Measuring Up: the health of NHS Cancer Services is a report from Cancer Research UK.

I have no difficulty accepting much of what they have discovered and the report’s key points are sensible. But, two main conclusions are unsurprising and disappointing: more money

English: A male Freckled Duck (Stictonetta nae...

Paradigm Shift: If it sounds like a duck, it’s a duck. English: A male Freckled Duck (Stictonetta naevosa) (Photo credit: Wikipedia)

and better leadership.

There will never be enough money, so we need to think differently about how we organise care itself. More leadership is a typical lament which says that the people responsible for the service haven’t done what they need to do. When I read reports such as this that call for more leadership I can only shake my head that they were not able to think further about the underlying causal landscape.

Their use of tipping point language is useful, though, as it does suggest catastrophic, rather than incremental, changes are likely. A tipping point means a move from one state to another (like tipping over the milk pitcher), where other factors come into play (otherwise it wouldn’t be tipping!). That suggests that there will be a change of state in which the old rules are unlikely to apply or be useful. After Kuhn, we call this a paradigm shift. Edward de Bono characterises two situations: one he called a problem, where you use existing rules; the other is a crisis for which you need new rules. My take is that the NHS is moving into territory where the need for different thinking is more important than problem-solving. That healthcare is a complex (wicked) and adaptive system should alert us and not surprise us that solutions create new problems and indeed crises.

Based on the report, though, we’re more likely to see hyperactive civil servants and NHS “leaders” rushing about with Powerpoint presentations full of exhortations and flow charts, accountability matrices and maps. We’ve tried that so often, one wonders if there are any other tools in the box. However, that the current state of affairs may have been caused by past reform and changes is an important insight, but to argue for essentially what is more of the same is plain silly. If past actions have destabilised cancer services and tipping is likely, then new thinking and new rules are needed. Did I miss something in the report?

If we take the simple flow of patients through the system, we are told the rate of entry is rising as GPs shift to ‘urgent’ referral, presumably the only way they know to get an oncologist’s attention, but the velocity through the system hasn’t changed. Why should that be surprising when resources are rigid and constrained by NHS structures (such as lack of effective transfer of patient information), and what appears to be performance measurement of the wrong things, creating perverse incentives.

The diagnostic phase is what appears to be rate-limiting across the patient and treatment pathway and hence is the primary blockage. While increased investment in diagnostics would be timely, how to do that is where a paradigm shift is needed. The delay in procuring proton beam equipment (so much in the news) illustrates the procurement logic that undermines service delivery. Entrepreneurial creation of free-standing diagnostic centres, providing on-demand services to oncologists and patients would be one way to deal with this. Does the NHS need to own the equipment, labs etc. or does it just need access to the service? By-passing the GP would also be another option, as the gatekeeping function appears to be another form of avoidable delay (ask women how long it took for ovarian cancer, for instance). Would it not be better for patients to access directly oncology diagnostic centres, which might also speed GP referral in turn?

The policy-down focus on leadership has clearly produced organisations of dubious purpose, but with evocative titles: Clinical Senate. Wow! But systems are judged by their performance, not what they’re called. A focus on leadership shifts cognitive priorities from a service orientation to one of lining up organisational structures, job descriptions, role definitions and mandates, meetings, minutes, but distractions if the challenge is where the rubber meets the road. The intersection of patient with system defines the leadership challenge, not the other way round.

So, what is to be done? I don’t buy the authors’ argument that change-weary people don’t need more change. They may embrace the logic of wholesale paradigm change if it got rid of the nonsense that stops them from doing what needs to be done. My take is that there is a strong case to be made for unbundling cancer services (this logic can apply in other clinical service areas, too) defined by the demands of the patient pathway. I would also look for ways to encourage entrepreneurial solutions, particularly in the form of investment in diagnostic technologies, and in enabling oncologists to work autonomously with each other and with patients. This would call time on the hospitals’ monopoly control of oncologists, cancer diagnosis, testing, and services, which is organisationally rate-limiting, and many of the identified problems are consequences of a system subjected to serious rate-limiting blockers, but lacking the ability to alter its structure to bypass, elminate, or reform those blockers.

