Mixed economy of healthcare is more intelligent than a supertanker

From the UK Guardian: private healthcare providers.

The research on comparative performance of for profit and not for profit healthcare providers is well developed, so it is surprising to see such a weak quality assessment about private providers in the NHS.

The NHS is a very difficult customer for a number of reasons, primarily the glass box of public scrutiny and politics. But many countries successfully navigate public scrutiny of providers in general. So what is the story behind this newspaper article?

  1. It is true that many private providers have handed back their contracts to the NHS usually because either they didn’t do their sums properly, or found the environment more challenging than they expected. But a significant number of NHS providers are in substantial financial trouble, too, and they can’t hand back their contracts, but instead get a state bail-out. This is hardly a level playing field of course, but indicates that the financial regimes for public and private providers is different and that the commissioners may be unable to purchase care services from a mixed economy of providers.
  2. Private providers are often accused of not providing the highest standards of care. This is an interesting problem as virtually all the doctors on private contracts work the bulk of their time in the NHS and all belong to their Royal Colleges and the GMC regulates doctors, not just NHS doctors. It is worth being reminded that the NHS employs 57% or so of all registered nurses, while 37% work in private settings and an additional 7% in nursing homes. As well, the public sector is not the major employer of pharmacists and nutritionists, and the list goes on. Are these health professionals agreeing to work in less well-run and managed private facilities or do they believe they are providing a higher personal standard of care.
  3. Yes, the private hospitals are free-riders on the training system for health professionals as they don’t participate in that system, but there is no reason they couldn’t. They also don’t have emergency facilities, which is pointed to as evidence of poorer standards of care as a patient in trouble would need to be transferred to an NHS provider. But in the NHS, A&Es are being rationalised, converted into trauma centres, and patients transferred to superior treatment facilities when a particular hospital cannot cope. Patients and ambulances are apparently queuing outside the A&Es. There could be a case to be made for private urgi-care centres (18 hours a day, out-patients only), but the private sector would need to made a strategic decision that they wanted to elevate their service mix above elective, private insured care. Until they do something to fix that fault line, they’ll likely be continuing target.
  4. As for the money, in the total scheme of things, private contracting is still less than 10% of total expenditure on the NHS. The article typically falls into the trap of making numbers look big, when as a proportion they are quite small.
  5. NHS managerial expertise is generally what is used to run private hospitals. Many former NHS managers work in hospital contract management, where a hospital is run by a management team on contract.
  6. Circle had trouble not because the Hinchingbrooke is particularly challenging but because the managerial and financial environment was unsustainable partly because of underfunding of the contract by the NHS among other reasons.
  7. It is worth keeping in mind that while the US is seen as a bastion of private healthcare, the majority of providers are not-for-profits (including the hospitals associated with universities where the care is of world class excellence) and that the US care system is over 50% funded from the public purse. Private care providers exist globally and we might usefully look to countries in Asia, such as South Korea, to see what at future healthcare system might look like. Think Samsung.

What Cognology would say:

The government does not consider healthcare as a whole system but fragments regulation by ownership type; this is the root cause rather than something intrinsically problematic with private care, especially given the substantial evidence of problems with NHS care. This means they have failed to create a single regulatory environment to cover both public and private providers which would benefit all citizens in the country regardless of their personal choices. Taking this one step further, embedding intelligence in organisations, hive mind type logic which drives complex adaptive systems, would alter the objectives of regulators and embolden the component parts toward greater autonomy.

 

 

Transformation in 5 ideas

The UK’s Guardian has an article on 5 things from other countries that could transform the NHS and presumably offer lessons for other countries, too.

The approaches while each in their own way are worthy, also reflect cultural thinking. At root, these ideas could have emerged if there were mechanisms in the NHS for instance to encourage disruptive or non-conforming solutions. However, risk aversion, bureaucratic overhang, dogma, doctrinaire thinking, fear of making changes, and an overwhelming need for the NHS to keep ministers happy dominate.

