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Domino Spiral

Death spiral or solution? (Photo credit: FracturedPixel)

There is a flurry of alarmist writing on the financial state of the NHS at the moment. Solutions are usually three: spend more, spend less, find money from other places.

These are not solutions but facts of state involvement in healthcare. While I would not disagree that financing issues are important, they do not alone define the problem. Choices of funding mechanisms are essentially political in most countries and hence reflect the usual rhetoric of political positions. Is there another way forward?

Let me begin by saying that many problems arise because of the descriptive models used and which limit creativity. The NHS has been compared to a supertanker, hard to turn around — so change the story to a school of fish (in organisational terms: greater autonomy and decision-making within smaller functional units). Candace Imison at the King’s Fund wrote recently on her blog that NHS reform was like ripping up plants in a garden and then sticking them back (or in policy terms: reform was careless and presumably didn’t pay enough respect to the fabric of the garden itself). Models such as this summarise a position, without the necessity of intellectual substance. May we be delivered from this.

I prefer to start my policy analysis at the other end, so to speak. What results do we want from healthcare systems and what do we need to realise those results. Keep in mind the current underlying logic of the NHS policy stems from a period that the majority of the population have no experience of, when the UK faced existential risks and government had almost no policy levers to do what needed to be done, except to take over and run the whole show. While evolved over the years, the essential organising logic of the NHS has not changed. Today, though, we have more nuanced policy instruments available, including much better educated clinical expertise, public literacy, higher general standards of education, better ways of looking after the health of people (not perfect, just better) and importantly the ability (not yet realised) of using information better, in real time, predictively, and to anticipate rather than react to healthcare needs of people.

What we do need to do is avoid the death spiral into thinking healthcare is only about funding (“health economics does not equal health policy” hard though that may be for some). Funding is in fact a policy tool, not an outcome. Regardless of how the money is provided, how it is used is what matters.

My suggestion to avoid this dealth spiral is to think about why disconnects arising from financial handoffs cause such major problems with service, impact patient care so badly and contribute to poorer rather than better outcomes. Indeed, my view is that there is enough money (the evidence is pretty clear that outcomes do not correlate with percentage of GDP spent, but on the organisation of care itself) but it will never actually be enough, so we need to be creative, not profligate.

One way forward is to embed payment in the patient, who is the only person to actually experience integrated care (i.e. care that is not disintermediated by funding gaps). The logic of patient action triggers connectivity amongst disparate providers and the patient takes on the responsibility for the stewardship of their own care. The NHS trivialises the potentially disruptive impact of patient choice by financially disempowering that choice as policymakers fear the consequences of disruption more than poor care. Many of the disconnects in NHS and social care are constructs of policy logic constrained by untenable premises. This is not so much about patient empowerment, but the consequences to the structure of healthcare delivery when patient actions determine the funding flows. Berwick and colleagues Triple Aim, which I have operationalised into a decision tool [email me], depends on the ability to intervene and set priorities within a whole-system view of healthcare. This is not hard. The will to do this is.

Organisational logic and clinical will-power alone will not be sufficient to integrate care — if that were true, then the last 20 years in the NHS should be the golden age of integrated care! But what is necessary (but not sufficient) is the ability to redesign and flexibly innovate and introduce change in service structure locally. We will no doubt hear a lot about accountable care organisations from the US, and like in so many cases, UK folk will flock off on site visits to tour these (stopping off for some shopping along the way). ACOs are interesting because they are an organisational solution to care integration (they are also a response to how provider performance will impact their income so survival is part of the logic here). There is nothing difficult about merging health and social care, as long as the providers of these can merge. It is, in this case, not about the money, but about the logic of organisational design for purpose. Regretfully, for the NHS, there is a fear of disruptive new entrants into care delivery. Policy objectives are constrained by two rules: the first is that there is no real (by that I mean meaningful)  failure regime (which is really a set of rules about financial viability) and second that there is a general avoidance within NHS policymaking of the creative destruction of publicly funded institutions (which is a rule about the prudential use of taxpayers’ money).

