better.

I just hope that great thundering herd is also thinking as it charges along.

Bureaucracy by Magritte

The well-known organisational practice of delaying has emerged as one way to achieve public sector austerity. This is to be aplauded, not regretted as it is applied to the English NHS. In fact, those looking to the total costs of running health systems should be taking serious note of what this is all about.

Public sector work has tended to favour layers of bureaucracy, to respond to the tendency of civil servants to do what is called rent-seeking, which in the end means building empires, or expand a sphere of influence. In the regulatory context, it is called regulatory creep, as mandates are progressively, but subtly expanded by rent-seeking regulators.

The end result is large spans of control for civil servants, but little actual progress in achieving public sector objectives and goals. This stifles creativity and further rigidifies individual behaviour into highly structured ways of working — further compounding the potential waste of public money.

In addition, the tendency of bureaucracies to create bureaucracies means that individual jobs are often highly compartmentalised from other jobs, as individuals carry specific dossiers or briefs. The compartmentalisation of government into ministerial portfolios adds additional barriers to sharing work, ideas, or insights across government, further compounding the opportunities to deliver better value for money.

The White Paper on the NHS plus the overall behaviour of the UK’s coalition government reflect a consistent and simple message about the way the public sector should be organised to undertake its tasks. De-layering means removing non-value-adding levels of organisational bureaucracy, layers with the sole purpose of either move information up (or down), or checking or verifying the work of others.

The NHS itself has been too long likened to a supertanker, but a school of fish is what we want — nimble organisations that can respond quickly to change. Instead, some commentators have questioned the proposed reforms, asking what will happen when you need to pull some strings centrally to get things done? What these commentators don’t realise is that healthcare is a complex adaptive system, which means that there aren’t really strings to pull.  Decades of belief in this assumption has produced ill-thought out control mechanisms, and inappropriate and pointless layers of supervisory control (such as Strategic Health Authorities), which really can be only weakly effective at best and destructive of initiative at worst. It is not unusual for SHA staff insert themselves into processes to assert  a measure of control reflecting their priorities, ignoring the real needs of people dealing with a front-line challenge.  Indeed, the rent-seeking behaviour of these quasi-civil servants challenges the validity, the very authority, of those who own the front-line problems in healthcare to actually solve these problems. Before all this, we had the failed Modernisation Agency, the failed NHS Training this, or NHS University that.

The insights in the White Paper have put paid to the assumption that overarching control mechanisms can work, putting the onsus on problem owners to solve these problems. There are proposals in the While Paper which accept the need for flexible and dynamic responsiveness to the local and real-world interface between the patient and their care provider. Many in the NHS will fail to understand this, and as in any organisational change process  there are some people who ‘don’t get it’.  By and large, failure to alter personal behaviours is a recognised barrier to implementing reforms, and many such people will need to be shown the door and encouraged to pursue other careers. The NHS often forgets to bury its dead and it frequently eats its young, meaning that failed bureaucrats get recycled and good ideas destroyed by a controlling culture.

I have immense confidence in the ability of the right people to solve the problems, (indeed of the ability of GPs to ‘get it’). There are also real challenges for the chief executives of the foundation trusts and other NHS providers to demonstrate the necessary leadership and management skills to drive out the costs and inefficiencies that are shot through the system; CEOs will be particularly challenged as they must now actually manage, and not simply administer a publicly funded entity and avoid rocking the boat.

There are too many quangos and other organisations around staffed with individuals from failed agencies so one must be vigilant to ensure that the delayering process does not just turn into a recycling exercise.

Want to know  more?

Charles Perrow’s important work, Complex Organisations, highlighted the hierarchical structure of professional organisations and asks important questions about how and why we construct overly complex organisations, and why they can become dysfunctional.

Tightly coupled systems usually fail catastrophically, and reveal our inability to respond effectively

The challenges facing the UK’s coalition government, and many other governments around the world, point to potentially catastrophic failure of the ways we have thought about problems in the past, with an obvious need to adopt new problem-solving methods going forward.

One cause of the financial crisis, for instance, can be seen as the too-tightly coupled nature of the financial system, so problems in one area were almost immediately exported to other areas; tightly coupled systems mean in effect that you have no redundancy capabilities, but also that no area can easily be insulated from the pernicious contagion from another area.  You want more loosely coupled financial systems.  Is that what we see going forward? To some extent, efforts to decouple high-street banking from riskier investment banking suggest some understanding here, but the continuing dominance of large highly integrated banks is not promising.  Corporate behaviour being what it is, banks will try to recouple in order to ensure that no money is left on the table, as some might say. In the end, it may come done to a combination of loose coupling of systems, real, not Chinese, walls, and different compensation and incentive systems. It also might help if the business schools taught business for the real world, not an idealised fantasy world of private jets and personal fortunes.

