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Herd mentality

Better this than trying something new

Steve Field was asked to lead the collective rethink by another group of vested interests of proposed NHS reform.  He apparently thinks, according to the Guardian, that the English NHS reforms are not workable. Apart from the rather pointless delay in getting on with reform, in the patient’s interest, rather than the interest of providers, he overstates the challenges faced by competition.

There is a general fear of what is called ‘creative destruction’ being applied to public institutions. But governments for years (think back to Thatcher, Blair) have tried to reform Whitehall, trim the scale of the public sector, and bring needed new thinking — the New Synthesis project is one example of people trying to rethink the public domain. Most of the changes in the NHS over the past two decades have been clearly in this direction, but regretfully, the Coalition failed to signal that they were tidying things up — who suggested all this needed primary legislation anyway as the SoS has enough power to do this anyway.  The push-back from entrenched public institutions can be unnerving to governments, in particular Coalitions, who need to keep their political dance partners happy.

So what to make of the comments in this interview:

  1. Head to head competition is unlikely across the bulk of England as integrated Foundation Trusts tend to be the sole and dominant provider in their areas. Major cities are the exception and the high operating costs, difficulty accessing services, and duplication of services is something that needs to be dealt with through targetted commissioning. Failure to do the hard bits will simply drive costs further skyward, and reward failure.
  2. There already is competition with the private hospitals, but they have their own interests, and launching a major assault on the NHS would be largely pointless — their customers are NHS consultants who provide their services to people who have taken out private insurance in order to opt-out of the NHS.
  3. So-called cherry picking is not a bad thing — aggregating similar cases in specialist units is clinically sensible as it produces better outcomes. Now why has the NHS resisted this sort of service rationalisation? If NHS providers are unable to sort out their clinical priorities they why shouldn’t a new entrant offer this service if they can do it better? I reviewed two hospitals once that duplicated services, and seemed unable to provide a single service between them. Outcomes weren’t good either.
  4. The ‘rules’ the Department of Health works with have rigged the market anyway in favour of incumbent NHS providers, whether they are providing a high quality service or not. There is real fear here in Government, but the patients’ priorities for a high quality service they can value may be more important than ideological considerations.  Perhaps we have to wait for the Facebook generation to start consuming health services for the mandarins to ‘get it’.
  5. Unbundling hospitals is something that can be done, but understanding the complex interaction of hospital-based services also needs to take account of the general shift toward out-patient services and increased focus on primary care, meaning hospitals aren’t going out of business soon, anyway. Field is right to point to shroud-waving, but misses the point that it was this shroud-waving that caused the panic in the Coalition.
  6. He uses the term ‘free market’ when in fact it won’t be, it will be a regulated market as there are very few free markets anyway (including in the US where there isn’t really a free market in their largely publicly/federally funded system of not-for-profits and loss-making hospital chains — try getting care from an HMO that you aren’t a member of).  The only existing health market regulator in the Netherlands seems to be managing just fine.
  7. Other countries have forms of competition between hospitals (France, Germany, Netherlands, Belgium, Spain, golly, this list could go on and on) and their systems haven’t crashed into some incomprensible quagmire of service chaos. Field overstates the problems, but it may betray some degree of fear that competition will unearth further underlying challenges that provider managers may be ill-equiped to deal with. There are some incredibly well-run hospitals in countries like the Netherlands, France, Switerland, Sweden, Belgium, not to ignore some of the best US hospitals but training in hospital management in the UK is not to world standards.
  8. That some NHS hospitals are badly run seems apparent, and something needs to be done about that, so removing motivation for an executive focus on financial and service performance seems a bad idea, at least to those who would be faced with the job of actually managing a hospital, and not just taking up office space.
  9. You don’t go out to tender for a trauma centre, as you need a catchment population in the millions to justify the necessary skills. Commissioners who don’t understand this shouldn’t be allowed anywhere near the NHS.
  10. There are examples where novel solutions to challenges have been inspired, my favourite being the establishment of five world-class academic health science centres; all we need now is for them to assume a leadership role in driving excellence in management and patient care through the wider system.