In the end, the report is a narrative exhortation to get people to meet and plan to do what they are currently not able to do, or otherwise they would have done what needed to be done. Why not?

 

 

Conceptual work by Yves Klein at Rue Gentil-Be...

When rules don’t work [Conceptual work by Yves Klein at Rue Gentil-Bernard, Fontenay-aux-Roses, October 1960, photo by Harry Shunk. Le Saut dans le Vide (Leap into the Void) (Photo credit: Wikipedia)]

 

 

 

 

 

 

Sir Andrew Dillon, the erstwhile leader of NICE as said that it is irrational for the Cancer Drug Fund to pay for drugs that NICE has turned down.

 

He’s right of course, it is irrational. But only if NICE’s logic is compelling.

 

The problem for Sir Andrew, and likemined people, is that there is another logic that trumps NICE’s rational world. Don’t get me wrong. NICE performs a useful, but technocratic, function with analytical assessments that any rational person would indeed want to know. Where we part company is believing that NICE’s logic is the final word on the matter. Which it isn’t.

 

Tasked, perhaps unenviably, with parsing the performance of medicines and clinical practice, cannot also mean that they are above challenge. Many of NICE’s rulings fly in the face, not of logic, but of our beliefs as humans. It is why we do things when the odds are against us, because not to do so would be wrong. If we think of the challenges NICE faces as wicked problems, that is complex problems with a multiplicity of solutions, it becomes self-evident that their logic is just one way of deciding and choosing. We could use other rules, other criteria. The Cancer Drug Fund is just such an approach. It is another matter whether we should have in place alternative funding approaches that individuals can avail themselves of (such as co-payments or co-insurance); for extraordinarily costly therapies, co-funding would not apply, so we’ll back to the problem anyway.

 

NICE has a troublesome relationship with the notion of ‘rule of rescue’ and so has decided to ignore it. There replacement, the “end-of-life premium” is really just a reweighting of the logic they use.

 

You see, the rule of rescue is what we might call a meta-rule — it is a rule that tells us if other rules are working properly, and importantly, as a moral imperative which tells us what to do. The rule is often invoked in a particular form: that people facing death should be treated regardless of cost. The rule as originally formulated is really about assisting identifiable individuals facing avoidable death (Jonson, 1986); the bioethicists and economists have shifted this to a cost-effectiveness approach, making it one about trade-offs instead.

 

The problem for healthcare systems is that all patients are becoming identifiable as medicines become personalised (medicines may become orphan drugs). The problem for the NHS is that it does not allow such people to rescue themselves because it prohibits any sort of co-funding or other arrangements. The only option is an opt-out (and private medical insurance has rules about pre-existing conditions). Given the funding priorities of the NHS, we should be reflecting not so much on how to make the pot bigger, but on using the money that is available better (there will never be enough money), and ways to introduce practical co-funding.

 

Since individuals have no other options in the NHS, the rule of rescue as a moral imperative will be violated and we will act, not out of analytical error (i.e. make a technical mistake), but unethically. You see, the NHS must be the healthcare system of last resort and therefore of rescue, otherwise, identified individuals are destined to a death sanctioned by public policy and is that a policy or healthcare system worth having?

 

We have seen a similar challenge to NHS/NICE logic recently with the King family and proton beam therapy, and the NHS will also use NICE logic to determine access. Whether beams or drugs, it is the same argument.

 

But why cancer? The main public policy question is why should cancer patients be given preferential treatment as against any other deserving group? This may in part be driven by the often astronomical costs of new cancer therapies themselves, which demarcate cancer patients decisively from equally deserving patients with less cost-contentious therapies. I have just finished some work on motor neuron disease, for which there is one specific medicine and life expectancy from diagnosis is 3 to 5 years, with median survival rates that are measured in months. NICE reportedly is developing guidelines for this disease. Costs are considerable, and at least in the UK, highlight the bureaucratic illogic of separate healthcare and social care, but that is another story.

