“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

Halting the investigation of preferred providers in the NHS does appear political as King’s Fund colleague John Appleby has said. It also illustrates the risky territory the policy would take the NHS into.

Preferred providers are by their nature preferred, but for what reasons? As a patient and taxpayer, I would hope that they were preferred for their ability to deliver exemplary care, not for the nature of their ownership. The latter would ideology ahead of patient care and indeed safety and would hardly be defensible should a patient choose to challenge it in a court.  “M’Lud, the patient is complaining the operation went awry because she was treated at a twice failed preferred provider.” I wouldn’t want to be on the receiving end of that!

This isn’t really about NHS or not NHS, it is really about clinical and service quality, which is what the Department of Health should be focusing on.  Things are only going to get worse for publicly funded NHS provision in England anyway over the next few years.

I am also think there may be a lesson from European law and so-called emanations of the state that are automatically assumed to have a dominant market position, and are therefore enjoined from behaving in certain ways. I am reminded of a German case at the ECJ that found that the state cannot be a monopoly supplier of a service if it manifestly is unable to meet public demand for a service — in other words, you can’t freeze out new market entrants if the sole purpose of the policy is to protect state-funded incumbents.

As for the UK’s NHS, I think I’d want to know if my local provider was a failing preferred provider. I think any Health Department anywhere would not want a policy that looked the other way. Any willing provider should be up the quality standards that would make them preferred providers; anything less is bad policy.

UK, NHS, “bad idea”

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.

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.

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.

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.

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.

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.

NICE’s position on the rule of rescue is incompatible with the purpose of the NHS as a state mandated healthcare system which must at least be the option of last resort for people where social values and preference would provide healthcare — despite NICE’s analysis.  Government cannot let HTA bodies such as NICE ignore the rule of rescue.  NICE argues that it adequately takes account of this — but there is a discontinuity in the applicable decision logic below and above NICE’s QALY threshold.  NICE in effect is applying below the line logic to above the line issues.  The issue of compliance and indeed civil disobedience may be applicable as doctors are prohibited from violating their professional codes of conduct, or acquiescing in acts or procedures that would cause them to violate their ethical code.  A doctor strictly speaking cannot not aid a person caught by the NICE threshold cutoff, where they are able.  The state is obligated to interevene and pay for expensive care as it is not an act of supererogation, but it is the State’s duty. Therefore, the State must act in cases above the line out of duty –  aiding people who might cost a lot by HTA QALY benchmarks but if the state doesn’t act, and who will?  This is especially troublesome in the UK where the NHS is presented as the health provider of last resort — not something NICE has clearly thought through.  Will the politicians allow NICE to wag, so to speak, the objectives of universal healthcare?

As other countries adopt NICE-like thinking, how will they come to understand the role of the state?