I find it interesting that those who have the greatest stake in maintaining the status quo are those who are leading the listening exercise; why didn’t the Department of Health select perhaps an international panel or empanel a group of people with alternative perspectives? The vested interests run deep in the corridors of power.

As for some of the pending conclusions:

  1. no problem reserving a spot for nurses, but what about pharmacists, occupational therapists, and a host of others? Oh dear, patients and users?
  2. why hospital doctors on commissioning bodies; aren’t they part of the system that most would keep services in hospitals. There is serious risk of provider capture here. Including them because they might feel alienated is plain silly. The most alienated part of the NHS is the patient.
  3. inclusiveness is running mad here, and would make any ‘clinical cabinets’ virtually unworkable — when will they all have their group hug? I think it will just make work for consultants in organisational dynamics, who will be needed to help develop them, and keep them from constant bickering. The NHS spends too much time worrying about emotional intelligence of managers and whether their leaders are getting enough cheese. The proof is in the pudding and the leaders aren’t leading.
  4. GPs can acquire skills to commission anything they like, and to say otherwise is insulting and perhaps other words might be more applicable.  This is a lame excuse, otherwise we would never get anybody doing anything because one could always argue that they don’t know what they are doing and someone else could do a better job. The NHS Commissioning Board isn’t needed; it is just the continuing felt need for ‘national’ bodies and will hoard expertise that should be distributed around the system, to avoid the problem Field thinks exists.
  5. I doubt plans to reform medical or other professional education will be affected. This the job of the universities anyway, and they should get on with the job regardless. If that were true, then the NHS has colonised the education field inappropriately.
  6. The levy on private hospitals is unworkable. Half of nutritionists don’t work in the NHS — should Waitrose pay for the nutritionists they employ, should self-employed physiotherapists reimburse the NHS, and what about the 25% of nurses that work in the private sector.

What is clear is that listening exercise has beneficially galvanised those who didn’t have a problem with reforms to point out that this is now delaying essential service innovation — not the NHS innovates at the drop of a hat! France recently reformed its system. Anyone notice. Quick and likely to be quite effective.

I look forward to their final report, to see what changes I need to make in my comments above.

 

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M16 The Eagle Nebula

The truth is out there

So things are heating up in the English NHS. Reforms are rushed, reckless, at a time of crisis, many are warning. Is that strictly true? Reform to those who have to implement it can always seem rushed, especially when driven by a reforming coalition government and a mounting debt burden. The past, oh, say 20 years, have not been easy for the NHS, but what is becoming evident is that a reforming mindset has not set in.

What do I mean by a reforming mindset? I mean a willingness for clinicians, managers and all the other staff to engage with the challenge of improving the quality of the healthcare patients receive — indeed, of justifying the public expenditure by providing a service that patients and the taxpayers more generally will value and use with confidence. With an obviously too broad a brush, this means that opportunities to innovate are missed, opportunities to try something new are avoided. It means that the ‘top’ has failed to manage, preferring perhaps to be stewards of their NHS organisations, adopting an inclusive approach that avoids confrontation, never upsets a particular stakeholder group too much, and in general avoids making waves. Apart from the day-to-day challenges of clinicians, we see, despite the McKinsey report on managerial excellence, weak strategic execution. Now the chips are down, decisions need to be made that will upset people — see my earlier post on shroud-waving. Each profession seems to be taking turns highlighting how their specific interests will be threatened.

Rather than coming forward with innovative and creative solutions, minds are retreating into denial and avoidance of the challenges ahead.

As any regular reader of this blog will know, I quite like disruptive innovations. Healthcare hasn’t had much of it really, just a sustained litany of top down reform pressure, but the real reforms, which need to come from those who are in daily contact with patients cannot be best served by organisations parachuted in to ‘encourage innovation’. This has to be embedded in people’s daily approach to work. Having run an internal consultancy in a very big academic health science centre, I appreciate the fundamental importance of using internal capabilities and building internal capacity.

But what might act as an incentive? We now know that being publicly owned and funded does not guarantee that organisations will be kind and caring toward patients. There are just too many instances where NHS or social care organisations have been able to abuse the public’s trust behind a veil of public ownership. The challenge facing Monitor and the Care Quality Commission isn’t just to regulate, but to disinfect.