But as long as the taxpayer is funding the system, the government will claim the right to pre-empt good ideas, to ensure the continuing politicisation of care, to the distress of the patient. The “5 year forward view” was presented as a set of ideas to galvanise decentralised thinking; instead fearful NHS managers turned it into a blueprint. The problems stem from there and lead to the current crisis.

This approach will only ensure feet of clay.

But let’s look at each in turn.

New Zealand: integrated health and social care

The NHS has been saddled with the failure in 1948 to resolve the disconnect with social care. Integration, though, is a good idea, but is hampered by the fact the NHS is free and social care is means-tested. However, other countries have succeeded in payment integration across health and social care through the use of co-payments, which remove the arbitrary fault line that dogs the UK (of course, Northern Ireland has integrated health and social care but in England, who pays attention…). The aversion to any type of copayment in part blocks new thinking as it challenges the ‘free at the point of service’ principle. As other countries achieve better outcomes, less waiting while having co-payments suggests that the government is willing to sacrifice service access for equity.

Of course, the real blocker is that the hospitals in the English NHS cannot extend their services without running into arbitrary barriers either from the Treasury (about intermingling statutory monies) or legal barriers that box NHS providers. There is no reason for a hospital not to work with social care providers to develop proper referral protocols and care pathways that extend across organisational boundaries and developed shared case management; it can be done, but not if doctrinaire rules lock providers into these boxes from which there is little chance of escape. Vanguard trusts opportunities to develop novel models of care according to the NAO has been what one might characterise as a spectacular waste of public money and probably frustrated a large number of people. Will Manchester be able to pull the rabbit out of the hat?

Solution: Remove all responsibility for social care from local authorities and allow charities, independent care providers and NHS organisations to simply build the necessary structures in whatever form is needed in their local area. Pool the money and let providers move money, people and facilities around as they see fit and if a hospital wants to buy a nursing home to deliver intermediate care then let them. The regulatory regime is probably unfit for purpose. This should also enable the emergence of more intelligent thinking from the insurers to develop suitable policies to enable people to buy appropriate supplemental insurance. How will people pay for this, though? That solution is to unbundle a component of the National Insurance and remit it back to taxpayers to be used to buy the insurance, but with an cost-inflater to ensure there is a reserve in place for inflation.

Sweden: paediatricians on the frontline

The use of gatekeeping blocks patients from direct access to specialists and is seen by some as a serious barrier to patient-centred care. All social insurance systems provide for much easier access to specialists.

NHS hospitals are monopoly suppliers of specialists as that is the only place they work and the only way to get to them is through a GP gatekeeping referral process. And one of the major reasons for a child being admitted to a hospital is parental anxiety because the paediatricians are only available through a hospital. Indeed, the UK is at the bottom of the league table for numbers of children’s doctors, and at the top of the list for inappropriate hospital admission of children.

It isn’t so much putting paediatricians on the frontline, as removing monopoly control of access, to free up specialists to work more flexibly. Areas where similar unbundling would be of immense value is cardiology, oncology, ophthalmology, rheumatology, physiotherapy, golly, this list will cover everything. Yes. A design flaw in the NHS logic is the use of hospitals to warehouse clinical specialist expertise and services. NHS hospitals are also monopoly suppliers of lab tests; GPs account for about 50 tests provided by hospital labs and about 40% of their workload, so community labs are a good idea. As for imaging services, the same applies; for example, an outpatient can wait ages for a CT/MRI whatever, only to be bumped at the last minute by an urgent inpatient imaging requirement. Better to have community based imaging, as this will have the added benefit of keeping people out of hospitals, as GPs will be better able to manage their case load with community based radiologists.

Solution: Enable freer access by patients to specialists and have specialists to set up their clinical offices in the community for direct patient access. Same for labs and imaging.

Israel: single patient record

This is not hard, but is complicated by the way the NHS approaches IT. Flexible patient centred solutions are very hard to achieve, when the bureaucracy spends vast sums on failing IT projects, indeed billions of pounds have been wasted. Solutions exist but not when you approach the problem from the top.

