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Capturing race

Is HTA like GO? (Photo credit: Wikipedia)

Increasingly widespread amongst the world’s healthcare systems is the assessment of medicines and devices using various types of cost-benefit or cost-utility analysis; this is called health technology assessment or HTA. HTA seeks to determine, using evidence of one sort or another, whether something is broadly speaking affordable, taking account of the cost of the medicine/device taken against the benefit to a particular constellation of diagnostic attributes in patients. This is usually quantified in a measure called a QALY: a quality-adjusted life year, which is a way to assess the value for money of a particular health technology. In short, it is a way of valuing lives.

HTA is a utilitarian approach to assessment. To some extent, this is not surprising as HTA is in the main a method developed by health economists, who, like economists in general, hypothesise that we make daily decisions based on the utilty of this or that, in terms of trade-offs (Pareto optimisation, for instance) and rational decision making (that people seek to maximise value, or utility in what they do). This approach is increasingly in dispute in light of the findings from neurosciences and behaviour economics: by posting that people do not always make decisions that are in their own best interests, a key assumption of traditional economics, that of the rational actor, always calculating trade-offs and maximising benefits, and so on, is questioned.

The problem with utilitarianism, though, is it doesn’t pay attention to the freedom of the individual; it positions the justification of its results on the net benefit to society, regardless of the impact on rights of individuals. Obviously, health economists don’t watch Star Trek or they would know that the needs of the one outweigh the needs of the many. But then, that, too, is a moral position.

Indeed, it is perhaps the sense that utilitarian conclusions don’t seem to correlate with many people’s moral sentiments that may explain why decisions of HTA agencies, for instance NICE in the UK (England) lead to moral outrage and a sense of, if not injustice, at least unfairness. While the results of an HTA process may lead to a quantitatively defensible conclusion, people sense that this conclusion is not morally defensible.

How are we to judge? Few would use utilitarian arguments in this way in other spheres: would we calculate who needs welfare in terms of the net benefit to society in terms of quality of life years, though perhaps we do allocate welfare on moral assumptions that some people deserve welfare while others don’t.

Do we allocate support to communities ravaged by floods based on their overall contribution, or utility, to society.  If you could donate £10 million to a university, would you pick Oxford University or Thames Valley University; which one is more worthy? But would you want to treat people this way?

HTA doesn’t even let us value lives in quite this way, since it neatly avoids deciding about the worth of any particular type of person, who just happens through misfortune to find themselves needing some medicine that fails the HTA tests. HTA keeps us from confronting the fact that HTA is a way of drawing a conclusion, without actually having to decide any allocations for any one person in particular. Bentham would approve.

There is, though, a technical problem with HTA and it has to do with whether at one level of assessment outcome, a utilitarian models can be used when the decision to be made does not have life threatening consequences for some people.

If the QALY threshold is, say £35,000, as it apparently is in the case of NICE, are the decisions below that threshold, which tend toward ‘yes’ or ‘approval’ morally different from decisions above that threshold?  I suggest that different moral criteria come into play above the threshold and this is where I think out moral outrage should be directed and where HTA fails.  Regretfully, HTA models see the results as broadly continuous, that is, decisions above and below this threshold are seen as essentially of the same type.  But I have argued elsewhere that above the threshold, HTA models fail but for reasons other their analytical soundness, because above this threshold, the conclusions may lead to a lessened quality of life, in other words, they actually crystallise the health outcome rather than avoid it.

Therefore, in valuing lives, those above the threshold experience greater injustice than those below; they are treated differently, unfairly, unjustly, perhaps less worthy, but certainly differently.  Indeed, above the threshold, we feel we are more in the realm of our moral sentiments about the value of human life, and less our moral sentiments about the allocation of scarce resources.

If this were not so, then we would be living in a society that believes that the determinant of all important moral and political decisions is affordability, and if that were so, they we could not even afford the costs of inefficiency brought on by democracy, the inconvenience of not being able to exploit people, the costs of equal rights.

Perhaps, though, on our financially contaminated world, all we can think about today is money and that is further contaminating our perception of what sort of society we are actually trying to foster.  Certainly, protests on Wall Street and elsewhere point to the view that there seems to be some unjust allocation of the benefits of government bail-outs that just doesn’t benefit those ‘at the bottom’.