Other areas have become tightly wound together too, with one aspect of social benefits creating dependencies on others, so benefits from one area implicate benefits from another. Separating the two and not calibrated criteria might help.

It is the logic of linking together what really needs to be linked, and keeping apart that which should be separate that is important.

The analogy I draw is what I do when my computer malfunctions — I turn it off and then on again — I reboot it.  I also get rid of software than has the effect of making my system work less well.

What would it mean to reboot a whole economy? What would it mean to reboot Britain?

It would mean identifying areas where systems are too tightly coupled. An example has recently been addressed whereby people have difficulty moving to take up employment because of the problems with housing and often social welfare benefits which lock people in.

But we can obviously go further. Re-booting Britain also means ensuring economic capacity is not concentrated in one or two centres, indeed, in London and no where else. The US has highly regionalised economies, and a fairly mobile labour force, with strong regional universities, and labour markets, and excellent transportation infrastructure. This creates redundancy capabilities which can be exploited to avoid the ‘eggs in one basket’ approach to planning.  Developing high-speed rail would help regionalise the UK economically and ensure easy movement of goods and services. Ensuring a strong regional infrastructure breaks down the tightly coupling of systems, so that alternatives become economically viable. As one area falls into economic decline or slump, other areas can respond with capabilities, knowing that infrastructure can accommodate in terms of housing, transportation, schooling and universities. Contrast this with, say, France, where virtually all biomedical research is done in and around Paris, so that none of the regional hubs have any significant impact in this area and so lack the necessary infrastructure.  Lyon, Bordeaux are regional centres but of little research significance and cannot therefore cannot generate economic growth through entrepreneurial activity — Britain is avoiding this in the main on research, but it is useful to see the consequences of getting in wrong.

In the end, the trick is to avoid over-engineering solutions to create systems that are highly interconnected and locked together to form rigid, stable systems — this presents us with a paradox. From a policy perspective, a key goal will be to ensure that solutions are not “one size fits all”, that consumers have choices, even with public services, and that public services need to be more flexible and less formalised procedurally so that they can respond to changing conditions in the real-world.  It means differentiated local economies, incentives which enable clustering, and dissuade economic concentration which rigidifies the ability of systems to respond to shocks.

In the end, the route to social and economic stability may ultimately rest on counter-intuitive factors as flexibility, instability, responsiveness, change. The world after all may be just one giant complex adaptive system, and we as humans aren’t yet smart enough to understand this.

Want to know more?

Thomas Homer-Dixon’s The Upside of Down addresses the problems of tightly/loosely coupled systems. His work is in the same vein as Jared Diamond on the reasons why some societies succeed and some collapse (link to TED video presentation). Annalee Saxenian’s work on regional economic advantage is also worth considering.

What would she do?

One of the great mysteries of the modern world is how to get appointed to the board of a quango.

I have also wondered whether the concerns about the effectiveness or not of quangos may lie in the criteria used to identify the types of people to run or govern quangos. To that end, would the public and political perceptions be different if there were greater confidence that quangos were both purposeful AND engaged the right people to sit on their boards and lead their management teams.

When I was doing work on revalidation of doctors (in the UK), following the tragic baby deaths scandal at an NHS hospital, I observed to medical colleagues that if they didn’t get their medical house in order they would be seen as unable to govern their profession and would lose their autonomy and control of the GMC: in which case, the chair of the General Medical Council would be lay chair, and they would be outnumbered by lay members. I observed that I might be the chair of the GMC since I knew a fair bit about what doctors do, which put the issue quite starkly.

The real issue is whether the criteria used to select candidates for quangos by appointing bodies fully engages the widest possible talent pool, or does it favour certain types of people, who in the end want to work with people like themselves, presumably in some respect professional quango-ites. Part of the challenge is that in many cases quangos should actually be putting themselves out of business. Other quangos should be driving reform and change. But the characteristics of people who get to sit on quango boards have to a great degree established their legitimacy, not as reformers, but as a ‘safe pair of hands’.  Radical, reforming, challenging individuals will never fit as quangos exude stability and bureaucratic purpose, not the instability that comes from reform and general disruption of the status quo.