While regression models may have been appropriate a decade ago, new computational risk models (artificial intelligence) should be the preferred route for identification of patients at risk, including trawling through EHRs that do exist to find misdiagnosed and undiagnosed individuals (a common problem with 6% of patients with rare conditions).

Way back, Enthoven suggested the HMO model for the NHS. Perhaps Manchester is channelling that approach, which had the government taken Enthoven’s advice at the time, would have removed much pointless NHS reform, and heralded integrated care in the early 1990s.

Of course, this might be a small plurality of systems, but integration of information, portability of records are now much easier to do, and don’t require a massive public bureaucracy to achieve.

However, the fault line between public and private care and between medicine and dentistry and other therapies needs to be closed. Dentists account for perhaps 40% of antibiotic prescriptions yet where do we see integration of medicines prescribing here? And while the Department for the NHS may not like it, there is a large private healthcare sector, and patients move between the two over the years. Records must be agnostic with respect to who the provider is, otherwise all sorts of gaps don’t get filled. The ill-fated electronic prescribing plans of the past studiously ignored private prescriptions because the civil servant involved didn’t take a whole system approach to healthcare.

Solution: Take a whole system perspective on healthcare information that is agnostic to the type of provider. Ideally, the patient should own and hold the health record, as the patient is the only person who actually has an experience across the whole care pathway, so having data follow the patient integrates the information flow across disparate providers of care.

Canada: innovation procurement

The clue here is engaging industry with care providers to work collaboratively. Canada’s somewhat fragmented system (the article refers to Ontario) is a public and private mix, but providers can develop close working relationships with industry.

Relations with the healthcare, medicines and device industries is managed by the Department of Health and whatever it is called today, and not by the Department that deals with industry. Over the years, there have been ill-fated efforts to build relationships with industry, but these will fail if the NHS itself remains hostile to industry engagement. Seeing industry simply as a supplier won’t do. Value added procurement processes ensure that industry has ‘skin in the game’ and therefore will put its best plans forward to collaborative and even risk-shared approaches to solving major problems.

Solution: Re-think the prejudices that hamper adoption of innovation in the NHS as this may be the clue to improving care through a wider committed stakeholder community. But this is a mind-set problem for the NHS and is how value based healthcare will come about.

What Cognology would say.

These solutions all seem very ‘industrial era’. While each in its own way is instructive, what we are not seeing is the embedding of intelligence within clinical and managerial systems.

The Turps Diaries: September 2017

NOTE: This is the final review period so this journal entry was the last.

Where I have been

I’ve be doing the usual reading and looking; Ellen Pearlman’s Nothing and Everything is very much where I sit in my own world view and has led to helpful reflection.

I had some pieces in an art exhibition, Elemental, in the Dungeness Nuclear Power Station with Ashford Visual Artists. EDF, the owner, was really helpful in setting us up in a novel environment for an art show. I showed three pieces, two were abstract landscapes, and the other was an interpretation of quantum energy states (an interesting tension between modern science, and some very old thinking about the nature of the real world). I got to meet the mayors of the Cinque Ports, which has great historical resonance in this part of the country. Dungeness itself is a desert and I find it hugely stimulating.