 

The moral dilemma that the economists at NICE are trying to reduce to an equation is whether a new therapy is extending life, or delaying death. The Oregon approach collapsed when the hard choices emerged and people were unable to resolve this dilemma, which is not a quantitative issue, but one of how we value our humanity. Kierkegaard’s Concluding Unscientific Postscript speaks of the leap to faith as involving self-reflection and the emergence of scepticism. It is worrisome that NICE is so confident.

Further reading

 

Cookson R, McCabe C, Tsuchiya A. Public healthcare resource allocation and the Rule of Rescue. J Med Ethics. 2008 Jan 7 [cited 2014 Sep 4];34(7):540–4.
Jonsen, AR 1986, Bentham in a box: technology assessment and health care allocation, Law, Medicine and Health Care, Vol 14, pp172–4.
Richardson J, McKie J. The rule of rescue, working paper 112, Centre for Health Program Evaluation, Monash University
English: Broken glass

Sometimes, the system is the problem. Broken glass (Photo credit: Wikipedia)

This report on the regulation of private hospitals in England from the Centre for Health and the Public Interest is important, but 15 years too late.

The UK has had and continues to have a love/hate relationship with the private (or independent as it is termed) healthcare sector. This has created a significant fault line across all reform and policy making on the NHS for at least 15 years. Reluctance to create a level regulatory playing field has been evident for years, despite the obvious need for one. I think part of the reason is that creating a level regulatory playing field so that the NHS and private hospitals had to meet common standards would legitimate the private sector itself.

However, when I first worked with a colleague to suggest, around the early 1990s, that the NHS hospitals should undergo some sort of accreditation, resistance was clear. At the time, I noted to others that there were more deaths in NHS hospitals arising from substandard care than from road traffic accidents.

But the view at the time was to ring-fence the NHS from that sort of performance and quality scrutiny at an institutional level. Based on some of the work I was doing at the time, and my own experience with accreditation systems, I felt that the negative reaction reflected a fear that NHS hospitals would fail; using pretty standard accreditation standards from the US, Canada and Australia at the time, I perceived that many NHS trusts would indeed fail. Mainly on safety and quality control grounds (I was teaching NHS managers about quality and quantitative methods in healthcare at the time). Many hospitals lacked any quantitative analytical or operations management capabilities within their organisation and had rather weak data for quality control and performance management purposes. The Department of Health, it must be said, had such expertise on contract but that was to inform their own policy making, not to improve operational performance. I would suggest that such quantitative expertise for quality is still missing at the hospital level.

The consequence has been years of fiddling with quality assurance and inspection regimes. Government has been advised, I think badly, by people who also shared the operative underlying assumption that a single regulatory and inspection system for both the NHS and private hospitals would be politically a step too far. Consequently, the private sector and the NHS have moved in different directions. The private sector has been both an opt-out for patients through private insurance arrangements, and an overflow supplier to the NHS when it ran into capacity constraints. Only more recently, has it been a direct and core supplier of services.

The UK situation constrasts wildly with practices in other countries where ownership of the hospital does not exempt the organisation from regulatory oversight. Indeed, many European hospitals seek out US-based Joint Commission International accreditation, a very high standard. Interestingly, there are no private providers in the UK that have achieved this standard, while (with any type of accreditation) there are 26 in Ireland, 3 in Belgium, 2 in Netherlands, 4 in Germany, 26 in Italy, 15 in Portugal, 23 in Spain, 13 in Malaysia and so on. Perhaps they know something?

