Tag Archives: Europe

The UK government is releasing, over time, its review of the balance of competencies of EU legislation. Within the first 6 papers released is the one on Health, Review of the Balance of Competencies between the United Kingdom and the European Union: Health.

At minimum, these reviews provide a timely perspective on this balance of competencies, and provides a focus for further commentary. Other EU members states may find it useful to be reminded what this balance is. It is not always in the interests of the European project to look at all things taken together as it shows whether overall the claimed benefits are in fact there. But such policy review, if that is another way of talking about them, does draw a line in the sand against which to measure and assess changes in the future, and avoids the problem of the boiled frog syndrome, where small incremental changes are not noticed until it is too late.

Health is a funny subject for the EU as it is both inside and outside the European competency box, depending on how you define things. Countries can run their healthcare systems broadly as they wish, and maintain control of financing, but the European Court of Justice, in a variety of decisions, has defined the contours of that national control, as seen through the lens of the single market, and freedom of movement of goods and services in particular — both of which are agnostic with respect to health. It all depends whether you think of healthcare systems commercially or socially. That hospitals are socially beneficial but also commercial entities does not help, any more than drugs as goods flowing across EU borders, and so on.

The report concludes in the main that the balance is about right. There is little argument with the benefits of European action in medicines regulation, public health, tobacco, etc. Where the UK has a problem is with employment policy as it impacts the UK more generally and the National Health Service specifically. Different logic of the relationship between the employee and the workplace applies in the UK and this throws up a wide range of relevant issues.

The Working Time Directive is the elephant in the room here. The concerns are how the NHS structures clinical work, trains junior doctors, and generally organises itself to provide for continuity of care. Other countries, not just the European ones, have the same concerns about over-worked doctors. The heroic fictional doctors on television, who nap on couches and awake fully prepped to save patients is fantasy. Next time you’re in mid-Atlantic, be grateful your pilots got a good night’s sleep. The criticism of the WTD is more an indictment of the inability of the NHS and its massive provider infrastructure to put in place appropriate patient management systems that ensure a sensible balance of workload and rest. But the Health Paper makes the point that the European Court’s judgements have actually further constrained operational flexibily within the NHS. While the paper notes that the NHS operates on a 24 hour system, it actually doesn’t as it isn’t fully staffed on weekends, and many services operate within a traditional working hour day (e.g. laboratories, imaging). Much of this arises from the politically influenced structure of the NHS which has made it very difficult for alternative providers to enter the healthcare market in the UK, and thus offer relevant services, whether day-case surgery, or imaging, at times more convenient to patients. However, other countries in Europe appear able to manage demand and service provision more easily, so one much wonder why the NHS problems of their own doing.

The other area that exercises the NHS is free movement of patients. Medical tourism is a big issue in the UK, as its health system is based on residency. Social insurance systems have built often formidable barriers to gaining healthcare cover because they generally link the insurability with the workplace. Self-employed individuals are frequently disenfranchised from full benefits, and often pay disproportionately. Retired people continue to need insurance. But an insurance system does make cross-border transactions much easier. The UK has not really understand the operational dimension of the differences for UK taxpayers moving within Europe. The Limosa Convention is not mentioned in the briefing, while the European Health Insurance Card is. The EHIC is only really for tourists and retired people and the paper promotes the benefits of them. However, the EHIC is not for people temporarily located in another country for employment or work purposes.  They do not refer to the bureaucratic overhang of the A1 and S1 forms needed for people working in other EU countries and the forum-shopping associated with it as countries seek to get ‘the other country’ to pay the bills. I wonder how many people realise they need an S1 to run a seminar in another country as this is defined as work, or that working from home and living in country A while your office is in country B could be a bureaucratic nightmare. The report is silent here.

Surpluses (and deadweight loss) created by a m...

If only it were that simple!