My thoughts, though, turn to patients as a force for change. I have always felt that patient involvement is the most disruptive force in healthcare, and we have had years of this or that programme to engage patients in their healthcare to uneven effect. The one thing, though, that might actually make a difference would be to introduce a substantial co-payment which patients would pay, as part of the funding of the system. Now, the health economists will jump up here and call such a proposal a ‘policy zombie’, a term for an idea that should stay dead. However, co-payments are used in such advanced health systems as France and Spain.  Indeed, I think the best thing the NHS could learn from these other systems is the use of co-payments to align patients’ and clinicians’ interests. The old adage ‘fog in Channel, Europe cut off’, can also mean that good ideas ‘out there’ never get ‘in here’. If you don’t look, you don’t see, and won’t find.

Paying for this is offers an interesting option. A huge amount of money is raised every year through National Insurance ‘tax’, which is a broadly hypothecated (but regressive) tax for health, social care, unemployment, that sort of thing; its original purpose as a form of ‘insurance’ has now been lost. In 2007-8 it raised some £98 billion.  My proposal is this. Abolish NI and return the money to individual taxpayers and employers. In turn, individuals will use this money for a variety of purposes such as the healthcare co-payment, investing in pensions, funding ‘retirement’ social care insurance, and probably a lot of other things I can’t think of, and which are currently paid for out of public coffers — isn’t one issue facing the coalition government how to shrink the public side of the balance sheet and shift funds into spending from individuals based on choice?

The NHS funding side looks like this. Over the next few years, the NHS has to find around £20 bn of its current £110 bn or so annual cost as savings.  The NHS continues to make these savings. In time, annual NHS spend (ceteris paribus) of around £90 bn would now be composed of £70 bn in central state funding and £20 bn in income from patient co-payments. The effect of this is liberating more generally, but achieves an important social benefit as it broadly aligns the interests of all parties, and engages patients in the actual cost of their healthcare — a tax-funded system with no co-payment insulates patients from the financial consequences of their healthcare decisions. Of course, I know that some design features are needed to take account of people with no income, fraud, and so on, but nothing that is a deal-breaker as other countries have managed this so presumably it can be done.

Removing probably the bulk of NI income from the public revenues has enormous consequences, and it does require comparable reinvestment in those services currently funded by the NI system, but by individual taxpayers instead. Most of the discussion on the abolition of NI has focused on the government continuing to be responsible for the items NI pays for (e.g. the apparent position of the Institute of Directors in the UK). My proposal shifts this burden entirely to an insurance model and has the effect of shrinking the state by building up individuals — goodness, a big society.

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Data Source http://www.irdes.fr/EcoSante/DownL...

GDP Expenditure

With the new coalition government in the UK, we are seeing early signs of a serious assault on public spending on the state run NHS. Similar challenges await other European countries with bloated public debt. Part of the debt run up by Greece, for instance, arose from efforts to off-shore hospital debt.

In the end the question remains, as it always has, how much money should a country spend on healthcare. The answer, as has always been the case, is as much as you can afford. Research shows that levels of spending (in terms of percentage of GDP, for example) do not correlate well with health status, outcomes and other key indicators of the performance of a health system. Indeed, it can be said with some degree of confidence that GDP spending is NOT an indicator of health system performance.

What does appear to be a factor though is HOW that money is spent and HOW the system is organised to deliver health services.  Recent OECD work has clarified various characteristics of health systems. What is striking are a couple of already familiar features:

  • Not all countries pay 100% of the health bill from the public purse; many, such as France, use co-payments. Countries with socially unacceptable waiting lists have tended to be those with the highest levels of pure public expenditure (such as the UK, Norway and Canada). What this suggests is that there may be important features in how health systems organise themselves to deliver care that is adversely affected when the system is funded from general taxation. Efforts to introduce purchaser/provider separation, for instance, is an effort to create distance between the two quite different objectives, which in tax funded systems have been merged and caused considerable policy confusion, as well as operational difficulties. (I can mention the situation in the Canadian province of Alberta, where the response to funding constraints has been essentially to ‘nationalise’ the system, thus removing key drivers for reform. I can also refer to the Nuffield, UK, study that showed poorer health outcomes in the centralised health system in Scotland compared to now quite devolved purchaser/provider based system in England; and this despite having higher per capita expenditure in Scotland.)
  • Most countries have mixed economies of provision and relatively easier ways for new types of providers to emerge. Lower performing health systems seem to discourage new providers of care to enter the health market; this is an element of overall system design, perhaps regulatory over-reach and dated statist thinking.  But perhaps we are becoming smart enough to know how to design more responsive health systems, which in the end are almost chaotic given the nature of human beings and illness (random?) and so need to be understood as complex adaptive systems rather than tightly managed and controlled (think of the tightly coupled banking system which lacked the ability to realign itself quickly and effectively in response to a financial shock; Homer-Dixon’s remarkably prescient work here is worth looking up).  Managed designs usually end in tears, as they fail to deliver the responsiveness and flexibility that is critical for healthcare to respond to changing demand and fluctuations caused by shocks to the system.

There is no right number of doctors or nurses or hospitals or beds. What there is, though, is the right number of these for the design and structures necessary to deliver effective care.  And these can be designed and developed to use human talent differently, and more effectively.

In the UK, we will hear a lot about ‘front line services’ and protecting them from cuts. I have no problem with protecting front line services, but that does not mean that they will not be delivered in different and novel ways, that may be a better use of the expertise available.  The health professions will undoubtedly circle the wagons and predict dire consequences to the public, so called shroud waving. But what is better is a recognition that healthcare systems are highly inefficient; they are weak adopters of revolutionary change, and they are protective of established working practices — part of the reason for this protectiveness arises from the health professions having become co-dependents to the addiction to public money on the one hand and protected ways of working on the other. In a nutshell, they have become resistant to innovation and reform, and in some respects lost control of the their profession and the profession has ceased to evolve to meet the care needs of people — an emergent adaptive response characteristic of complex systems.

Hospitals are artefacts of industrial era organisational design principles — they embody craft mentalities in the organisation of care, and build on public support to protect their infrastructure (from closure, for example), rather than the public demanding better services, which may not require a hospital in the first place. The difficulty people have in unbundling a hospital (it can be done and I can share the algorithm with you in another post if you like) simply reinforces the protected nature of healthcare work. In part, the emergence of e-health (more precisely, the use of digital information and communication technologies, artificial intelligence/neural networks, predictive algorithms, smart devices, etc) offers a serious challenge to established patterns of working, as these various components have the collective effect of redistributing knowledge, embedding knowledge and skill in devices, and altering the use of bricks and mortar infrastructure — a high-tech/low touch outcome is not the necessary outcome if we are clear on our outcomes.

It is also not just a matter of a cost-effectiveness study of whether an e-consultation is better than a face-to-face consultation.  The evidence for this is actually quite easy — when the telephone was invented, businesses might have one, on a stand, which people would queue up to use. Now, a modern business would hardly do a business case to put a telephone on everyone’s desk — indeed, it hardly needs a business case to ensure everyone has a smart phone — yet in healthcare, smart phones are still rare, yet have the potential to radically alter information flows and hence work flows — 25% of US doctors now have one and ePocrates is one of the most downloaded clinical apps from Apple store, so it is coming. You don’t do a business case when the underlying business logic itself is what will fundamentally change and that is really what e-health is all about.

They say, in capitalism, that it works partly through a process of creative destruction. Otherwise, we’d still be riding around in horse-drawn buggies, and you wouldn’t be reading this note on a computer linked to the internet. There is, however, a general reluctance to apply that process to publicly funded institutions, and by extension to publicly funded ways of working.  The words government and entrepreneur are an oxymoron for many people. But that does not have to mean that public funding cannot be used to incentivise new ways of working and new forms of healthcare delivery. The challenges, in the end, lie in our heart and willingness to change, to create and innovate.

And so to austerity. There is little to fear, except our ability to resist change, protect legacy ways of working, and failing to grasp the real prize, that of doing things better and more effectively.  We will, no doubt, hear the opposite.