I agree with the report’s sentiments, though perhaps not so much how it characterises the private sector as exceptionally risky. Indeed, the past years have demonstrated that NHS hospitals can be exceedingly risky. For instance, the report notes the 6000 admissions per year to the NHS from independent hospitals, while also noting that such hospitals do not have emergency facilities. One might ask whether a common regulatory environment would have led some independent hospitals to invest in such facilities? But such a figure should not be a surprise any more than transfer between NHS secondary hospitals of patients who need more complex tertiary and quaternary care; not every organisation can do everything. In respect of equipment, NHS equipment, too, has failed, gone missing or not worked properly (I have had personal experience of a nurse using equipment that lacked recent calibation); so before we cast the net, let’s make sure we know what we’re fishing for.

The report notes that the private hospitals do not directly employ their doctors, as though this were a problem. Many countries do not directly employ doctors, using fee-for-service type arrangements for compensation. What the report failed to note is that the private hospitals in the UK employ a system called “privileges”, which requires doctors to prove competency in areas for which the hospital in turn grants them privileges to offer that service in the hospital; NHS hospitals do not use a comparable system. I have argued that the NHS should introduce a privileges system, which would bring a more rigourous standard of clinical performance management than the NHS consultant employment contract does and would have the additional benefit of increasing flexibility in the supply of doctors, and perhaps importantly, keep doctors within their scope of primary competency.

A few other points that struck me:

1. Clinical risk does not transfer to the private provider when treating an NHS-funded patient. I’m not sure how this is a useful restriction, especially if the patient chose the private hospital. It seems to me that part of a level playing field would ensure that clinical risk transferred, too. The report addresses this obliquely in terms of whether the NHS is the provider of last resort.

2. The observation that clinical workflow is different is interesting, but it does appear somewhat anecdotal. The private sector is excluded from the requirement to take trainees, and that may contribute to the lack of depth, but I doubt the public would feel reassured that the clinical depth the authors referred to was reliance on trainees! We know what that looked like with registrars. The solution is to ensure the private hospitals are included in the system for training the health professions as a consequence of a common regulatory regime. By the way, I’ve looked at the supervision and training of junior doctors and other health professions and one should not be complacent that it is done well. However, I share the authors’ concerns over the organisation of clinical work, but would not single out the private sector on this point.

3. The volume of work in specific areas is a point well taken. However, I would again suggest that is an artefact of the regulatory system, and lack of effective use of the clinical resources themselves. Proper contracts for suitable volume, rather than handling overflow, would shift workload closer to levels where higher quality standards apply. It might also enable the consultant, for instance, to integrate their clinical workloads, rather than adding the private patients on at the end of an already busy day. Again, organisation of work arises from the current rules and may perhaps be causative of may of the identified problems.

4. I note that only one of the two authors is a specialist in healthcare or health policy, particularly patient safety with grounded expertise.

Many of the report’s comments, with which I broadly agree can seem quite disturbing, really arise from the regulatory box that the private sector has been put in. Given that private hospitals use the same doctors in the main as practise in the NHS, do these doctors lose their minds when they practice privately, or something else is certainly wrong at a system level. My guess is that the box is the problem, and the private hospitals are quite capable of meeting care standards, given a level playing field.

My remarks are meant to focus attention on the important distinction between the NHS as an organising principle for ensuring (and assuring) healthcare to people and the mechanisms used to identify and engage providers who meet the requisite standards. Focusing on the latter, would necessite doing what the report recommends, but ’tis a shame it has taken this long, to say once again, what has been said for years.

Is now any different?

Further reading: Vito Tanzi’s excellent book, Government versus Markets The Changing Economic Role of the State. Then think again about this

report.

Disclosure:

1. I don’t have private health insurance.

2. I have received NHS-funded care in a private hospital.

3. My NHS trust has recently been reviewed as overall inadequate by CQC.

4. I know something about the issues I am writing about.

It is reassuring that the UK’s Telegraph (see for instance the Telegraph) is maintaining in its pages the stories that Google is removing from seach.

What a right to be forgotten looks like.

What a right to be forgotten looks like.

The European Court of Justice’s illiberal ruling has reminded us that the digital media are in the end ephemeral, easily deleted and perhaps unreliable. The hard copy newspapers are proving themselves what we had forgotten they were — a way of archiving history. If digital storage becomes so corrupted by selective amnesia caused by deletion of links to stories, it will prove unreliable in the end, and undermine the whole point of search.