John Rawls wrote that the we should distribute opportunity in a society in such a way as to ensure that the least well off benefit the most. In the context of HTA, medicines and technologies that benefit only a few, but at great cost, represent a cost worth having as the least well off, namely those who would need it most ( have the condition it treats, and in some societies can afford it least), would benefit, even if a little, as that is the price we pay for justice.

This, I suggest, is the root of our moral outrage at HTA, that is unjustly fails to serve those who need it most.

I am left with wondering about the underlying morality of HTA as a government scheme. Governments, as we know, are the last resort, when things are tough and one would hope, ensure that the least well-off in society are not penalised simply in virtue of being least well-off.  In healthcare, someone has to be the carer of last resort; using HTA as a way of avoiding this responsibility is not morally defensible.

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Urinal

Industry accountability for public contracts. (Photo credit: Ron Knox 2001)

I was watching the Public Accounts Committee on 23 May 2011 take evidence from IT suppliers and NHS executives on the NHS IT contracts. This monstrous contract was doomed from the start, yet few seemed to be in a position of influence to alter the ‘group think’ that prevailed in government. Civil servants and ministers seemed to breath each other’s air as they pursued this pig in a poke. Worringly, the PAC exchanges shed a bit of light but more revealing was the lack of common language amongst those concerned. Frequently, answers were not relevant to the question, used jargon or introduced further obfuscation.

In the end, whether supplier or NHS exec, the PAC was faced with a sea of denial, avoidance, or sheer hubris. I say hubris as NHS executives in particular were at pains to avoid rocking their own boat by being completely candid about things, preferring warm phrases that all was well, despite the CEO of the NHS being unable to answer many questions clearly, and seemed painfully ill-informed of his brief.

Evidence of obfuscation abounded as the MPs had to ask suppliers many times to answer with yes/no to what were straightforward questions. I was impressed with the efforts of some MPs (Bacon in particular) to get clear answers to important questions.  As a rule, complex answers betray a lack of understanding of the underlying logic — there are simple answers to these questions, not ‘it depends’ or ‘you’re comparing apples and oranges, pears’; indeed, at one point, the sessions seemed more about the comparative merits of different fruits than IT procurement. As well, the lack of clarity of underlying logic also evidences people were unable to agree on what the core problems were.  Now, granted for some this is likely to be a complex problem (in the technical sense of the word, a wicked problem), but I doubt that — the NHS’s needs and responsibilities are complex, but an electronic health record is a thing, with a defined functionality.

I remember sitting in a room just as this NHS IT for heatlhwas being firmed up (2002), and hearing the Director (Granger) at the time speak glowingly of the benefits. Upon hearing this, others in the international teleconference asked, “surely you’re not serious about doing this”, to be told, “absolutely”. As is said, act in haste, repent at leisure.

An important question was, knowing what we know today, was the original decision to proceed with this central and top-down approach sensible? The answers were evasive and broadly technically wrong. In 2002, it was perfectly possible to develop distributed systems, with broadly distributed functionality using various systems integration options to enable diverse technical architectures to co-exist to deliver uniform service. No one wanted to think that way for a couple of reasons. The first is ego: grand plans appeal to people’s ego needs, to be in charge of something big. The Director at the time exhibited serious Machiavellian behaviours, and failed miserably to engage users.  The second is conceptual: at the time, Department of Health and NHS executives were still thinking the NHS was a single lumpen thing that needed single solutions to its complex problems. In the early 2000s and late 1990s, that the NHS should be seen as a complex adaptive system was understood, but not acknowledged as it flew in the face of prevailing ideology about central control, driven by the mistaken (technical) belief that a distributed system, while diverse and pluralistic, would be unable to deliver a common standard of performance.

In the end, you end up with a system that is rigid, technically obsolete as soon as it starts operating and because it fails to evolve with changing clinical needs, which will change as clinicians become familiar with the technology and comfortable with its use, and start to specify more sophisticated applications. That some PAC evidence said that clinician need had evolved is nonsense — we know then that these were the core needs. Anyway, we’re moving on to smartphone apps, and there is little evidence that the system can accommodate the wireless world of healthcare. The best selling clinical app is ePocrates, for drug information. How many clinicians have that app? How many clinicians are using smartphones? Distributed and simple systems can deliver often quite complex solutions; for instance, the Danish electronic prescribing system was built on simple secure emails.