Concluding comments

  1. I need to let paintings have space to breathe on the surface and not try to fill the available space. Review 4 explored this but not particularly successfully as my objective to develop free floating images did not address exploration of colour choices sufficiently as the critique noted. I have, though, revisited the pieces done in Review 4 and ‘refined’ the colour treatment. No piece is included here.
  2. I am reassured that glazing, working wet and mixing on the surface are effective approaches. I have done a lot of paintings where this layering of paint is the primary approach to colour formation, to elicit various emotional and visual reactions. I sent a response to your 4th critique on my use of glazing to produce layered colour fields. Untitled mediaeval geometric in this review illustrates this with a motif (appropriated?) from illuminated manuscripts.
  3. I am slowly becoming more comfortable bridging my work in Sumi-e to (monochromatic) abstraction, and transitioning from Japanese papers to other surfaces. I’ve started exploring this approach by looking at some of my photographs (I used to do a lot of abstract photography with leaky cameras and broken lenses), which yield an ambiguous visual treatment. See Untitled Abstracted Landscape for this review.
  4. My experience in France seeing the work of Anne-Eva Bergman is still working through in my mind as she abstracted from the landscape. I have continuing challenges deciding whether to work introspectively (noumenon?), or use landscape (more widely, the visual fields we see), in a way that is cognitively challenging and interesting. This is also a feature of Untitled Abstracted Landscape.
  5. The piece I chose from the 1st Review is Fire and Ice. This was the first piece I worked the paint with plastering tools and was a watershed is some respects. This led to me working more often on wood panels and produced the pieces  such as Emergent, which got confused with Richter… and again the comment on colour choices; that review also included the free-floating (Field) pieces. It sits in contrast to the work submitted for this final review.

Parting Shot: why keep painting?

I have found the commentary and thought processes helped me locate myself within the act of painting, so it is natural now to take stock and reflect.

I had some difficulty with the suggestion arising from the 2nd Review about dimensionality, which led to an experimental piece for the 3rd Review (Shades of Blue). While you liked this, I am unconvinced this is a direction that unpacks my own reasons why I paint.

I’m asking here “what is a painting”, (perhaps more in the spirit of the critics, “is painting dead”). I would distinguish such claims of demise from the behaviour of the art market (which is defined by curated taste), and perhaps what comes out of art schools (in the main, failing institutions as I’ve written about).

Clement Greenberg (why is he so vilified?) described some art as polyphonic (a music term) and monotonous. His easel crisis of 70 years ago is/was likely real; today, would much art be called “polyphonic randomness” (or algorithmic polyphony, or “noise”). But I think this is to conflate “art making” with “mark making” and associated tools and techniques – a bit like confusing a writer’s manuscript with their handwriting style. This would reduce artists to “technique-istas”. If this is what is meant by “zombie formalism” [ZF] then Michael Findlay’s The Value of Art is the travel guide that unpacks the art market as an invisible spasming hand (rather than Adam Smith’s invisible hand). How do I avoid going down the ZF rabbit hole, though?

Alva Noë proposes that art is an experimental and organising approach to constructing meaning and which positions art within human cognition; this jives with views in Thinking Through Painting, which takes abstract art as quasi-persons. I think these views say that art cannot be meaningful if it is solipsistic (by definition) and self-indulgent, a helpful distinction to remind artists to have something to say. For me, painting is a cognitive act of creation rather than a performative act. But the zombie stuff has me worried.

The Turps Diaries: June 2017

NOTE: This review involved my main mentor and two of the other course mentors commenting on the submitted work.

The reflection has focused on the challenge of developing not so much a ‘style’, but a visual vocabulary. Does that make sense?

I quite liked the work of Pae White who speaks of exploring spaces between things. Juan Usle was a real treat to discover; I learnt he paints to the rhythm of his heart, much as the late composer John Tavener used his heart murmur as a natural metronome. The reference to Taschist work was new, but the link to Cobra helped (there’s a Bruxelles restaurant full of the work of the Cobra artist Alechinsky).

While I don’t do tapestry now, I have been influenced by how light is mixed on the woven surface since blending light leads to white not black. I think you understood the objective of the Emergent works, which were about how patterns emerge from complex even chaotic systems and the result is in the mind; as I wasn’t channelling Richter, I think of these now as exploratory rather than end pieces.

Where I think I’m going

The critiquing has helped me reflect on the purposefulness of what I’m doing, rather than just pushing paint around. This led me to look anew at the way I went about thinking through what I paint. A number of ‘trajectories’ emerged from this reflection of which two are for review submission.