In that respect, the ECJ’s ruling is regretfully Luddite. It assumes that a right to be forgotten really makes sense. We can instead still hunt through back copies of hard copy journals, newspapers and pamphlets and see both the good, the bad and the ugly of history. Efforts to redraft the historical record by authoritarian regimes now appear to pale when compared to the ECJ’s ruling.

Clearly, there really is no right to be forgotten, otherwise editors and librarians would be far too busy with their physical scissors cutting out references to people and events from their collections. And we all know what history looks like when regimes do that.

There is a view called ‘internet exceptionalism’, that the internet changes everything, and in many respects it has, but we cannot define our fundamental rights solely on the contingent features of a particular technology. I have experience with this in terms of public access to health information over the internet. There have been efforts to censor false and misleading information on the internet, without also noting that much of that same information is available in hard copy in libraries, and bookstores. The spread of ill-informed medical opinions on internet chat rooms is hardly a reason to censor content any more than the state should eavesdrop on private conversations in case someone gives inaccurate medical advice. The world just doesn’t work like that and freedom won’t permit it.

There is another view, ‘technological agnosticism’, that says that we should not construct laws in such a way that they depend on a particular technology which can change, rendering the law meaningless or hard to enforce.  In terms of access to health information, since patients can buy books in bookstores that are just as unreliable as information on the internet, why pick on the internet when the problem lies elsewhere.  The key is to focus not on what the technology does but whether what is perceived to be the problem can be solved without specific reference to the technology. This cannot be done ‘forgetting’, hence there can be no right to enforce it without crossing the line into censorship — and there is no way to square the circle when it comes to censorship.

Unfortunately, we now have a silly ruling that seeks to treat the internet exceptionally, and in an uninformed way.  Indexed library holdings or the table of contents of a newspaper archive not subject to that ruling since putting the index online should not cause that information suddenly to be censorable and in and of itself create a right to be forgotten. But, that appears to be the consequences of the ECJ’s illogic.

So, thank goodness there still exists hard copies of things and that the legitimate press are working to protect access to these stories. As they say, what goes around comes around. If people find that digital archives are being selectively censored, they will lose their value, and with that will come the loss of confidence in the new media, itself. The snake devours itself.

Time to pick up my copy of today’s paper.

The US-based Commonwealth Fund has released a new 11-country comparative ranking of health systems. See the diagram. commonwealth fund table

Before the UK pops the champagne corks, let’s decode this ranking a little bit. Oh yes, before we also get too excited, rankings like this are useful only as a discusion tool. What does it say say operationally, if you had to choose a system to be ill in?

In effect the UK is tops and the US bottom, overall. But there are some disturbing issues with the data that necessitate a reflective pause.

If the UK is 1 for Quality of Care, and 1 or 3 for Access, and 1 for Efficiency, why doesn’t that translate into Healthy Lives? If the US is middling for these, which it appears to be, are we surprised that they have poor efficiency, equity and healthy lives?

What strikes me is that the UK despite having scored 1, that all this effective care, etc. is really ineffective as it doesn’t translate into better results. Efficiency, too, seems a technical measure, and one which also seems to fail to translate. So two quite different systems on the ground, and which are poles apart on the ranking, are competing with each other for impact on people’s healthy lives.

If we look at the other countries through that same lens, we’re struck by how much better they are at driving improved results (in the jargon of the Fund: mortality amenable to medical care, infant mortality, and healthy life expectancy at age 60. It seems to me on this basis, that while France has poor access (really!), it produces the highest ranking for Healthy Lives. Now isn’t that the point of having a healthcare system in the first place? Something else is going on that this ranking is illustrating but which isn’t being drawn out from any commentary,

So, my summary:

  1. The reason the US is last on Healthy Lives is mainly ideological and not for a lack of trying to things better, but regretfully, only for those who have insurance cover, with eye-watering variances from state to state. I do find this surprising to some extent as the US is very well served by a research community that analyses costs and treatment flows and the ability of payers to drive incentives into the system. Perhaps the distributional inequity of access will pass the reform, while the relative inefficiency may be a measure of the tolerance of a wealthy country has for ensuring people who can afford the care do in fact get it. Hmmmm.
  2. The failure of the UK to translate all those 1’s into Healthy Lives is evidence of the dysfunctional nature of the design of the health care system to actually deliver care itself and a fetish with structural reform, rather than organisational reforms which would enable other models of care to emerge. This focus on driving out variance actually drives out innovation rather than enables it: the UK’s public health system eats its young and fails to bury its dead, so the system goes round and round, in some massive holding pattern and people wonder why things don’t change. The system is efficient once you get the care and access, at least defined in terms of general practice is great, but waiting times for tests and access to the hospital based specialists doesn’t really translate well into timeliness. I question the 3 for the UK as countries with direct access to specialists enjoy much quicker access to care and this indeed does translate into the higher Healthy Lives rankings we see.
  3. I’m not sure how you can have a healthcare system that scores 10 for effective care and 2 for Healthy Lives. If you’re getting ineffective care, wouldn’t that translate into poorer results like in Sweden? Hmmmm, again.
  4. It is interesting to see how poorly performing very wealthy Norway is, but then it has a state-run monoply health system. But again, how can you square all those 11’s?  Are the poor results evidence that a state-run bureaucracy is not working? Probably.
  5. Canada’s system is a fragmented mess at the best of times, and affected by a powerful mythology about its performance, premissed mainly on it not being like the US. Restrictions on patient access to care are systemic, and designed in by the slavish belief in the Canada Health Act prohibiting alternatives. A real policy straitjacket, I think.
  6. Finally, the one’s that in the middle, so to speak, Australia, Netherlands, Switzerland may be more worthy of further consideration.

 

The Wanderer above a sea of fog by Caspar Davi...

Why limit your view when you can see this far? The Wanderer above a sea of fog by Caspar David Friedrich, around 1818 (Photo credit: Wikipedia)

“The Open Data Era in Health and Social Care”, prepared by GovLab (NYU) has been released.

I have no issue with open data, and the more open the better. However, doctrine may interfere in respect of the way data are viewed in the UK.

The typical model is to focus on the NHS, as the main provider of healthcare services. Certainly, this makes good sense, on its own. But the NHS is not on its own. The title is a bit misleading, in that while Social Care in included, the English NHS this is not integrated, suffers from bureaucratic accounting rules that prohibit pooling of budgets (hence the problems with the Better Care Fund), coupled with means testing, a cash market, and a major role of charities in filling in service gaps. Countries with patient-copayments and transaction data manage to integrate health and social care around the patient because of the ability to avoid arbitary distinctions between provider types and their ownership. As a result of what is both a strength and weakness of the NHS, policymakers have had and continue to have considerable conceptual difficulty integrating public and private provision into a patient-centric and whole-system model of seamless care.

Healthcare is bigger than the NHS as people in the UK can buy private health/medical insurance, pay cash for private treatment or use private hospitals under NHS contracts. In addition, patients seek services from dentists, physiotherapists and pharmacists, and others, who in the main are outside the NHS in terms of practice patterns.

Let’s take medicines. Years ago the NHS explored electronic prescribing, a project initiative I was doing some policy work on. I had asked whether private prescriptions and dental prescriptions were to be included and was told, no, they were excluded as this was an NHS project. Of course, thinking such as this means that they were failing to look at the whole system of medicines prescribing. A patient for instance who is prescribed an antibiotic by a dentist (and they prescribe a lot of antibiotics) would discover not only that that information was not available to their GP, but the GP would likely not know that dental surgery had even taken place. And private/independent prescriptions were simply off the table!

The only way that Open Data Era thinking can prevail is when the English NHS and the Department of Health adopt whole systems thinking. The modern world is full of boundaries that are being breached by new technologies, that are challenging assumptions of the past that in the future will prove dysfunctional.