The approach that was ignored at the time was this:

  1. specify common standards of interconnectivity and functionality, that is results;
  2. allow providers to use whatever system they wished as long as it met these requirements;
  3. allow the system to evolve over time as needs become better understood;
  4. start with the patients who are heavy users (high risk/high utilisation) and roll out from there.

That’s it.

Where the English NHS and Department also lost the plot was failing to exploit the NHS IT project to drive innovation into the IT sector to encourage the formation of a potentially world-class health IT industry in the UK. Is it any coincidence that the main solutions are from outside the UK and the critical supplier expertise betrayed North American origins?

This is a real shame, as once again the Department has shown antipathy toward enabling a commercially successful and innovative health supplier industry, in favour of mean-spirited control. This was perhaps the greatest missed opportunity, as instead, the Department came up with false logic of needing suppliers of scale (who are now quasi-monopolists).  Indeed, one member of the PAC did question whether CSC’s corporate logic was to make itself a monopoly supplier to the NHS.

The tragedy, too, is that virtually all the functionality that the NHS needs can be downloaded for free in the form of open source software.

Finally, the best thing the NHS and the Department could do is make sure all that intellectual property that has accumulated is given away, to try again to jump-start a health IT industry. If there is a value-for-money lesson the PAC could draw it is to determine whether there is sufficient residual value in the NHS IT procurement to be translated into investment in the economy, to build new suppliers to the NHS and perhaps the world. An opportunity awaits.

UPDATE

I thought I’d add reference to this diagram on distributed clinical systems. The copyright dates from 2002, a time when the PAC was told such capability didn’t exist. The diagram is taken from the OpenEHR website, which adds “Much of the current openEHR thinking on distributed computing environments in health is based on the excellent previous works of the (then) OMG Corbamed taskforce, and the Distributed Healthcare Environment (DHE) work done in Europe in EU-funded projects such as RICHE and EDITH, and the HANSA and PICNIC implementation projects.”  In those days, the UK’s NHS was still charting a proprietary, and non-standard, approach to EHRs and clinical systems; an example of one failed programme is the ‘common basic specification’ — there is an interesting commentary here on some reasons why it failed.

 

Diagram of a distributed clinical system, ca 2002

 

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300 The Movie

Health Politics (Photo credit: Quang Minh (YILKA))

The NHS Confederation wants it all to stop, according to journalist reporting in the press (for example, here).

Over the years, there has always been this fear of the words NHS and political football being in the same sentence. Perhaps the better approach for both the government and the NHS would be for the NHS to more explicitly engage in the political debate.

Mike Farrar, the new head of the NHS Confederation (which seems to have its own problems), says that the system is a democracy. Yes, but what does that mean? It should mean empowered to participate in the machinery of democracy and political debate, and not just take orders.

By explictly engaging in the political debate, NHS actors would widen the marketplace in ideas that the political space needs to chart the future direction for the NHS. This would create greater political space between the NHS (whatever that actually means these days), the civil servants in the Department of Health, and the political machinery of government. At least at a public level, NHS actors have avoided the political dimension, thinking it a better strategy not to become ensnared in the politics. But of course, their political debates are more likely to be argued through responses to government consultation documents, presentations to the Health Commmittee, exchanges at professional conferences (but this is frequently a one-way dialogue), and closed door meetings. They are all generally well-behaved, articulate and ineffective, but importantly not engaging citizen preferences.

This stance may be past it usefulness, especially if the providers of care are supposed to really engage with their local communities.

The purchasing side of the equation is equally fraught with avoidance of too much public engagement and as a consequence, purchasers (I do like that word), seem destined for provider capture, and the protection of legacy provision (mainly to avoid any hint of private sector participation). Hardly a reform agenda. The new Agences Regionales de Sante in France may actually show how this should be done, but again that is another story. Major reform is not just a UK thing.

Providers have weak public affairs capabilities, little political nous, and less ability to galvanise public understanding of the options facing providers. They, too, may be subject to capture by their own professional staff, so disruptive changes are avoided to keep the peace.  Foundation Trusts may not exercise their autonomy well, perhaps discomfited with the notion of too much autonomy generating an unfavourable press.

Anyway, one benefit of greater engagement in the political arena would be to shift the logic internally from the NHS being a policy-taker, waiting for the politicians to decide what to do, to becoming a more active participant in the marketplace of ideas for the healthcare, in effect a policy-giver. As such, the NHS, taken together, has virtually no political capacity, no capacity to develop structural options, no formal relationship with the public to seek their views on this or that.