One last point is about the patient’s entry point to healthcare itself and the logic of general practice as a policy instrument to deliver primary care. I am worried that there are untested assumptions about general practice. I have asked whether general practice is fit for purpose, taking into account questions about what purpose general practice is supposed to have. If general practice is to meaningfully achieve its potential, then we need to see greater care integration around the general practice itself. This is a simple logic that suggests that services should migrate to the point at which they are most used or needed. Obvious examples are at least three. The first is that public over-reliance on accident and emergency (or emergency rooms) reflects a lack of timely resource availability in general practice. (US research shows that emergency room users have insurance and could use their GP, but for the lack of being open). So there is some logic in anchoring around GPs emergency care services. Hospitals, with their own integration logic, can extend their services into general practice (I worked in a hospital that did just that) — this is called the innovator’s dilemma and reflects the inability of incumbents (GPs) to meet their own challenges but we are faced with the fear of disruptive new entrants. The second is that patients often experience a diagnostic revolving door between GPs and hospitals/specialists, until they get a diagnosis and treatment. UK evidence is stark here with delayed diagnosis for many cancers, and I’ll highlight ovarian cancer, cardiovascular disease, and neurological disorders. What we need in general practice is direct access to specialists such as oncologists, neurologists and cardiologists and break the monopoly control by hospitals of these services. The third is whether there is an appetite for general practice to unbundle acute services into primary care, or for hospitals to vertically integrate into primary care. Some wil say, ah, polyclinics, tried that. Well, they weren’t tried. In fact many innovations from abroad have been tried and failed because of the failure of the system to alter its underlying assumptions. The Evercare programme from the US failed in the UK because the test sites would not send cardiologists into people’s homes — the essential enabling logic of the Evercare programme itself. Failure dogs NHS innovations because of the inability to alter assumptions (perhaps the new CEO of NHS England Simon Stevens will reflect on how his former employer, UnitedHealthcare achieved such good results over such a long perid of time and why the NHS failed). (have a look at this for some evidence)

In any case, I hold little hope for disruptive entrants or solutions that challenge the NHS paradigm. The strenght of the funding glue is far too great to let that happen.

Euractiv is reporting some concerns that there will be a decrease in research spending in the EU. The article is here.

According to the survey that triggered the anxiety, some 93% of those surveyed said that “investing in innovation is one of the best ways

Innovation

Innovation can also be quite mundane, it all depends on what problem you're trying to solve (Photo credit: Stephanie Booth)

to create jobs in Europe.” This is absolutely right! However, investing in innovation is not the same thing as spending more on research.

There are two, broad schools of thought here. The first sees spending money on research, translating into innovation. The other is that innovation occurs when real-world problems are solved. The EU and most EU member states have pursued the first approach; the problem of job creation is pursued through the second approach. The evidence on job creation might suggest that the first approach is not working.

Spending more on research is not, in itself a bad thing. However, the quality of the research has to be good, results disseminated and academic researchers held to account for their work. I am not a big fan of state-run or controlled higher education, and less a fan of protected job status for academics. According to this model, more research literally pushes innovations into the market where hungry investors snap these great ideas up and go off start companies and hire people. And so it goes. This approach does not generally work. It is called the ‘research push’ model, and is faced with the tremendously difficult challenge of research translation, that is, of linking the research through various arrangements to people who can create innovations from the research. Research, itself, is not an innovation; it only becomes an innovation when it becomes useful.  [see Michael Gibbons et al The New Production of Knowledge”, Sage 1994 on the distinction between ‘use-less’ and ‘use-full’ knowledge]

The other model involves innovation emerging in markets, which have needs and which investors, inventors and others are encouraged to respond to. This is called the ‘adoption pull’ model, as it focuses on how markets (that’s you and me needing something and buying it) adopt innovations which respond to our requirements. The value of any research is precisely in the context of whether it feeds this innovation or adoption pull. The research translation process here is about identifying knowledge needs that research can fill, and which in turn can be converted into innovations that people will want and value.