The current debate in the UK, specifically England, on reforms of the publicly funded health service have raised the red-flag of privatisation. Hostility has centred in the main on private firms offering health services and the scope and meaning of ‘any willing provider’.  Signals from politicians are confusing given they are walzing back and forth across the dancefloor depending on criticisms. Indeed, there appears to be some risk that dance partners may change, as the Lambs, for instance, change sides to avoid slaughter in the arena of public opinion. Such self-interested face-saving aside, is there an issue to answer here?

Article 106(2) TFEU as a general interest exception: which involves invoking public interest grounds, specifically, “undertakings entrusted with the operation of services of general economic interest … shall be subject to the rules contained in this Treaty … in so far as they application of such rules does not obstruct the performance … of the particular task assigned to them. The development of trade must not be affected to such an extent as would be contrary to the needs of the Community.” [Community here referring the EU, not the local community.]

In operationalising competition arrangements, the EU approach is built on simple foundations, of equal treatment, and that firms given special treatment cannot also be protected through public measures which favour them.  There has always been some debate about public monopolies and what has been called ’emanations of the state’, and through it all a recognition that state organisations are deemed to have a dominant position that they cannot abuse — perhaps more importantly, state organisations delivering a service cannot be protected by the government engaging in abusive market practices simply to protect them. It is certainly an abuse for a government to create a monopoly that cannot deliver the services required.

From an EU perspective, can states create a monopoly situation simply because they want to avoid competition in a particular area of the economy? Well, presumably yes, if it is of general economic interest, and if the prohibition of competition is necessary for the resulting bodies to do their job.

The ‘get-out’ clause is whether restriction on competition is necessary for the NHS to do its job. What is the job of the NHS?

If it is to procure health services from any “qualified” provider, then it is a procurement body and restrictions on competition would not be appropriate as this might lead to contracting for services from a subset of qualified providers who would be preferred on other than a level playing field — that public and private firms compete on an equal basis. The interesting question underlying the assumption is also that there would be market failure otherwise. But one test of market failure is that there are no providers willing to enter the market. But an any provider situation presupposes that isn’t true, that firms would enter the market and provide health services. So prohibiting competition effectively partitions the market in favour of public providers and that doesn’t seem to sit with the general EU competition tests. There is a subtle change in terminology that may be political but may be important (hah!): between any willing provider and any qualified provider — being willing isn’t enough, being qualified is, but can the determination of being qualified act to restrict access to the provision of health services, as being qualified may preclude organisations that might provide care, i.e. they are willing, but currently aren’t.  A bit like the only way to learn glass is fragile is to break it, the only way to find out if an organisation is qualified is to let it offer services. Of course, with an onus on qualified, there could be a presumption in favour of legacy providers, as obviously they are willing and qualified. (How many angels was that again?)

Does the EU treaty permit monopolists to abuse their dominant position by providing a service to a level less than is needed? In other words, can the purchasers purchase in such a way as to ignore lower cost/higher service level providers in order to protect the legacy NHS providers? Not really, as that violates the simple test of neutrality with respect to ownership status under competition law.

Granted that the purchasers could argue that financial controls are necessary as not everything would be affordable for everyone all at once, but the ECJ healthcare rulings have established a base line test: would the person involved eventually get treated? Saying ‘no’ is not an option for a state monopoly health service as that is called rationing and the ECJ has ruled that such decisions must be made on the basis of international clinical evidence, not administrative niceties.

So we are left with the question whether the prohibition of competition is necessary for the NHS to provide care. This is where it is necessary to decide whether the providers of health services in England are really state-owned entities, or simply contracted-in subcontractors. GPs in England have always been private businesses, though they have badged themselves as within the NHS since 1948, unlike community pharmacies, who similarly have virtually monopolistic contracts with the government, but are more readily perceived as not part of the NHS. It seems that as soon as you create a distinction between the delivery of services from the purchase of those services, you create the basic conditions for a market, for contestability, and by definition have eliminated the applicability of the market failure argument.  So the NHS delivers services of general economic interest, but it is not necessary for the delivery of that service to prohibit competition.

That means that the competition rules apply.