All this has been handled by the Department of Health which sets the tone for the political debate and defines what is and isn’t in the frame from a reform perspective. This serves the Department just fine, as it furthers the role of the Department of Health as being responsible for the publicly funded health system, which is not a bad thing given how much public money it consumes. But it also means that the Department is the only one framing the political debate, and that is not particularly good for democracy. And not all political positions need to be played out in the Commons, but can be debated vigourously in the real world as NHS organisations drive forward changes. Keeping NHS organisations on a short lead only means more work for the Department of Health, but less value being derived from all the people running hospitals and clinics.  It is time to replace notions of the NHS as a single ‘thing’, like supertanker which takes forever to change, with the concept of a school of fish, which can change direction really easily and quickly.  See my blog post on distributed systems in health care here.

But arguments are what they get because the object of their affections has weak autonomous and collective decision-making structures, and a cognitive capacity to engage in the arena of ideas except through special interest groups such as the health professions or Royal Colleges, or the Confed. These do not represent the interests of the provider side of the NHS, but only their interpretation of these interests through their own lens on the NHS.

The Confed is not sufficiently robust to act in a political capacity in this arena despite publishing various position papers and having a lobby office in Brussels (funded I believe in part by the soon to depart Strategic Health Authorities), and attracting high-profile people, all of which are worthy.  But the Confed is shot through with conflict of interest problems and may not be certain what its role is — time will tell.

Mr Farrar speaks in this article of a ‘public interest test’, for example. Well, the challenge for NHS structures is simply to introduce it as a matter of managerial autonomy and good practice. If it is such a good idea, why wait for the government to make up its mind. With all the smart people supposedly thinking grand thoughts about the future of the NHS, would it be too much to expect someone to be courageous enough simply to get on with putting these ideas into practice, to test them out.

It would also nicely balance the political realm, as the NHS actors would be demonstrating their ability to get on their job of managing the healthcare system with innovative approaches, without legislative intervention.

The problem as always is courage.

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Sumerian contract: selling of a field and a ho...

A Department of Health contract with a private provider of healthcare

The Bureau for Investigative Journalism reports that £500 million was spent on private health clinics in the NHS that in their view represents poor value for money. No doubt commentators will point to the private aspects of these contracts as evidence that they failed. A few comments on their Report:

  1. The contracts were pre-paid block contracts, and in most cases the complement of procedures paid for were not used. Now whose fault is that? In the same way as hospitals do not go around soliciting business from GPs, these clinics need referrals. The question in my mind is was there so much capacity that the pre-paid procedures weren’t needed? How many patients did not get treated because of a failure to use these contracts? Of course the same thing can happen in the NHS, just people don’t see it as quite the same waste of money as when private contractors are involved. But they are the same.
  2. That the Department of Health is buying them back is the Department’s problem, which the taxpayer has to deal with. I’m not sure what the point of buying them is, especially since they will close and their treatment capacity lost to the doctors. Is there that much excess capacity in the NHS that they can take out that much capacity? The Report doesn’t clarify what is actually going to happen next. I don’t disagree with them about this being a poor use of money, but the decision to remove these facilities from available capacity is a bad decision, regardless of who runs them. The firms running them have excellent clinical performance track records in the main.
  3. The original contracts were commercially naive. But the UK’s NHS has a very poor track record with commercial suppliers, and so to get anyone interested at a time when there were serious shortages of capacity (and still are of course), they had to underwrite some of the risk. Of course, what might be thought of NHS facilities such as Foundation Trusts are increasingly not publicly owned as such but owned by the organisations that run them, and there are similar contracts with them. (GP premises are also private) Keep in mind, too, that pre-paid block contracts are an acknowledged (but poor) way for buying hospital services, so NHS facilities have also benefited from this — but just to be clear, many NHS facilities over-provide on these contracts, run out of money, usually 9 months into the contracts, then have to pull back in the last quarter. With payments based actual activity, you pay for what you buy, which explains in part why NHS facilities are running out of money — they cost more to run than the activity they are providing based on the income they derive from that activity. Nothing to do with being a public or private organisation, but a lot to do with how contracts are structured and of course how the hospital is managed. One hopes that more sophisticated contracting will emerge.
  4. NHS contracts are generally risk-free, that’s why there is the current fuss over competition in the NHS, as it would introduce risk. If risk were introduced, it would naturally level the playing field for private providers. But with risk-free public contracts, all the private providers wanted was the same contract conditions as NHS providers. The sensitivies around this, though, tend to favour a default assumption that the publicly owned, if that is strictly true anymore, institutions are better value-for-money than the private ones, when it comes to clinical activity.