The key distinction is that the needs of academic researchers, to do research, solve problems, learn new things, etc., is not the same thing as the needs people have for innovations. Research commercialisation by European universities is generally very poor, and particularly so in countries which operate the research welfare state. They also have poor access to risk capital, burdensome public ownership of publicly funded research (as though no one learned anything from the role of Bayh-Dole in the United States, or hadn’t gone back to the 1940s and read Vannevar Bush) and generally complex labour market rules which frustrate businesses startups (for those who wonder why this is important, a business start-up is something new, creates employment, is risky, but is where all large companies start from. How they get to become big is not just a function of their products and innovation, but the flexibility by which they can grow, and that is often a function of the perverse impact of national bureaucracies.)

Spending more on research won’t address the development of innovation or create jobs as such. Spending more on research will of course expand the research system, and possibly expand the research welfare state.  I am not ignoring the real challenge of what proportion of research funding should be for pure or curiosity research and which should be mission directed (or linked to Grand Challenges, which are proving such an effective way to align researchers’ interests with compelling real-world challenges.

If you want innovation to create jobs, as apparently 93% of people surveyed want, then you want different things from just more research spending; you need things that in Europe and particularly in some Eurozone countries are proving particularly hard to do, namely:

  1. You need a risk culture where it is easy to start companies, try out new things, and if they don’t work, start again; but many countries penalise innovators who go bankrupt, for instance, while other countries load small start ups with massive social costs, inflexible labour rules, so the company can hardly get going for the tax-burden.
  2. You need an environment which encourages adoption of research findings; perhaps better, you need the academic institutions to be more proactive in encouraging entrepreneurialism amongst academics. Secure employment contracts that restrict freedom to explore alternatives are not help. Key concepts here are: flexible academic employment contracts, real-world incentives within universities to encourage a career focus on problems as well as new knowledge.

Of course, this list can go on. The key message is that equating research spending with innovation investment is a broken paradigm that should be quickly abandoned.

Want to know more?

Well there is a lot out there. I’m going to recommend these for starters:

Roger Miller and Marcel Cote, Innovation Reinvented: six games that drive innovation. University of Toronto Press, 2012.

An older book that is worth a read about companies and innovation (remember that the SME is the engine of job creation, not the public sector) is this one:

Ikujiro Nonaka and Hirotaka Takeuchi, The Knowledge-creating Company: how Japanese companies create the dynamics of innovation, Oxford University Press, 1995.

And because this blog is about healthcare, everyone must be mindful that research and innovation in healthcare, as in other sectors, can be highly disruptive (this creates unemployment and new jobs at the same time and may even bend the cost curve down), I’m suggesting a read of this new book:

Eric Topol, The Creative Destruction of Medicine: how the digital revolution will create better healthcare, Basic Books, 2012.

 

 

In this Age of Austerity, good ideas risk being lost. The dynamics of funding of innovations has always been full of risk. But as various debt-laden governments try to balance bloated public balance sheets, should we worry about where the ‘next big thing’ will come from? Yes, if you believe that governments can find and fund winners (the evidence says they can’t by the way, but can act as catalyst or midwife), no if you believe that the wisdom of crowds, otherwise known as markets, might be a useful driver of innovation development and adoption.

The diagram below summarises the funding of innovation, identifying in particular the so-called ‘valley of death’ where good and bad ideas go to die for lack of funding. The risk we, as taxpayers, face is that governments will continue to fund innovations into the valley of death, perpetuating what I call the ‘research funding welfare state’, where research happens, but innovations don’t. Hyperactive civil servants with indelible portfolios will continue to pursue dead-end projects despite evidence that the world has moved on. The real problem for governments isn’t finding money for funding research (though that is hard enough), but realising a simple algorithm:

  1. the world is characterised by change
  2. the world will change faster than our ability to respond
  3. this will not change.

Europe has a shortage of innovation gorillas compared to other countries, and if the politics of some countries are to be believed, would rather retreat into a safe haven of social solidarity and protected interest groups, than face the harsh realities of the modern world. This Fortress mentality will not keep the disruptive wolf from the door and will only add to domestic turmoil as native talent packs up and leaves for more encouraging countries.

The harsh reality of innovation is that it can be violent, overthrow trusted ways of doing things, and challenge what may be thought of as defining cultural norms and social innovation is just as much part of innovation as the inventions themselves. The other true thing about innovation is that it knows no favoured nation or culture — anyone and any country can do this.