Quangos could even be seen as evidence that the status quo is alive and well!  A quango focused on innovation should itself be innovative, it might instead suffer from the usual pressures to deliver performance metrics on attendees at workshops on innovation rather than evidence of innovative outcomes.  A quango on research would be disinclined to consider speculative more risky research proposals, as they must prove the value of taxpayers’ money. Quangos that invest in early stage high technology research spin-offs from research labs would need to demonstrate in some budgetary cycle that their investments were creating jobs, for instance, despite evidence that such start-ups might take 5 years before they would have any impact.  And so it goes.

In the meantime, taxpayers’ money is spent on people whose careers are simply to sit on quangos. And when do we have a discussion about whether the very criteria for public appointments to quangos are themselves part of the problem? Perhaps there’s a quango for that?

Daily we read of the debts that governments have run up, whether Greece, Hungary, UK or elsewhere. How has this come to pass will require all of us to reflect on what we expect from government and indeed what is government for. Folks such as Robert Nozick argued for the minimal state, all the way over to the bankrupted ideology of the collectivist state. In between lies reality.

Therefore, in the spirit of redefining the purpose and function of the modern state, I am asking this question:

what are the Grand Challenges for modern government?

In effect, what is the purpose of government? What is on the list will reflect the current priorities, but also an effort to anticipate the consequences of current actions by public bodies — if governments stop doing some things, what will happen down the road.

Here is some to get us going. I think we need 10 at the most as they must in the be both grand and challenges; my list may in the end be neither, but let’s see.

Like any good challenge, one needs to know what is in the problem, what is outside the problem and line that demarcates the two

1. A challenge is to ensure that governments are subjected to the same rules and regulations as everyone else.  Someone said, it would be a shame to waste a good crisis, so many governments find themselves in a crisis, and in many cases they are part of the problem, not part of the solution. Governments have some role to pay in aligning efforts to solve the crisis, but they are not exempt from the solutions.
2. A challenge is to design a simple tax system. We don’t need governments to create complex, full of exceptions tax systems. We have complex tax systems that have becomes ends in themselves, inscrutable and reflecting overly bureaucratic approaches. Rebooting our logic of taxation is a non-trivial challenge. The problem though is that governments use financial instruments as carrots and sticks to alter behaviour, whether of individuals or corporations. We need to rethink our use of financial instruments as tools of policy and that these financial instruments must deliver social outcomes, not just be used to fund government programmes.
3. A challenge is to better control adventuresome, rent-seeking behaviour of civil servants.  Too often, hyperactive civil servants follow a logic of state intervention because in the end it may be easier to do and please political masters, than to do the harder, consultative and more developmental approach which will produce the best outcomes, but with the least amount of government. The problem is that civil servants are rent-seeking, and are rewarded for expansionist activities. We see this with regulators who either do their jobs badly (regulators are after all monopoly suppliers of regulation, so if they do a bad job, we the regulated have little choice), or seek to expand the scope of their mandates, like a gas (there is always some reason to expand a mandate, when there is no one to say no). To be fair, the private sector also has adventuresome corporate executives who need to prove themselves through adventuresome corporate mergers and acquisitions — fortunately they don’t always get their way, such as the shareholder response to the plans of the relatively new CEO at Prudential (on the job only 5 months and he thought this made sense). The challenge here is a general problem, but acute in government.
4. A challenge is for governments need to know how to recognise market failure, and having identified this, decide what they should do it anything. Is there market failure in funding medical research, is there market failure in higher education? Understanding this will help define the boundaries of the government role, and importantly define the boundary conditions that tell us that different logic and problem solving is needed. At the root, we need to  first decide what the role of government should really be. Integral to this is determining a proportional response — in other words, there is identifying the need for intervention, and there is separately deciding what to do, how much to do, and importantly when to stop.

Some New Thoughts on Education are needed

The new Government’s plans to scrap SHAs by 2012 in an effort to slash NHS administration costs will have ‘major ramifications’ for the future of GP training, and could see budgets cut, warns the GMC. From the GP Bulletin, Pulse, 1 June 2010.

As Mark Twain said, rumors of his death, etc. the issue is overstated as always.  Fear replaces optimism as vested interests worry that they won’t be getting their education funding. But what was it doing with the SHAs in the first place? The creation of some form of market in health professions education, tied in some way to supply management does not in the end ensure a steady and flexible supply of health professions, any more than a similar system would ensure a reliable supply of geologists or accountants. The higher education system fails to evolve in response to the funding, as it is quite separate from the students or the continuing professional development needs of practising professionals.