The first trajectory for want of a rubric, I’ll call Fields: What I did was replace geometric shapes with more gestural ones, gave the shapes more room to breath, and did not cover the surface with a colour overlay. The results capture space more materially than in previous work where everything was under layers of glaze. These are giving me a way of bridging to Sumi-e (and more Zen), through ambiguity and simplification. What had been a block to overcome was the boundaries of the worked surface. Colour is now more challenging, as I’ve usually mixed on the surface so need to see how this works procedurally so colours lack subtlety at this stage. I suspect I’m rediscovering something already in the aether, but is usefully challenging the starting points I had when I entered this programme, so I am not where I started, which is good.

The second trajectory is about Framing: I took Missing Shade of Blue from the last round and reworked it. The piece is more documenting this than a final piece as I need to think on this further. I have done a lot of paintings where they are layered using tape to cover areas that get painted over, then removing the tape. The tape in this case sharpened the framing and the shades of blue, which are randomly covered with thin paper. This is more structured and perhaps a polar opposite to Fields. I think this might help me explore the unstretched/unprimed canvas creating painted tapestry, and introduce fabric considerations more.

Where I have been

Artistic journeys this period included visiting Domaine de Kerguehennec in Brittany for an exhibition of Anne-Eva Bergman, “l’Atelier d’Antibes 1973-1987”. Her focus was on abstract landscapes, drawing on her Norwegian upbringing. This proved insightful as I grew up with big skies and land all the way to the horizon with nary a building in sight. I liked “Vague baroque” for its surface treatment and restrained colour.

 

Bergman, “Vague baroque”, 1973

I read “Thinking Through Painting: reflexivity and agency beyond the canvas” (written a few years ago but I just came across it) which explores, inter alia, the view that painting is dead. Parts of the book are written in ‘that’ style that often leaves referents free-floating, but the authors did seem to understand that this obscurity was a problem, though that didn’t stop them from using jargon. That aside, though, two thoughts arise. Is Painting Dead made me think of Francis Fukuyama’s claim that history is dead, in light of the end of the cold war and the apparent success of liberal democracy. Given the events of today, it is hard to image what evidence would support that claim today. The same for painting as it feels to me like a dilettante-esque assertion said more for effect than the evidence base it can draw upon.. Isabelle Graw in her essay does offer a definition of painting as: “a form of production of signs that is experienced as highly personalised”. My view is that Merleau-Ponty’s work is more relevant here than the authors’ attachment to critical theory and all its baggage. This definition does at least put art into the cognitive experience of the maker and of the viewer. The notion of painting as quasi-persons may not withstand scrutiny: objects such as paintings seem autonomous because of agency and indeed meaning attributed to them either by the artist or the (informed?) viewer; they become autonomous from a social process where they become iconic and thus stand on their own. But not all “art” is Art.

The other thought had to do with the commentary, in an eschatological context of Tuymans’ Gaskamer. The point, in the context of this painting was of the impossibility of representing some things. Can this be true, I wondered? If something can be thought, it can be expressed (verbal, musical, visual). That one may not know how to do it is irrelevant. And that one may feel an impulse that representation is strictly not possible seems more about arbitrary limits (censorship, political correctness) than human cognition. At the time I was thinking about this, I saw the film Denial, the court case between David Irving, the author of books on the holocaust, and Penguin Books (Deborah Lipstadt the author). There is a scene in Auschwitz when the lead barrister for the defendant is walking around one of the collapsed gas chambers and is seen by the Lipstadt character as not suitably reverential. He makes the point that this is a crime scene; for the defendant it is something else. As art then, such representation depends on context which supplies the basis for meaning; despite what some may wish, all that is solid does not melt into air. In the end the precision of the legal case which demonstrated that Irving lied, is balanced against the defendant’s belief that the proper representation is through survivors’ stories which in the end says that depiction is possible and can arbitrary expression.

