Learning system design from ants

How ARE we to think of healthcare systems? It has been fashionable to think of them supertankers — the images conjured up of something big, slow and as the politicians and managers were wont to say, slow to turn, so (to cite Piet Hein’s TTT) things take time. But such thinking is wrong-headed and always has been — it reflected a top-down technocratic mind-set that saw healthcare as rational and plannable.  I have never bought this argument, and argued that healthcare systems should be conceptualised as a school of fish, as they can turn on a dime! We have much to learn from a swam of bees, a colony of ants or a flock of birds. (and even a school of fish). The bigger and more complex a system becomes (like healthcare systems) the least likely it is to be amenable to notions of levers to push or string to pull type thinking — but such thinking veritably oozes from academe where reductionist and linear analytical models are easier to research, but fail to take account of reality itself.  (the academic group that seems to consistently get things wrong for similar reasons is economics, and surprise, surprise, many people think that health economics has something to tell us about health reform — but similar models and thinking are pervasive!)

Now, Peter Miller’s book, Smart Swarm has received laudable coverage in the Economist newspaper. The book and many articles in the popular press have highlighted the efficient design that comes from the apparently unplanned but linked behaviour of individual generally unintelligent ants or bees, which collectively bring order to complex natural environments.

For our cherished health system planners, it suggests that they have overstated their impact and relevance, if indeed they ever were really effective. For me, it suggests that health policy has become a bit too much like the old Soviet bread planners, thinking that since people needed the bread, planning for it would ensure is got to people’s table, but of course the planning was part of the problem, not the solution. (I’m trying not to make the bread an issue of markets but of coordinated behaviour of linked systems.)

The best way to understand complex systems is to embed intelligence within the behaviour of the bits that make it up, rather than impose it from above, or fruitlessly planned in. The key factor which makes these distributed systems work is the ability to exchange information — planners create funnels through which information flows and if you get the funnels wrong, the system fails to optimise, or indeed work at all! By allowing parts to exchange information easily, on an as-needed basis and act accordingly, coordinated behaviours emerge, which effectively bring the desired order without some remote planner deciding how it should work. It all comes down to information flow and exchange.

And so to health systems.  We all want joined up, linked, coordinated healthcare; that patients seen in clinic A who go to clinic B can be seen by people who have information about you; that when you show up for your operation, they know you’re coming, and so on. Healthcare systems are really all about patients, but we plan then on the basis of the behaviour of health professionals, who actually communicate with each other quite a lot — and indeed, construct informal systems to make the healthcare system work better often despite formal planned structures . One might say they behave like the bees and ants by simply getting on with things. It does raise the question of what roles are needed within healthcare systems to ensure the flow of information — this is usually seen as a reason for managers, but managerial models frequently fail to understand the purposeful behaviour of interconnecting systems as management is a reductionist organisational notion.

The information that patients carry is critical, but generally not accessed — it is important to realise that only the patient has experience of the whole care pathway, not the health professionals within it. This is important information that is lost within formally planned systems, which focus on structuring care, rather than the flow of information that links the bits together. I call this information structure the “healthcare information value chain” and it is the most important, but generally least understood, aspect of healthcare systems, as embedded within this value chain is the information needed for the various components of a healthcare system to coordinate their activities, without the great planner in the sky. This information value chain is not some construction of an IT system, it is information used in the course of people going about their work — of the ant hill at work. It is worth noting that ants or bees manage complex systems without IT systems, but researchers have needed IT systems to understand them!

Want to know more?

Ants may have an edge when designing efficient systems, a commentary on US health system reform, by  Joseph Reisert.

Emergence: The connected lives of ants, brains, cities, and software, a book by Steven Johnson.

It may also be helpful to understand how complex adaptive systems work: for instance,

The US National Academy of Medicine has thought about healthcare as a complex adaptive system in “Health Care as a Complex Adaptive System: Implications for Design and Management”. [here]

Implementation Science is an open source journal that has articles on this subject, including this example [here] on making change in healthcare settings.

Regretfully, much useful literature is not available to the informed or interested public, as it is squirrelled away in the academic journals for which the publishers require passwords, subscriptions etc. in order to access.  Any research that has been funded from public sources should be available for public access in open source locations or journals. I will not cite reference material that is not generally available to the public. If authors have material on this subject that they would like to enable public access to, please send me the links to be added to this (very) selective list.

An Auditor of One checking on surgical performance

The UK’s coalition government’s reform agenda continues to unfold with the planned scrapping of the Audit Commission. While the Commission has good analytical capacity and did focus on issues of importance, the need to shift the audit function further into systems and out into the community was not one of its core objectives.

In healthcare, I have written and spoken of the patient as the “auditor of one”, as the patient is the only person who has a real experience of the continuum of care, and it is only through the patient that the integration or not of services is achieved. While bureaucratic processes may try to knit systems together at their edges, only users have that ‘joined up experience’, and it is by engaging with them more effectively that radical service improvement will come about (the use is really the most disruptive force for quality improvement we have).

The next test for audit in the UK will be ensuring that all these auditors of one can be effective; rather unfortunately, the government is referring to them as “armchair auditors” a term which tends to describe distant interest, rather than engaged in the critical appraisal of performance. But organised interest groups can emerge, or existing one expand their scope of interest to increase the salience of issues in the delivery of publicly funded services.

I think one auditor is really enough anyway, but the National Audit Office will need to expand its remit in at least two areas if it is to be really worthy of public expectations, to include:

1. value-for-money retrospective audits (and not just of assessing implementation against legislative intent);
2. prospective audits of planned legislation (similar to the US non-partisan Congressional Budget Office).

I might add a third, namely being advised by, and engaging with, the public, perhaps through regional citizen audit advisory groups who can act to bring local concerns together where national concerns, at least, are an issue. There are models for this sort of relationship which would enhance accountability, transparency and visibility with the public.

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.

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.