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Graph of the locations of water on EarthI attended the European Foundation for Management Development conference at Advancia 22-23 February 2010, to meet new colleagues as well as participate in a panel discussion on the challenges facing entrepreneurs. I organised my presentation around the question: “what sort of the future will the entrepreneur invent?”  I used two pictures to start my talk, one a 1530 Utopian painting and the other a poster of Fritz Lang’s dystopian film Metropolis.

Everything around us is invented, discovered, or created by the mind of people making sense of the world, so while it may be too much to see the entrepreneur as a super-human force of nature (as some discussed at the conference), the point is that human ingenuity is behind the world we live in, and our ability to be ingenious drives the

entrepreneurial spirit. I raised these issues in my presentation:

  • crises are really opportunities, especially for entrepreneurs;
  • the growing networking and interconnectedness of the world offers amazing opportunities for entrepreneurs to look at ways to bring people, information and services together; concerns about digital divides, social exclusion etc., in my view are transitional features of the current world, and not defining features, and that in time, these will be replaced with other forms of exclusion; the point being that technologies themselves are not exclusionary, but what people do with them is;
  • rising educational attainment is upon us, and there will be a substantial decline in the percentageof the population globally with only primary education, and doubling in the next decade or so of numbers of people with tertiary education; again, this offers amazing opportunities for learning in new ways, also considering the networking of the planet;
  • agricultural innovation is seriously important as over the next 20 or so growing seasons (years), the planet’s population will rise by about 30%, per capita food consumption will rise by 50%, dietary preferences will change, water and energy demand will also rise; this points to the need to ensure that fresh water is where the people are (right now, the fresh water is located mostly where people are fewer), and that each agriculturally productive hectare can add 50% of productive capacity — in very few growing seasons; with climate change, too, factors such as what grows where comes under stress, as different areas will need to learn to grow non-traditional crops, and other areas will become unproductive;
  • I also showed pictures of intelligent machines such as an autonomous GPS-guided farm tractor, and a similarly autonomous mining truck; the autonomous military robot with its gun on top is a telling reminder of the progress in military science, while the Utopian picture of the smart city of the future offers a different sort of hope;
  • finally, I showed a map of the world 4 degrees warmer, and wondered how we were going to deal with social displacement indicated by the growing numbers of people who will come to live in unihabitable or hostile environments (at risk of flooding, heat stress, and so on).

Having said all that, I am left to wondering though how we bridge the entrepreneurial challenges facing the public sector.  In many cases the challenges entrepreneurs face are caused by governments, and by regulation, as well as by restrictive banking practices which make access to capital so very hard. While we look to the entrepreneurial spirit in the private sector, and feed and encourage creativity, we find the opposite is true in the public sector. Indeed, Martin Lukes, from Prague, presented an excellent paper, with a telling conclusion that public sector people have less organisational support for innovation and entrepreneurial activity than their private sector counterparts. In some respects the elephant in the room is the public sector, consuming huge amounts of taxpayers’ money, yet often failing in two ways, failing to ensure entrepreneurial growth through poorly thought out rules and regulations (red-tape, regulatory burden and so on), and failing to get their own house in order.  Given the current state of affairs in some the world’s major economies, I don’t think the public sector can excuse itself from the need for entrepreneurial reform and effort.

The invention of the future requires all hands on deck, and no one can be spectator any more.

Stained glass window of St. Thomas Becket in C...
Thomas Beckett spoke Truth to Power

Professor David Nutt, chairman of the UK’s Advisory Council on the Misuse of Drugs, is now a former chairman. He has joined by other scientists (2 so far) resigning in protest as the government’s heavy handed dismissal of Professor Nutt.  The minister, Alan Johnson, has said he had ‘lost confidence’ in the scientist for something he wrote in a scientific article.

The thought police are out in force once again.  But more important is the apparent abuse by this government minister of the whole point of advisors.  They must speak truth to power. In the absence of the speaking of truth, we will have self-censorship, political correctness, and general bowing and scraping to the political powers.  What the politicians don’t get, and Alan Johnson in particular, is that a candid and often challenging relationship is part of this delicate balancing of truth and power.

