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Group Shot

So we all agree? (Photo credit: Jayel Aheram)

“Linda Sanders, director of social care at Hillingdon, accepted that Steven and his father had been let down by collective errors of judgment.” [from the UK Telegraph]

There is a court in the UK that belies belief that such an authoritarian and secretive judicial entity could exist in a democracy. Away from public scrutiny, legal injustices occur in the name of protecting the interests of vulnerable people. Maybe.

But what this particular case indicates, and the quote is not the whole story, is that vulnerable people can be held essentially captive (the court ruled that his human rights had been violated and he had been ‘unlawfully detained’). It is further evidence that vulnerability and disability lead to a net diminution of an individual’s rights. I worked on the legal rights of disabled people at the beginning of my career, cataloguing one of the first directories of how officialdom removes rights from individuals through a systematic and bureaucratic process, sanctioned by law, and in this case enforced by all the power of the state.

What is worrying is the director’s comment that it was ‘collective errors of judgment’.  This is grovelling code for ‘group think‘.

Group Think is a deadly force that infects organisations, and allows bad things to happen because people fail to challenge injustices, go along with the crowd, or ignore their ethical and moral compass.

Collective errors of judgment are not accidents of nature either. They arise from systemic elements in organisational design and structure, reinforced by leaders that see dissent as evidence that someone is not a team-player, where deep ethical issues are viewed as interesting but not relevant to the task at hand. It emerges when no-one looks at a situation as a whole, and asks what is going on here, and why. The old adage, would you like to see your decisions on the front page of the newspaper, on Facebook or Twitter, apply.

It is hard not to blame the culture and management of social care organisations, as this is not the first case where there is evidence of systemic failure. It revolves around how organisations form opinions about the care needs of individuals, how individuals (not collectives) arrive at those decisions and in what way, how they discourage alternative perspectives, and fail to change their views when confronted with new evidence, evidence to the contrary, or as in this case, a clear challenge to their authority. A patronising organisational response no doubt prevailed.

Group think also infects decision-making in any organisation where actions are based on an hypothesis about what needs to be done, and from which various actions flow. Getting that initial starting point wrong, means actions flowing from it are wrong. This is not a collective error of judgment, it is evidence of deep failure of decision-making processes. Other social organisations work in this way.

The way forward includes directors of social work not blaming some vague collective, but examining how decisions are made, how challenges to decisions are received and their attitude to dissent. A clue is here: an organisations that describes itself as a ‘family’ is likely authoritarian. Family language means dissent is suppressed within an organisational type that is either matriarchal or patriarchal in form.  And you know what it means to disagree with your parents.

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20 Bonus 2 MW wind turbines at the Middelgrund...
fanning the ineffectiveness of Copenhagen

The whatever they are called talks in Copenhagen on climate demonstrate the broken nature of our approach to achieving consensus amongst a diversity of nations, views, and wishes. The circus will soon close and we may have very little to show for it, despite everyone’s hopes and wishes. A room with THAT many people in it could hardly agree what to put on a pizza, let alone work through a complex drafting of such an important document.

A few points are worth noting:

  1. Trying to achieve an agreement by having the negotiations stretch throughout the night, so no one gets any sleep is bull-headed, and is hardly evidence of clear and coherent thoughts at 3 in the morning.  Early morning tweets from politicians who have stayed up all night just adds to the impression that these people don’t know what they are doing.
  2. The notion that the backroom gang do all the heavy lifting and then the leaders swan in to sign the final draft is well-past its sell-by date. Clearly, neither works.

Savvy negotiators know that getting your opponent to go without sleep is one way to ensure both delay and achievement of your objectives. Tiredness doesn’t just kill on the road, but is a well-established brinkmanship tactic. It is particularly helpful when there is a hard deadline, and great expectations of results; the closer to the deadline with a lack of agreement, the more likely sleep will be deprived and decision-making and clear-thinking begin to fail. Better to add days than nights to negotiations, and drop this adolescent behaviour.