Find the risk

Cloche GFM (Ouvrage de l'Agaisen)

Fear, not protection. (Photo credit: Wikipedia)

As has been noted by other commentators, the French government has a problem with the internet, and endeavours to stave off its impact with ill-timed, and ill-thought out regulation. Of course, as a national government, they can try to build a digital Maginot line around France; they’re always doing that and as Santayana said, having failed to learn from history, they persist in repeating it.

One can only hope that such efforts will not be copied by other governments and certainly be given short shrift at the European level.

History shows that efforts to build up walls such as these are doomed to failure. Brute force, smarter opponents, and new technologies prevail in the end. France, regretfully, seems to prefer to hide behind its social-cultural rhethoric rather than deal with the opportunities that the internet offers, by fearing it more than understanding it.

The internet is not just a telecommunications novelty to send emails, view your vacation pictures, or keep in touch with friends. It is has become a digital glue that binds communities and nations together in a way that international treaties have failed. It could be seen as the ultimate success of the internationalisation of societies in a way that brings with it greater understanding and peace. Indeed, why do autocratic governments, usually just before they collapse, try to shut down the internet, for it, like the photocopier in what was the Soviet Union, represents all that they fear: openness, liberty.

Efforts to counter this new technological force of nature are at root authoritarian. They say the government in power knows better than individuals. Francis Bacon wrote in 1597, “knowledge is power” [Meditationes Sacrae], certainly not anticipating the internet, but deeply understanding that control of knowledge (or information as we think of things today) gave those who controlled it power. From this come cartels, censorship, autocratic governments, and authoritarian regulation from fearful democracies.

The former US Supreme Court justice, Louis Brandeis, is famous for saying that “sunlight is the best disinfectant”, and today the internet is the best disinfectant there is, for it is revealing where injustice lies, and uncovering official hypocracies. It is laying bare the landscape of opportunities for all, and not just a privileged few.

But some fear this for it also reveals where the internet challenges past comforts, vested interests, and the quiet whisper in the ear.

And so this digital maginot line that some countries are trying to build will fail, and fail for all the right reasons, as we don’t live in that kind of world anymore, and governments, both national and at the EU level need to grasp that as the internet changes everything, it also changes the very logic we use when we govern.

In a frictionless internet I can eliminate fr, .de, .uk, even .eu, with a mouse click, erase them from my universe more thoroughly than the thundering barbarian hoards.

Or I can make them the centre of my world.

 

 

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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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Did this work?

Did this work?

We are learning new things about how we make choices and decisions. The work of people like George Loewenstein, Robert Cialdini and Daniel Kahneman have introduced us to new thinking linking psychology and economic behaviour. This has translated into the health sector in a number of ways, including recent reports from both the UK and French governments on how to use the research from neurosciences and behaviour in public health.

This means that corporate strategists in the pharmaceutical and medical device industries as well as public policy makers will need to rethink many of the underlying assumptions driving their strategies, as simply put: there is a better way.

Coupled with our understanding of the complexity of regulated health markets, strategic thinking will need to look anew at market drivers, the logic underlying the assumptions of who key customers are, and the consequences changes in these assumptions have for commercial priorities.

For example: Novo Nordisk rethought who its customers were for insulin, and with new delivery technology, see the diabetic not the doctor as the customer. Bayer developed a little gadget to encourage children to maintain their insulin levels by aligning this health objective with Nintendo games.

Yet, device companies continue to target doctors as key decision-makers with technologies for patient use. The results are plain to see and most people would rightly reject such poorly designed equipment in their homes. The major device companies persist, despite falling market performance.

The pharmaceutical industry in prescription regulated markets continue to target doctors with a field force, much like door-to-door salespeople, when the real determinants of medicines use lie in patient behaviour. While ‘share of noise’ seems to be the reason for large sales forces, improving the calibration of their market objectives with new learning on decision-making opens up new avenues. In emerging markets, retail medicines are just like FMCGs. The challenge for the industry is how to market what is in effect a premium product (it costs more to develop a new medicine than all the developmental research (if any) undertaken by the luxury goods industries), without marketing “sickness”.