The Turps Diaries: March 2017

With respect to the two works on paper; while ‘colourful’ they are in retrospect unsatisfactory when compared to others with a better relationship of elements, and I fear they are too murky and ‘mute’. In respect of your comments on the painting “Investigation of an idea…”, I’m reworking it to tighten the composition.

I went back to my tapestries and art photos, and considered your suggestion to be more dimensional. I spent some time experimenting. I made some colour cards and considered how this might work, based on David Hume’s ‘missing shade of blue’ problem on how we perceive a gap in a continuum of colours (a bit like the link you provided, but I’ve tried to ‘abstractify’ it). Broadly, not pleased with the results but have included the process in the Journal notes for this period. I’d welcome further thoughts on dimensionality.

I also wonder about scale; I have a great big roll of canvas and I’m keen to paint on the unstretched canvas and hang the paintings more like tapestries (a la Frankenthaler and unprimed canvas). I find it odd to conceal the canvas texture; with paper and wood panels I integrate the surface texture into the painting. Any thoughts on this?

Experimentation

The mentor made suggestions about dimensionality and working paper differently. I tested this out in an experimental sequence, beginning with simple layering of torn paper, to cut cards, applied as suggested as ‘paint marks’. These are fun to do but were not satisfyingly expressive.

Need to think about whether this is a direction I want to mine further.

 
Exp 1: Torn and layered Xuan paper. Japanese black ink and acrylic red ink. ~40 cm x~50 cm x~1 cm Exp 2: Exploring colour layering. Japanese watercolour on Xuan paper. ~20 cm x~20 cm x~4 cm Exp 3: Torn Xuan paper, Japanese watercolour; glued down, raised ridge down the middle. 30 cm x 40 cm
Exp 4: painted cut paper to interpret ‘missing shade of blue’, 30 cm x 30 cm Exp 5, with additional layer, 30 cm x 30 cm Exp 6. Final experiment, paper, oiled paper overlays, acrylic. 30 cm x 30 cm

Reflection

I found the suggestion to alter the shape of the paper interesting. I have tended to use full sheets of paper and have done work that is differently shaped such as vertical ‘landscapes’. I did a series of paintings on paper that were folded vertically and designed to fit into the corners of rooms – corner art – but framers had a fit.

The comments also made me think of the film “Off the map”, which features a 40 foot long watercolour (Stan Berning in New Mexico did the painting). The film intrigued me to think of a painting emerging as a whole over time; I did a painting a month for a year in a bound book of handmade paper, telling a ‘story’ over the course of that year, with fabricated lettering (bit like the Voynich manuscript).

One of my early explorations was with torn paper, and I have thought how to blend paper and tapestry technique. I did a series based on Fibonacci ratios, and used that to build up layers of images. This was an early exploration of tapestry-type approaches to the painted surface. Here are some examples.

Fibonacci Fibonacci Fibonacci (sold)

With tapestry, I have done free form shapes (Breastplate), and object-as-loom (Adz). I find it interesting that paintings are done on a woven cloth surface that the artist often goes to great lengths to make invisible, so I took one of Kelly’s paintings and embedded it in a fabric/tapestry structure. (The Idea). Tapestry was enjoyable but tough on the back and even with two looms on the go it was very slow…..

Breast plate, wool, silk, ~30 cm x ~30 cm Adz, wool, cotton, watercolour, wood, metal, ~15 cm x ~15 cm The Idea (embedded interpretation of Kelly, “Red, Yellow, Blue”), wool, cotton, ~60 cm x~100 cm

 

The Turps Diaries: January 2017

Following the 1st review, I’ve started a Turps Journal where I’ve addressed issues in more detail, with illustrations, your comment about origins of work. I am mindful, as you noted, to avoid narcissistic starting or end points; it seems the way out of that rabbit hole is actually the notion of sunyata (emptiness).

In November, I viewed an exhibition of Avant-Garde, and had a short time to view an exhibition of Japanese expressionism in the 1950s and 1960s at Bozar in Brussels. I have also just seen an intimate exhibition of the Guggenheim abstract expressionists (ING Art Centre), which took me much closer to artists such as Frankenthaler, Mitchell and Francis (what a way of seeing!)