Setting expectations high also creates an opportunity for nay-sayers to bargain their way to a lower level of agreement, giving the impression of failure whereas they may actually have found the spot at which agreement is most likely, but having failed to establish a Plan B, meant that it was Plan A or failure. An existence of a Plan B, though, would have infuriated some advocates for agreement, as it would identify prima facie where compromise would be likely.  The problem in part was that compromise is often seen as failure, rather than agreement by other means. Perhaps it is better to under-promise and over-deliver.

The use of backroom staff is important, but it is evident from Copenhagen that a lot of fundamental bluesky disagreements remained and where solutions lay above the pay grades of the staff involved.  Better than leaders learn to do their own work, and have the backroom staff refine the language, than the other way round.

The problem with Copenhagen appears to be faltering over accountability; this is a re-run of the nuclear arms treaties. One could argue that objections may be well-founded, but we haven’t seen the basis for that. Agreements do need mechanisms to ensure they do what they are intended to do, but we don’t have sufficient vocabulary for what we need as in the past, most agreements were either treaties with broadly equal partners (e.g. Treaty of Rome) or were imposed by victors over vanquished (take your pick here). This seems more like a communitarian process, with considerable inequality. Perhaps some lessons from community development models would have been helpful.

Of course, this is all quite apart from whether a deal is pulled out of the hat, and whether it is a deal or just a political fix.

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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Magnetic Resonance Imaging. Timing Diagram for...
MRI timing diagram for spin echo pulse sequence (don’t ask)

Progress in healthcare can come from changes to the way clinical work is done.  An example is interventional radiology, which combines radiological investigation with treatment, in a single step.  It moves radiological technologies, such as MRI, CT, Ultrasound, from being mere diagnostic technologies to integration into the surgical work itself.

So why the slow uptake in the UK where a couple of years ago the Healthcare Commission, in one of its investigations, noted that this approach to treatment would have probably saved lives?

The NHS is a slow and late adopter of technologies.  Difficulties giving the necessary clinical freedom to health professionals means that important leading edge, but proven technologies, are slow to be adopted.  The exploration of novel approaches to offering clinical services, outside of hospitals, for instance, in free-standing “theranostic” (therapy and diagnostic) clinics would not only advance the cause of patients, but achieve a step change in service delivery by NHS providers.  Why aren’t the newly freed Foundation Trusts getting on the business of developing services wrapped around this approach to care?

People are obviously of good intent by urging reviews of funding to elected officials in the suitably hushed setting of the House of Commons, but in the gritty reality of healthcare delivery, creative solutions are needed to address not only the timely implementation of interventional radiology, but also overcome the fear of change, of novel technologies and of changes to  clinical practice that change and technology brings.

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Suck (film)
!

A recent two week work schedule in Toronto had me reflecting not only on how much snow there can be in my homeland, but also the need for a real electric charge to the province’s policy making.  The province is facing near meltdown, after an ill-conceived pursuit of manufacturing jobs in the automotive sector, with some 150,000 manufacturing jobs lost over recent years, never to be seen again.  Trying to jump-start this industry with taxpayers’ money seems a bit like investing in buggy whips while watching Henry Ford’s Model T drive you to town for a nice lunch!

Investing in universities and research has been coupled with a punitive tax regime, that drives new businesses into the arms of other provinces, or to the US.  Early-stage venture capital is scarce, and the mandarins on Bay Street that do profess to know what to do are more focused on generating returns to their funds (or these days just keeping the rent going on their plush offices), than on understanding the driving force that is the commercialisation of research.

Brains not brawn should be the cornerstone of provincial policy.  This will become especially important as the US, largest trading partner with a 10:1 ratio of US scientists to Ontario/Canadian scientists ramps up scientific investment after a near-decade of scientific politics under the last elected regime.  That sucking sound you will hear (apologies to Perot) will be American scientists returning home to the US.