It is good, though, to know that some see merit in this change as it will, in the end, clarify the purchaser/provider issues and redefine the necessary oversight of the health system. GPs and other health professions, though, do need to be assured that funding is in place to ensure that the programmes they need are properly funded, and accessible in ways that meet their requirements. It is, perhaps, no surprise that the revalidation argument fell at the final hurdle on the issue of a doctor’s time to do revalidation (having had some involvement in this issue in the past, I had calculated the full-time equivalents required to run the system, as well as the time it would take just to read the documents involved — but no one it seems had actually tried to read the paperwork, conduct the required activities with an eye to a clock!).

In the end, the simplest solution is to put the funding in the hands of both the students seeking the study a health profession, and in the hands of either the self-employed GP or their employer (the hospital) to decide what to do. With a level playing field on the provider side, this would ensure that the free-ride enjoyed by the private sector ended, and that all providers were properly responsible for both professional development generally, and CPD in particular. One benefit would be improved accountability by the higher education institutions that have come to monopolise this area, regardless of the quality of their offerings or not.

Something NICE needs to do

NEWS FLASH: Setting a minimum price for a unit of alcohol would help tackle Britain’s drink problem, health advisers are expected to recommend. The National Institute for Health and Clinical Excellence (Nice) will include the advice in its guidance on how to crack down on problem drinking. (1 June 2010)

This commentary is not on whether to set a minimum price for alcohol. This is a comment about expansion of the scope of NICE’s mandate.

What is NICE for and why are they now becoming involved in more fundamental health policy matters? Under the rubric of health excellence, one assumes they are pushing this as far as they can possibly go.

NICE is really a disguised authoritarian advisory body because of their lack of proper public accountability coupled with their privileged access to ministers in government.

NICE are not ‘health advisors’; they are a fourth hurdle advisory body with a focus on what works in healthcare service delivery, such as medicines and device technologies. By moving outside this, they are creating the impression that any area of health interest can be subjected to their methodologies. Indeed, that all matters of policy can be reduced to a QALY analysis and some economic modelling. No doubt at some point, they will pass judgement on the health impact of the national speed limit,  the salt content of food, the pub opening hours, as long as there is some way to tie the analysis to a health outcome. Invoking their brand of technocratic thinking to replace the fine art of public consultation is hardly the way ahead — that there is some evidence for the benefits or costs, does not lead inexorably to the conclusion that health policy should change.  Running health policy by the numbers in this way guts the democratic process for deciding social priorities.

This all-purpose extension of the mandate of NICE is not a good thing, for democracy or for health policy in the UK.

Lawmakers burning discredited health policies

‘Significantly, the core principles (and expected savings) of polysystems have proven difficult to achieve with more focus on the buildings rather than the changes to care and behaviours.’

So says a recently hitherto secret report that NHS London (UK) has been sitting on. What a surprise though. Healthcare change is difficult and the focus on so-called polysystems missed the point. In origin, they are really polyclinics, and well-designed would cut admission rates to secondary care; they would also bulk up on specialist services, including day-care work and short-stay facilities.

A bureaucratic orientation driven by doctrinaire thinking and misaligned incentives are clearly to blame, plus, of course, a fear, within the NHS of actual service reconfiguration and change that alters the structure and nature of clinical work.

Whether the new UK government coalition should actually stop the polysystems (a euphemism too far, I fear) is another question, as the underlying logic, used successfully in other countries is sound.  What really failed was management, and the vaunted commissioning system, which failed to demand, perhaps even conceptualise, service changes. No doubt, resistance from the clinical professions may have no small part in failure, but clinicians are been substantially disenfranchised from NHS reform, with the top-down, initiative driven thinking.

Less is more. Few but more substantial changes, may ultimately lead to the service and quality improvements.

Polyclinics are a missed opportunity, and having been badly conceived are now a tainted option. The political pull back to the status quo becomes a real a risk, when in fact greater effort than ever is needed to improve service delivery and productivity.

Education en plein air, Romania

Countries sink vast sums of money in higher education. Why?

Universities and colleges are at their root  ‘schools’, designed to enable the transfer of knowledge from one generation to another. It is where people go to learn how to be a doctor, lawyer, accountant, chemist, engineer, sociologist, and so and so on. What we expect them to do is deliver this knowledge transfer in an efficient and effective manner, to some degree of reliability and standards over time. To do that well, those who teach in these places are also expected to, in one form another, operate at the front line of their profession or discipline. There is really no point learning to be a lawyer from someone who doesn’t know what the meaning of recent court ruling is for civil liberties. So we expect those people to have an inordinate curiosity to know more than the average person would in order to structure the new knowledge, clean out the old, and ensure that we still get lawyers who can defend you in a court or a doctor who recognises you have a disease and knows what to do.

