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