Ontario, time to get the boots on, review taxation policy, look to rethinking what the best use for bail-out money really is.  Some industries will go and that is sad, but what will replace it will establish the future credentials for the province for at least this half of the 21st century.

Unless, of course, you like buggy whips.

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The mortar and pestle is an international symb...
A tainted symbol of trust

How can I be sure the medicine I take is genuine?  In some countries, there is an almost even chance that it is counterfeit; not just a cheap substitute, but a real fake,  ineffective,  probably harmful, and maybe fatal.  Some counterfeit medicines were found in Hamilton, Ontario, earlier this year and the pharmacist has now been charged by the RCMP.

Counterfeit medicines are a global problem, with trade estimated to exceed US $36 billion a year.  The World Health Organization estimates 8-10% of all drugs supplied globally are counterfeit.  The European Union estimates counterfeit drugs cost their health systems €1.5 billion annually.

Counterfeits are a clear and present danger to human health.  Africa is threatened by counterfeit AIDS drugs, while in Haiti, Nigeria, and Bangladesh almost 500 mainly children were killed from fake paracetamol syrup.  Perhaps 192,000 people were killed in 2001 in China from counterfeit medicines.  Counterfeits circulate in the European Union, with two recent cases in the UK alone.  And Canada.

Fake medicines are hazardous, with documented toxicity, instability and ineffectiveness but few people are experts in pill authentication (even pharmacists get fooled).  Counterfeit drugs are easier to make — in portable cement mixers – and fake than money.  But there is little patients can do but rely on assurances by others that drugs are genuine.  That may not be good enough.

Our health and medicines regulators believe there isn’t a problem because there are few cases.  But recent research in Europe counters this regulatory denial with evidence that regulators have little hard evidence on the scale of counterfeiting.  Problems with medicines are rarely associated with the drug being fake.

Counterfeit medicines don’t just show up in the local pharmacy, they are infiltrated into the supply and distribution of legitimate medicines by rogue, criminal organizations and individuals, who specifically target the weaknesses in this system.  But counterfeiting is seen as a patent issue not the criminal act it is.

Once a medicine has been factory sealed by the pharmaceutical manufacturer, there is no assurance that it will reach the patient unopened; a pharmacist and doctor can open it.  However, there are companies with the licensed authority to repackage factory-sealed medicines with new labels in new languages.  Unscrupulous distributors can conceal the illegal substitution of counterfeits within our apparently highly regulated system.  Canada, a net importer of medicines, is vulnerable from this as it imports medicines from countries that are known sources of counterfeit medicines.

While US/Canada medicines trade has focused on internet pharmacies, the real problem the internet is also a counterfeit drug delivery system and a real problem by the US, which views Canada’s system as easily compromised by counterfeiters.

Therefore, we need to ensure that any tampering with a product’s factory packaging is clearly evident to others.  Using ‘drug provenance’ would show who has handled, opened or repackaged a product; another way is to use advanced ‘track-and-trace’ technologies such as radio-frequency tags (RFIDs) to track shipments of medicines and determine if they have been tampered with.  However, there are stricter controls in place to deal with the movement of cattle than medicines.

Nevertheless, things are slowly improving, with the US FDA promoting the use of RFIDs by 2007, and efforts to improve data collection on counterfeiting.  But there is little public awareness of this global threat, as regulators focus on the operation of pharmacies rather than the origin and safety of the medicines themselves.  Legal sanctions are often weak, or inappropriate, considering the grave health risk counterfeit medicines represent.

The way forward will require ‘counterfeit proofing’ the supply and distribution of medicines.  The criminal law needs rethinking to link human health and counterfeit medicines.  Good data is needed to inform our actions and understanding to ensure appropriate regulation.  Finally, the problem must be viewed as a global one and Canada could show international leadership in proposing solutions in an area were there is common cause amongst regulators, health professionals, pharmaceutical companies, and healthcare organizations.

The health system works on the basis of trust, and patients must trust that the pills in that little bottle are what they are supposed to be.  But while the vast majority of drugs are perfectly legitimate, a more comprehensive solution to the problem of counterfeits is needed.