The research agenda has emerged as a big area of university activity, with many academics, perhaps most, have their careers almost trapped within expectations that they will do research and do it well, and be “published in prestigious international journals” (as a head of a higher education institutions once said to me).  Some more senior academics, perhaps the ones with the best understanding of a field, prefer not to teach, but beaver away on their pet research projects, or supervise the energetic activity of their graduate students.

In terms of the demands of the modern world, can the twin objectives of research and teaching co-exist together in the way that have in the past?

In the UK, the various university groups, such as the Russell Group, want greater freedom to set tuition fee levels, so they will get more money — this is the “big idea” that has come from institutions that are supposed to be the elite institutions in the UK, able to think the unthinkable, leap tall problems with a single bound.  I am dismayed at such lack of insight, but also at such self-serving indifference to the problems that lie within the academy.

Will this money go to better teaching? This is doubtful, as universities define themselves more through their research agenda than through their teaching agenda. Indeed, the careers of academics are made, not on the quality of their teaching, but on the steady production of research papers published in journals with a global audience of often a few hundred people, and books that embody the assembling of vast storehouses of information, but often fail to produce anything more than a wind-egg of insight.

There is the view, though, that teaching and research are intertwined; no doubt. But in the modern university, the research side rarely benefits the undergraduates (the focus is on the post-graduates), and higher performing academics are allowed to shrug off their teaching responsibilities, so they can concentrate on what interests them.  Perhaps all research intensive academics should be on soft money, ensuring that they are constantly focused on producing results from their research; this would also require greater sensitivity on the funding side, though, to ensure that good basic and preliminary or groundbreaking research continues to be funded. But at least it would eliminate the sinecure that protects many academics from accountability. But it would address the academic free-rider problem.

Like any clubby group, the universities see themselves benefiting FROM society, but not fully comprehending how they actually provide benefits TO society.

The solution is to break up the cosy world of higher education, like we would with any cartel. We need more contestability in the market for ideas, for teaching and for research.

That means that if students are to pay higher tuition fees, they should expect to get a higher quality learning experience.

That means professors teaching first year students, and graduate teaching assistants finding something else to do.

That means that we need to be able to decouple research productivity from the university’s teaching mission, enabling more free-standing and autonomous research facilities to exist, without the necessity of also carrying a teaching responsibility. It means that some institutions will concentrate on teaching and not be penalised for not doing research.

That means that some universities should go back to being polyclinics, and perhaps even technical colleges, to provide a more diversified educational system for the learners.

That means that we need more ways for students to learn, without the necessity of huge investment in building overheads and campuses,

That means we need smaller, more flexible learning and research-intensive environments, that can respond quickly and flexibly to areas of priority, such as we have seen with systems biology, conservation medicine, and other ways to integrate knowledge across often dysfunctional and artificial academic disciplines.

The new austerity isn’t only about money, it is also about purpose. Given the massive public investment in higher education, is it too much to ask the higher education sector to remind the hard-pressed taxpayer exactly what they are for?

Want to know more? Some suggestions…

The Marketplace of Ideas by Louis Menand (FT review of his book)

Reinventing Universities, a paper by Gowher Rizvi

We must set our universities free by Terence Kealey in Standpoint

Can American Research Universities Remain the Best in the World by Jonathan Cole in The Chronicle of Higher Education

GDP Expenditure

With the new coalition government in the UK, we are seeing early signs of a serious assault on public spending on the state run NHS. Similar challenges await other European countries with bloated public debt. Part of the debt run up by Greece, for instance, arose from efforts to off-shore hospital debt.

In the end the question remains, as it always has, how much money should a country spend on healthcare. The answer, as has always been the case, is as much as you can afford. Research shows that levels of spending (in terms of percentage of GDP, for example) do not correlate well with health status, outcomes and other key indicators of the performance of a health system. Indeed, it can be said with some degree of confidence that GDP spending is NOT an indicator of health system performance.