The NYU report (I am surprised at the lack of whole-system perspective — perhaps they didn’t know about the wider health system??) does not address the distinction between NHS and private/independent data (though they do make the point that Open Data might be used along with private or independently held data, but in the context of my remarks, this seems a fudge).

I won’t go into a detailed analysis of their logic model on page 45 of the report which crystalises their essential argument. Logic models are conceptual models that link various elements (inputs, outputs, outcomes) to desired impact in a coherent (logical) way. Needless to say, they start with NHS data. Examining the Activities/Outputs parts, would suggest that the full realisation of the stated benefits will not be possible. Limiting the data in, as the model does, means that achieving operational efficiency or resource allocation (impacts) will lack private sector comparators for instance. One output, Policies Created/Changed, is immediately compromised by the inability of the model to account for the role of the independent/private and not-for-profit sectors, which is about 10% of the total activity and expenditure. Indeed, their definition of ‘internal users’  (page 48) excludes non-NHS entitities, and they aren’t seen as ‘external users’ who might need to access NHS data. Furthermore, the approaches proposed to capture measurement limits the focus to state-mandated bodies (i.e. NHS), and therefore limits the ability of measurement to assess potentially new approaches to care that may be invented. So much for measuring innovation.

It would have been better to start  with the needs of data users and their objectives, in a whole system approach. This is the fundamental weakness in the logic model and limits the report considerabley. In the end, it makes me worry that the initiative will in the longer run fail to be as successful as it might be.As Einstein said: “No problem can be solved by the same kind of thinking that created it.”

Health care systems

How to choose? (Photo credit: Wikipedia)

The scandal that has now led to the ‘resignation’ of the head of the US VA Health System matters to more than just the US and US veterans. The VA health system is the closest thing the US has to the UK’s NHS and to the health systems of many other countries where the state is the controlling force.

According to reports in the New York Times, three factors are relevant and expanded in Forbes:

  1. shortage of physicians
  2. perverse incentives
  3. culture of dishonesty

Boiling this down to critical factors that are relevant to systems outside the US leads to specific considerations to countries which try to control healthcare through greater state intervention:

  1. Physician shortages are caused in the main by health systems limiting access to medical schools (and indeed to other professions). There is far too much evidence that labour force forecasting is inaccurate and given the highly specialised nature of healthcare, we really don’t know how many doctors, nurses, etc. we need, just that it is unlikely the current system of rationing produces sufficient supply. While the costs of training of health professionals are high, the rewards are also high and of good quality. These benefits accrue to the individuals as well as society. Why, though, the public purse should subsidise this as much as it does, and also limit access needs to be rethought.
  2. Health systems use a variety of incentives to coerce or alter clinical behaviour. While putting doctors on the payroll is assumed to limit financial conflicts of interest, it embeds clinical behaviour within a managed system full of rules and regulations which invariably will put administrative convenience above clinical and patient needs. Falsifying records is nothing new, but using data to influence rewards only creates the incentive to game those rules to maximise the benefits. Gaming of incentives is not new, but it is possible to model/test whether the proposed incentives will work and how they might be perverse.
  3. Dishonesty is embedded in the culture of work, and rooting out dishonesty needs to go back to, perhaps incentives again, to understand why it is more beneficial to lie. This may exist more easily within highly bureaucratised systems, where people are dislocated from the patients, and see themselves simply tasked with ensuring the stability of the system. This is a tough one but in some countries doctors’ employment contracts explicitly put them in a conflict with their employers by emphasising the relationship between their work and costs.

As the US has noted on the VA, the system often put the doctor in a conflict of interest between the patient and their paymaster, the government. Many countries have the same arrangements and should not, therefore, be complacent.

It is certainly timely and appropriate for policymakers and those who think systematically about healthcare systems, to study carefully what happened at VA, and apply that learning on their own healthcare systems. I am sure there would be much to think about.

If anyone wants to do this, give me a call.