This Report focuses on the expenditure of money without asking the next level of questions which go the heart of how and why money gets wasted in healthcare and why the NHS has so much difficulty with its contracts (let’s not get started on NPfIT).

But the Report is useful by illuminating the financial consequences of poor commercial decisions within the Department and the NHS. I just wonder whether there has been any learning as a result.

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Sticker advocating dissent: "dissent deve...

Something autocratic leaders don't understand

Another day, another perspective. The Guardian reports that another member of the select few advising the PM, Cameron, on health reform has been a bit off-message. It just goes to show that the people who held positions of power and authority in and around the NHS, when removed from that public duty, may just hold somewhat different views from they professed to hold. Did Mark Britnell think this way when we worked in the public sector? If so, why so silent?

Of course, part of the problem is the general lack of alternative perspectives within the NHS and the Department of Health, driven by the need to maintain a tight control on dissent (bad for decision-making). There is a somewhat natural and regretable tendency that when governments get into trouble, they behave like authoritarians, meaning they move to suppress dissent. Of course, the result is that they also legislate, or act in haste, and then repent at leisure, often courtesy of the courts, as decisions are progressively unpicked.

Britnell said things to please his audience, hardly unguarded, but certainly counched in language familar to Americans. Having chaired a conference on how to export American healthcare expertise to Europe, it is easy to get drawn into thinking that all things are possible when talking with Americans, something that folks familiar with the NHS would find seductive for its novelty.

Let’s look at what Britnell might have meant. There is nothing strange for the NHS to be a state insurer, since that is what it in effect is. Why were the premiums called ‘National Insurance’ anyway. The term insurance is also more easily understood in the US, and it more familar to those within the EU, as well. Perhaps the problem lies more in these shores, at not understanding the need to ‘translate’ language so people in fact can understand you. But then fog in channel, England cut off.

The NHS is highly politically polarising in the US; it is associated with rationing, queuing, and at least to many on one health discussion group, poor clinical outcomes. So the evidence, from the US side, is the NHS is not something to copy. The Canadian system is also highly politically polarising. Neither system particularly fascinates Amercians anymore, they are much more interested in the Netherlands. So it is with some courage that Britnell talked about the NHS in the first place — into the lion’s den and all that.

Would it be such a bad thing for the health system to thought more like an insurance system? Probably not. There is some evidence, controversial to some, that Bismarckian systems (i.e. insurance-based health systems), are more productive, easier to incentivise and provide better care than Beveridgean (i.e. the NHS, tax funded) systems, which are seen as better at managing costs. When Bismarckian systems get into financial trouble, they adopt centralised or other control systems familar to tax funded systems (cue recent reforms in France or Germany), while tax funded systems when they need to improve outcomes, shift toward insurance-type approaches, cue managed care, co-payments, clinical carve-outs (disease or medicines management) and so on.

The one big issue, hospital autonomy, or state ownership, is largely a non-starter if you really think about it. There is really no need for the public sector to own the means of production (i.e. the organisations that delivery health services), unless one is an unreformed Marxist. The NHS is probably better thought of as a guarantor of quality, access, and the purchaser of the care itself, something more akin to what proactive insurers should be doing. What appears to be interesting results from the last decades of reform is that public ownership of hospitals apparently concealed poor management, weak financial controls, convoluted clinical workflow, all of which led to poor productivity and value-for-money. These types of problems are not fixed by simply throwing more public money at them, but by changing the way they operate, the incentives that drive organisational behaviour. If you want to reduce emergency 7-day readmission rates (where most of the problems really lie, not at 30 days), some disincentives are appropriate, otherwise people don’t pay attention. A type of tough love.

One good thing is there is some possibility that this closet advisory group may not be breathing each other’s air, and that some original thinking may actually be taking place. However, I remain doubtful, since the people involved built their reputations within the very system they are now being asked to reflect upon. If they were that good at thinking this way, why weren’t they doing it before? Perhaps they were too obediant and on-message.

Regretfully, this mantra appears to be more important than the problem of NHS reform.

“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.

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