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Magnetoencephalography

Integrated treatment is an important step in service innovation, and it is no less important to see how the convergence of diagnostic technologies and methods with treatment methods will lead to integrated, one-stop encounters.  This is more than an integrated provider, but the development of theranostics (therapy/diagnostics), which combine what in the past have been discreet clinical steps into a single diagnostic and treatment encounter.

We are still developing methods here, but in the image guided surgery is an example. The ability to bring together disparate knowledge, currently spread across different brains (i.e. experts) into a single brain will create new clinical professions, shift knowledge from higher levels of expertise to others who delivery services augmented with machine intelligence embedded in the devices. These sorts of development disintermediate clinical workflow, to use disruptive terminology, but reintegrate the clinical workflow in new ways, this time around the patient, rather than the clinician.

Importantly, the diagnostic bottleneck which health systems find causes waiting and delay is likely to be largely eliminated for a wide range of procedures, as at the point of diagnosis, treatment would also be provided. With improved detection methods, too, this treatment will start sooner — we are still learning of the clinical benefits of bio-conjugated quantum dots, and biosilicon, and other new materials, but they are likely to underpin a new health service delivery paradigm.

The equation in the title simplistically represents the shift toward integrated therapeutics, which in the end may be the biggest next step in medicine since discovering germs as will germs came specialisation and the burgeoning of clinicians and expertise, coupled with the universities in creating specialist bodies of knowledge. Ix, integrated care, builds on integrated knowledge (IKnow?) which is something we are slowly appreciating as the problems we face effectively challenge the narrow disciplinary models we see at university and in clinical practice.

The question though is whether policy and decision makers will be bold enough to face up to these opportunities or will vested legacy interests prevail?

A swarm of robots in the Open-source micro-rob...
Robot Swarm: planning a revolution?

We have had years of reform efforts in healthcare, and despite what country one picks, the themes are depressingly familiar: cost-containment, more health professionals, patient empowerment, more primary care, value for money, and so on.  These types of reforms are rarely revolutionary, despite the claims, and the benefits not as readily forthcoming as forecast. For instance, we have had perhaps 20 years of integrated care pathways, yet such simple knitting together of care is still elusive.  What is clear, though, is that you can’t continue to spend good taxpayers’ money on unreformed health systems.

Reform models reflect the history of our healthcare (and other) systems, deriving from organisational and service delivery models of the industrial age.  Hospitals are really just 1030s conglomerates, and the claims that vertical integration likely to improve care and drive down costs, are simply copying the corporate models of General Motors, General Electric, GEC, Westinghouse, some of which are no more.  We don’t really live in that sort of world anymore, and despite the vast amount of money spent on healthcare, it is still the least information-enabled of all sectors of our economy, even though healthcare floats on an ever-changing sea of knowledge and clinical/patient information.  Our current notion of healthcare is wedded to the brains of individuals (i.e. health professionals), not the collective intelligence of many people working together (dare I call this cloud cognition, hive minds, or distributed cognitive systems…?).

I think we need to take a different look at reform models, and embrace a new terminology, one built on disruption.  Disruptive technologies in particular are game-changing, they alter our modes of interaction with other people, change how we manage information, make decisions, perhaps even think. They, of course, produce winners and losers, as these sorts of changes often are zero-sum. Keep in mind that health reform has tended to be non-zero-sum; there has been a fear of creating losers while at the same time trying to reward winners, so-called protection of legacy providers, and we see this in the most recent UK Department of Health plans to allow failing NHS providers two tries to improve performance before alternative providers will be allowed to take over the work. Disruption says enough is enough, and we must do things differently.

We don’t know that much about disruption except by what its effect is on us, but there are efforts to understand  disruption.  But this work has been weakly connected to both the policy space in which these insights can achieve some measure of meaning, and the real-world.  Healthcare systems can go to great lengths to frustrate innovation and change.  It is, therefore, timely and pleasing to see efforts of understand disruption, and the forthcoming report on disruptive forecasting from the US Committee on Forecasting Disruptive Technologies, National Research Council, may offer a renewed impetus not just to the forecasting work, but to its utility.