What does appear to be a factor though is HOW that money is spent and HOW the system is organised to deliver health services.  Recent OECD work has clarified various characteristics of health systems. What is striking are a couple of already familiar features:

• Not all countries pay 100% of the health bill from the public purse; many, such as France, use co-payments. Countries with socially unacceptable waiting lists have tended to be those with the highest levels of pure public expenditure (such as the UK, Norway and Canada). What this suggests is that there may be important features in how health systems organise themselves to deliver care that is adversely affected when the system is funded from general taxation. Efforts to introduce purchaser/provider separation, for instance, is an effort to create distance between the two quite different objectives, which in tax funded systems have been merged and caused considerable policy confusion, as well as operational difficulties. (I can mention the situation in the Canadian province of Alberta, where the response to funding constraints has been essentially to ‘nationalise’ the system, thus removing key drivers for reform. I can also refer to the Nuffield, UK, study that showed poorer health outcomes in the centralised health system in Scotland compared to now quite devolved purchaser/provider based system in England; and this despite having higher per capita expenditure in Scotland.)
• Most countries have mixed economies of provision and relatively easier ways for new types of providers to emerge. Lower performing health systems seem to discourage new providers of care to enter the health market; this is an element of overall system design, perhaps regulatory over-reach and dated statist thinking.  But perhaps we are becoming smart enough to know how to design more responsive health systems, which in the end are almost chaotic given the nature of human beings and illness (random?) and so need to be understood as complex adaptive systems rather than tightly managed and controlled (think of the tightly coupled banking system which lacked the ability to realign itself quickly and effectively in response to a financial shock; Homer-Dixon’s remarkably prescient work here is worth looking up).  Managed designs usually end in tears, as they fail to deliver the responsiveness and flexibility that is critical for healthcare to respond to changing demand and fluctuations caused by shocks to the system.

There is no right number of doctors or nurses or hospitals or beds. What there is, though, is the right number of these for the design and structures necessary to deliver effective care.  And these can be designed and developed to use human talent differently, and more effectively.

In the UK, we will hear a lot about ‘front line services’ and protecting them from cuts. I have no problem with protecting front line services, but that does not mean that they will not be delivered in different and novel ways, that may be a better use of the expertise available.  The health professions will undoubtedly circle the wagons and predict dire consequences to the public, so called shroud waving. But what is better is a recognition that healthcare systems are highly inefficient; they are weak adopters of revolutionary change, and they are protective of established working practices — part of the reason for this protectiveness arises from the health professions having become co-dependents to the addiction to public money on the one hand and protected ways of working on the other. In a nutshell, they have become resistant to innovation and reform, and in some respects lost control of the their profession and the profession has ceased to evolve to meet the care needs of people — an emergent adaptive response characteristic of complex systems.

Hospitals are artefacts of industrial era organisational design principles — they embody craft mentalities in the organisation of care, and build on public support to protect their infrastructure (from closure, for example), rather than the public demanding better services, which may not require a hospital in the first place. The difficulty people have in unbundling a hospital (it can be done and I can share the algorithm with you in another post if you like) simply reinforces the protected nature of healthcare work. In part, the emergence of e-health (more precisely, the use of digital information and communication technologies, artificial intelligence/neural networks, predictive algorithms, smart devices, etc) offers a serious challenge to established patterns of working, as these various components have the collective effect of redistributing knowledge, embedding knowledge and skill in devices, and altering the use of bricks and mortar infrastructure — a high-tech/low touch outcome is not the necessary outcome if we are clear on our outcomes.

It is also not just a matter of a cost-effectiveness study of whether an e-consultation is better than a face-to-face consultation.  The evidence for this is actually quite easy — when the telephone was invented, businesses might have one, on a stand, which people would queue up to use. Now, a modern business would hardly do a business case to put a telephone on everyone’s desk — indeed, it hardly needs a business case to ensure everyone has a smart phone — yet in healthcare, smart phones are still rare, yet have the potential to radically alter information flows and hence work flows — 25% of US doctors now have one and ePocrates is one of the most downloaded clinical apps from Apple store, so it is coming. You don’t do a business case when the underlying business logic itself is what will fundamentally change and that is really what e-health is all about.

They say, in capitalism, that it works partly through a process of creative destruction. Otherwise, we’d still be riding around in horse-drawn buggies, and you wouldn’t be reading this note on a computer linked to the internet. There is, however, a general reluctance to apply that process to publicly funded institutions, and by extension to publicly funded ways of working.  The words government and entrepreneur are an oxymoron for many people. But that does not have to mean that public funding cannot be used to incentivise new ways of working and new forms of healthcare delivery. The challenges, in the end, lie in our heart and willingness to change, to create and innovate.

And so to austerity. There is little to fear, except our ability to resist change, protect legacy ways of working, and failing to grasp the real prize, that of doing things better and more effectively.  We will, no doubt, hear the opposite.