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Reflecting on my recent visit to Canada, and discussions with many key people on challenges facing Canadian health care, I am struck by the extent to which Canadian policy makers are groping for direction, with both feet firmly glued to the floor!

New ideas abound, and intelligent and thoughtful people are proposing challenging ideas, but at the same time, I find a narrowing in the solution space — changes are needed and quickly, but we can only go so far, or do so much. Perhaps whilst a mood of crisis pervades some circles, complacency prevails?

Andrew Cohen, in his While Canada Slept: how we lost our place in the world, has cogently articulated a malaise in the Canadian self-image. Senator Michael Kirby and his colleague Senator Wilbert Keon, have proposed the introduction of competition into Canadian health care, and not the least challenged the prevailing mythology that surrounds our health care system. As legal challenges to the Canada Health Act proliferate and the Supreme Court reflects on the way ahead, it is worth noting that regardless of the legal outcomes, there will be ructions at the policy level, and we need to anticipate them. Experience in Europe, where the European Court of Justice rulings have altered the cross-border health care environment to the surprise and denial of the member countries, should suggest that it is time to shelve the mythologies in Canada.

My discussions with my colleagues in Canada suggest that some key issues are paramount, and I share these as much to offer these thoughts to others as to suggest they offer a framework for a policy agenda:

Learn from others

Canadians are not learning from the experiences of other countries and may have retreated to certainty of the mythologies. Sure, people make the pilgrimage to selected reforming systems, and some folk bring their hot ideas to Canada, but sustained international engagement on practical learning is weak. Perhaps it is the fear/fascination with the US that says that Canadian health care is at least “not like that!”, but much can be learned from other systems and the agenda for learning needs to take into account the strengths of the Canadian system, and the weaknesses of others. Countries with strong policy-driven reform programs attract interest like bears to honey, but in many cases deficiencies in the service delivery system undermine these plans. What is needed is greater engagement internationally at all levels of the service delivery sector, and in particular major reform of health management training is needed.

Disrupt the existing service delivery paradigm

The hot money is that competition is the way forward, and as Kirby and Keon have also suggested deal with labour market rigidities. But let’s look at competition. Raw, brute competition between hospitals in Canada is most likely to occur on University Avenue in Toronto, and probably no other place. The public’s interest is is service. If we start with the disruptive potential of patient choice, we find that it is not competition between providers that will improve services and drive efficiencies, but competition around quality, service options, and the opportunity of new providers to enter the market easily and offer services people want. Ministers of Health who profess to protect the public interest by blocking service innovation at the Rainbow Bridge, are shielding us from service improvement by playing to the bleachers. Labour market rigidities exist partly because health care professionals have become institutionalized around their roles and now successfully protect this, cartel-like. But patient-centric reform will call on these same professionals to explore how they can be leaders and innovators. Why bother try to improve services if you can’t create that service because of systematic barriers to service-led reform?

We only need one thing: Innovative Contestability: permit innovators to drive service-focused reform to challenge the existing service providers; this will unbundle service configurations as patients vote with their feet for the service that meets their needs.

Develop citizen-centred e-health

The concern that health system productivity is not improving is widespread and is caused in part by the failure of the service delivery paradigm to be able to reform. Central, though, to this thinking, is the view that new information and communication technologies will drive productivity and service improvement. Why should that be true? In other sectors of the economy, massive investment in information technology has taken in some cases decades to get to work properly, and most major projects generally fail to deliver the benefits that were breathlessly promised. What industry does know, though, is that a focus on service improvement and productivity is led through customer responsiveness, not an internal focus on organizational change. Customer engagement in health care will drive productivity improvement, and e-health technologies that fail to start with patient use as a key driver, will not lead to productivity gains. Patient access though to their electronic health record or prescription database will ensure that it is accurate, complete and current, as this quality inspector of one has a greater vested interest in its accuracy than any health professional.