I like disruptive technologies for their ability to shift our thinking away from industrial age paradigms to information age paradigms.  In this way, we break the logic of physicality that defines, for instance, hospitals, and leads to new approaches anchored around the health information value chain, which unites patients and all actors in health systems (payers, providers, industry, academe).  Ehealth is one of these potentially disruptive technologies, as it achieves a couple of key disruptions, in terms of decoupling patients from physical location, and of the potential pooling of knowledge in distributed cognitive systems with machine intelligences through smart/remote diagnostics, predictive modelling and in time physical models of disease.

But disruptions are a much harder sell, but it seems to me that difficult public finances does offer an opportunity for rethinking: one should not waste a perfectly good crisis as it is an opportunity to evolve. (with apologies to Rahm Emanual who said “never waste a good crisis”.

READ an interview I gave on ehealth here: [LINK to Euractiv ehealth interview]

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There is no consensus on how closely the brain...
Prediction, intelligence and cognition: convergence a real possibility

Gaming and simulations plus modelling are health markets that look very interesting and offer considerable opportunity for disruption of existing knowledge processes in healthcare:

Predictive modelling

  • to help people understand and manage their health better by using modelling to visualise health states using avatars and body-image
  • moving beyond the use of predictive modelling and data mining to find high- or at-risk individuals for case management purposes
  • link modelling to powerful mapping visualisation technologies to enable better decision-making and planning

Simulations and games

  • engaging health professionals and consumers in simulated environments using gaming methods
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Innovation
Wait for it…!

There is a tension between health systems and their need for innovative technologies and the absorptive capacity of the health system itself to both adopt an innovation and modify existing clinical practice to release the full benefits of the innovation.  From a policy perspective, this presents a variety of problems not the least of which is that it is largely pointless to put more money into unreformed health systems.  From a commercial perspective, how is business to decide what are priorities, what are the innovations to back and what markets will adopt them.  Governments and payers can do much to signal markets what their priorities are and back that with appropriate reimbursement policies to enable these technologies to earn their way in the world.

But it is not that simple, and there is a clear need for policy makers and ‘the market’ to interact productively, so both win.  In the absence of this, we will have the continuing saga of the medico-industrial complex driving technologies forward but with no payers.

Competing interests characterise what people think are healthcare technology priorities.  With the often overbearing weight of government, healthcare technologies often reflect preferences that emerge from the policy priorities of governments  locked in an iron triangle with industry and (usually) doctors.  This medico-industrial complex leads to technologies that are sought by doctors, and when companies seek guidance for their own product development priorities, they consult doctors, and around we go. There is some good reason to do this, as it is widely argued that it is doctors who decide what services, medicines and devices patients will end up using, so it is sensible to ask them what they would like.  The problem with this is obvious, as doctors are not consumers of the functions of the medicines or devices they prescribe.  That countries are invariably forced into some form of economic evaluation of health technologies and the use of prescribing guidelines offer some evidence that doctors, in this case, cannot in the main be trusted to make appropriate decisions in this respect.

Let’s take e-health as a case in point.  Often confusingly called ‘telemedicine’, the priorities range from devices and services that patients may actually use, to technologies to facilitate consultations and information exchange between health professionals.  The latter, though, is really just the automation of existing clinical practice.  The former is far more interesting, and far more disruptive of existing practices — perhaps that is why we don’t have much of it?  Then there are technologies that really have a major impact on disease diagnosis, but which are expensive, but through elaborate clinical protocols are restricted or limited — why not adopt ‘best technology first’ and stop wasting the patient’s time.

Some priorities for further thought:

  1. Following work by Christensen and others, how can health systems identify technologies that will have the positive benefit of disrupting in the nicest possible way stale clinical practices and yield an order of magnitude improvement in health system productivity (with a corresponding decrease in per-capita costs)?
  2. What technologies are most effective from a patient/end-user’s perspective and that they will actually value and use?
  3. What commercial realities are needed to enable sensible reimbursement of e-health services by payors?
  4. How do we research, invest in and commercialise winning technologies and move them very quickly into use?

That is to say,

  • how much do we really want to reform health care delivery using innovative technologies, and what implications will that have on our current approaches and assumptions — this is as much about clinical change as political will;
  • what technologies can we have now, today or soon;
  • how can we use reimbursement/payment systems to encourage use and uptake, and
  • why is healthcare so slow to adopt new technologies?
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