“That” slide, which has now featured most recently in the NY Times, is a creature of a major consultancy firm. The slide obfuscates and confuses, and the Generals are right to wonder what it means.

Does the presentation of information such as this rest on critical thinking, with an evidence base; is it a conceptual model, without empirical importance; is it a sophisticated ‘guess’? In the end, it represents the thinking of a room full of people who designed this and thought it made sense.

The condensation of content onto the PowerPoint slide is bad enough. The mind-mapping software that they used to create this thing is also to be faulted, as such models lead to the suggestion of deep meaning; the authors have suitably coded the slide with colours, linking arrows, and a key explaining what the two little lines mean over an arrow — all this suggests meaning, but that meaning depends on how individuals make sense of it themselves; it does not emerge naturally from the slide itself.

I’ve loaded the whole image and you just need to click it to see all of it. Note the slide is from a working draft, v3, and calling it that is consultancy code so they can easily change it. That way they can avoid having to stand behind their conclusions. Note also it is page 22; I wonder what the preceding 21 pages looked like — maybe they were PowerPoint slides, too. What was the next slide? “…and in conclusion, General, this slide shows four bullet points summarising the key actions for the Afghan strategy…?”

The arrows bother me; there is some suggestion that they imply causality, a sort of ‘if/then’ for instance: IF ISR/Open Source Ops THEN Coalition Knowledge and Understanding of Social Structures.  Note too that the latter is also negatively affected by “Duration of Operation”.

This is the type of technocratic thinking McNamara’s ‘boys’ thought was helpful during the Vietnam war. To be fair, the situation is complex and dynamic, but we know that, and complex issues are often presented in this way.

What I want to know is this: if this is the answer, what was the question?

How to Muddy Water

Fast Ship

It is time for an honest explanation of how long the ash could disrupt travel, commerce, post, food and all those things we now depend on the airplane for. Certainly, waiting will do nothing, and while stranded passengers are indeed stranded, efforts must be taken to help them get home. A person leaving the UK by boat on Friday would be arriving in NY within a week, and they’d be home; better than waiting airside at the airport.  Clearly, too, our methods for handling large numbers of people stranded in such a way leaves much to be desired — it is hardly appropriate to trap them in airports because they lack entry visas — fresh thinking is needed, and quick, but we also need some longer term thinking.

We have air traffic chaos, probably some potential health problems for people inhaling the ash (COPD and asthma for example), potential acid rain in due course, and growing economic concerns that Kenyan fine beans will not reach the shops of Europe. But many people are also stranded and transatlantic travel is at a standstill — no people, no post, no FedEx.

What have been early responses apart from the silence of the governments?

We see business executives using teleconferencing instead, but this obviously does not interest the airline industry as the bulk of their profits come from business travellers, who cannot easily postpone their travel — they travel for a reason and now those reasons are being met in other ways. The shops will soon empty of produce air freighted in — so local farmers will have to do what they should have been doing anyway –growing the stuff that gets imported. As for Kenya, well, it will have to stop exporting its water. The international trade in flowers will suffer. We may see some industry restructuring downward, things will get more expensive, we may have another recession. We may need to get used to a lower standard of living, we may need to change our expectations, we may find other ways to have fun. We see people moaning that they can’t get to London from Scotland by air to sign a book of condolence at the Polish embassy — take the train m’lady! Air travel is useful, but far from essential, and rail, ferry, bus and shipping lines have moved to provide alternatives (at a price, it might be added). I won’t comment on the lack of clarity from the insurance industry — they are their own worst en

But what if this cloud bubbles away for a year and the ash continues to be a threat — sending it elsewhere just sends the problem elsewhere. Can we reasonably expect the airline industry to operate through small ash-free windows when they become safe and available? Hardly something scheduled airlines would be comfortable with and broadly useless as a sustainable strategy. Executives and business travellers will find other ways to do their business and I guess a lot of people will take their vacations at home, or at least places they can get to terrestrially. Perhaps new airline engines will be developed that are ash resistent (filters anyone). Perhaps some laggard countries will simply get on with building high-speed rail and toll roads to speed terrestrial movement — France seems particularly well positioned, the UK not. A smaller airline industry beckons (they are losing millions at the current scale of infrastructure, so shrink).

However, we do need reliable transatlantic travel; with air movement at risk, the alternative is the sea. My entrepreneurial question is this: how long before someone figures out there is a market for high-speed transatlantic ships (jet powered perhaps, hydrofoils, water skimming with perhaps a 2 day journey from Southampton to New York. Our response to date is that this will, literally blow over; but we’ve been lazy in our thinking because planes existed and made travel easy (though certainly less pleasant in the past few years). Train travel, though, slower is more pleasant, and perhaps with some roadside tweaking, travel by car could be more pleasant. Perhaps this is a hinge-point in our travel technology, that will open up alternatives.