Indeed, there is clear abuse of power in silencing critics. There is a candle that burns in Canterbury Cathedral, testimony to this very issue (referring to St Thomas Beckett).  Truth is the first casualty of ministerial hubris.

In the end, we, that is taxpayers, and the general well-being of society, suffer when ministers can be so cavalier in dismissing people they don’t agree with.

Distinguishing between giving advice based on science, and political commentary is difficult navigation, as both scientists hold political views, which ministers may not like, while ministers may express scientific commentary with little grasp of its meaning.  Both can get it wrong, and much nonsense has come out of the mouths of both scientists and politicians.  But rather than shoot the messenger, politicians need to remember that they are in the main wholly dependent on right-minded scientists for advice, ones who will often hold dissenting views from the ‘spin’ that ministers seek to put on science itself. Einstein and colleagues understood this when they wrote to Roosevelt about atomic energy in 1939. It is worth noting that the US government dragged its feet on this letter until at least 1941, and it was not until 1942 that the Manhatten project began.

It is worth listening, even if you don’t like what you are being told. If scientists and advisors must speak truth to power, so power must listen to truth.

Such is the politician’s duty. Pity such duty is so poorly observed.

The elephant in the room in healthcare is the hospital, about which I have suggested that we will build the last one in 2025.  What will “smart hospitals” look like, and why should we care?

Hospital Universitario Marqués de Valdecilla, ...
Hospital Complex, Spain

Why should we care?

Hospitals are expensive and complex labour intensive organisations originating in industrial era thinking.  Little has been done to modernise the institution itself, although much has been done of course to improve what hospitals do. We also know that hospitals account for a considerable carbon burden and consume a huge amount of energy since they operate 24 hours a day. We know that as labour intensive institutions they suffer from the challenges all such organisations face as they try to improve operating practices and reduce running costs. Healthcare delivery is characterised by regulated cartels, which serve both to protect the public, and protect professional practice from incursion by other health professionals.  A bit like an early 20th century factory with craft guilds.

We should care because these institutions need to become smarter in the use of modern technologies and practices, but this process is slow and cumbersome, and while they evolve, the taxpayer is faced with paying the costs of institutions which in many cases should be replaced. This is not to say that those who lead hospitals are not focused on these issues, but only to say that their job is not easy and with the many vested interests around, challenged.

What would be refreshing would be leadership for clinical workflow change to come from the professions themselves, due recognition of their need to evolve and reform rather than simply protect the status quo.  We need these groups to drive change in healthcare, rather than waiting for politicians or Ministries of Health to set the agenda. Of course, informed and empowered patients will eventually not put up with much of the nonsense that confronts them when they seek healthcare, but that is another story.

What will they look like?

We are left with wondering how to improve how they do what they do.  Enter ‘smarts’. This brings together a constellation of forces currently abroad in the world, ranging from automated building management systems, smart grids, energy recovery systems, to wireless technologies in hospitals to remove the wires.

Coupling smart systems together creates networks that can link patients in their home to monitoring facilities and first-responder capabilities. With the added advantage of wireless, we have untethered remote monitoring.  In the end, we have real-time healthcare.

Smart hospitals will not need to define themselves in terms of their geography or location, that is in terms of buildings. They will define themselves in terms of two factors:

  1. their capabilities and
  2. how they deliver these capabilities.

Indeed, the organising logic of the modern hospital will be replaced with one akin to a dating agency — it will link people with needs to capabilities to meet those needs — built on a sea of clinical, and patient information, and connectivity to various organisations that can deliver the services (healthcare) that is needed.  This breaks the current approach to vertical integration (based on the industrial conglomerate model) and replaces it with the virtual hospital, a network of focused and tasked organisations.

I had scoped such an approach to a redesign effort for a teaching hospital, which would have replaced a campus model (mainly an old building and some attached add-ons) with a distributed and electronically-linked (ehealth stuff here)  network of perhaps 24 centres scattered across a city of a million or so.  But industrial era logic prevailed and they went with the single building.

I guess we won’t get smart hospitals until we have smart planning.

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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Lifeboat (rescue)
Someone will come, we all hope.

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

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

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