The earth is always restless. This Icelandic eruption is showing how easily Europe and North America can become disconnected. It may be a lesson for us humans should similar events transpire with other volcanoes (we do tend to forget that nature follows different rules).

Here are a few places where the future is being invented with high-speed ships:

• Cutfinger Watercraft
• Bonanza Express
• Wave Adaptive Modular craft
• Hydrolance High Speed Cargo craft

Is it possible that “every ash cloud has a silver lining”?

Beware digital errors as they can bite

We all know accidents (unusual occurances in healthcare) can happen. Where systems are involved, errors can arise from how a system works, the way the various bits mesh, the knowledge and training of everyone involved working together.  It is no real surprise that some errors arise from the technologies that we use. In particular, health information technology systems can cause new types of errors and mistakes, beyond just not working properly.

In the US, the Health IT Policy Committee has proposed establishing a database to track potential safety risks related to IT systems.  These risks include:

• hardware and software failure and bugs
• workflow interactions between staff and users
• interoperability problems
• implementation and training deficits.

Since healthcare work is complex, the workflow risks are particularly complex and can arise from, for instance, inaccurately understanding how a manual system achieves its results, and thereby designing a software-based system that fails to do just that. There is a funny little thing that happens when a patient sees a doctor; the doctor often will use writing a prescription to terminate the patient encounter — tearing the piece of paper off the tab, a swirl of signature and handing the slip to the patient leads to the patient leaving, a neat way to end the consultation.

In an automated system (electronic prescribing, for instance), the consultation is not terminated in this behavioural manner, but involves essentially hitting the return key on the keyboard to enter the required prescription data in the system, and perhaps handing (or not) the patient a copy — but the Rx is off on electronic wings to the pharmacy for dispensing. There is an error that can occur if the doctor does not hit the return key between patients — the Rx list builds up, from patient to patient, until the return key gets hit (unless some sort of failsafe has been built in); this error actually happened and it was an alert pharmacist commenting to the patient that the doctor had added a lot of new drugs that the alarm was raised. Perhaps the patient should have been more distrustful, too.

We must be mindful of risk and error in any kind of technology, but particularly in systems where it is very hard to look inside the black box of software code.

I wrote a paper on digital risk some years ago, which can be found here: Patient Safety and Digital Risk. I have also raised the issue of risk in the even blacker box of predictive algorithms used to data mine record systems and profile risk of patients and this can be found here: Predictive Health. This second paper suggested that software may need to be subjected to comparable regulatory review like a medical device.

Just because you can’t drop it on your foot, doesn’t mean something can’t be dangerous.

Magnetoencephalography

Integrated treatment is an important step in service innovation, and it is no less important to see how the convergence of diagnostic technologies and methods with treatment methods will lead to integrated, one-stop encounters.  This is more than an integrated provider, but the development of theranostics (therapy/diagnostics), which combine what in the past have been discreet clinical steps into a single diagnostic and treatment encounter.

We are still developing methods here, but in the image guided surgery is an example. The ability to bring together disparate knowledge, currently spread across different brains (i.e. experts) into a single brain will create new clinical professions, shift knowledge from higher levels of expertise to others who delivery services augmented with machine intelligence embedded in the devices. These sorts of development disintermediate clinical workflow, to use disruptive terminology, but reintegrate the clinical workflow in new ways, this time around the patient, rather than the clinician.

Importantly, the diagnostic bottleneck which health systems find causes waiting and delay is likely to be largely eliminated for a wide range of procedures, as at the point of diagnosis, treatment would also be provided. With improved detection methods, too, this treatment will start sooner — we are still learning of the clinical benefits of bio-conjugated quantum dots, and biosilicon, and other new materials, but they are likely to underpin a new health service delivery paradigm.

The equation in the title simplistically represents the shift toward integrated therapeutics, which in the end may be the biggest next step in medicine since discovering germs as will germs came specialisation and the burgeoning of clinicians and expertise, coupled with the universities in creating specialist bodies of knowledge. Ix, integrated care, builds on integrated knowledge (IKnow?) which is something we are slowly appreciating as the problems we face effectively challenge the narrow disciplinary models we see at university and in clinical practice.

The question though is whether policy and decision makers will be bold enough to face up to these opportunities or will vested legacy interests prevail?