Two paintings so far from the first two shows: “Investigation of an idea under suspicion” was done very much in the moment, built up in layers (4 colours were used) and is more spontaneous. “Emergent” is testing the boundary between finished and unfinished, through the notion of emergence. Looking again at Investigation, following the ING show, I think I need to leave more white space for the images to breath and be less bounded by the surface itself.

Investigation of an idea under suspicion Emergent

Your comment on measuring success struck home. Abstracts are in some respect always failures or at least approximations of the ideation; getting it ‘right’ in some sense is impossible, at least empirically. But perhaps no one notices apart from ourselves, as each piece is itself an abstraction in the way to the next. This makes me more comfortable with the pieces that I think don’t work, but makes me wonder how to better integrate the process from one to the next: I tend to do one piece at a time, and if the idea holds, then a couple more emerge; should I think more in a series?

I have thought further on abstractions that use science as a starting point, as apart from, say introspection. The bonding of the subjective and empirical will never be a happy one, if all an artist is doing is visualising scientific phenomena, rather than what they mean. For instance, what is the visualisation of the physicist’s view that reality is made up of “fields”? This is to draw a parallel with Cubism and Relativity Theory. Conceptually, the two pieces I put up on Private View (sfmuto technique) is each a 3D painting (surface and layers) and the image is more how fields produce the phenomena we associate with the real world and which scientists study.

I read Kantrowitz [http://www.andreakantrowitz.com ] “The man behind the curtain, what cognitive science reveals about drawing” (J Aesth Ed, 45(1)2012: 1-14). This has helped influence my perceptions and no doubt will influence practice.

On origins

Few of my works arise in a linear process from sketches. Instead, a sui generis approach achieves a degree of disintermediation of the creative process, using the first marks as the starting point (in the sense of De Bono, it doesn’t matter where you start as long as you start).

I often find photography a helpful prompt; photographers such as Edward Burtynsky and Andreas Gursky have photographed scenes from high and distant perspectives.

     

Gursky: Montparnasse

Gursky: Rhine II

Burtynsky: Salt Pans in India

Montparnasse conveys urban isolation. It is anticipated that the bulk of humanity will live in cities in the future. This is not something necessarily to be celebrated, though. I did a sketch looking at the wall of Toronto building lights from my hotel room; I used to live in Toronto, so the city is familiar.

 

Skyline sketch

In the City 1

In the City 2

In the City 3

While the gridded type structure did not end up on the paintings, I took a perspective looking down, to capture the immensity and isolation. I put in little red marks for figures, but in hindsight, think they would be better left out. One of the paintings was chosen for the cover of a local magazine, which I thought odd, given my area is quite rural.

In Rhine II, Gursky shows the strong lines in the landscape. I painted a series “Six view of Dungeness” with that imagery in mind, but no sketching.

3 of the “6 Views of Dungeness”

Ellsworth Kelly did plant paintings throughout his life, and which were broadly ignored; however, they are seen as a significant creative source. For Kelly, they offered him a “bridge” as he called it to his abstraction. After the fact, it is much easier to explain, but how does it explain the here-and-now for him? I suspect they were to him a type of ‘found moment’, without antecedent which is important to understanding how he then approached the plant itself. By pruning the plant to the immediacy of his cognitive experience of it, I think he found a way that allowed him to empty his mind of ‘ego’ and self-aware cognitive processes, to get to the unmediated experience of the plant. The progression from that to a particular abstraction may not be direct, but it is the same mind at work.

I explored this process in the sequence below, to the level of something broadly representative but have not progressed to using this to do anything that would be an abstraction in a meaningful sense to me..

Sketch

1st extraction

2nd extraction

     

Plant sketch en plein air

Watercolour sketch, paper

Acrylic on 50×100 cm canvas

I explore many ideas using Sumi-e technique as it helps me explore the here and now, and freer expressiveness. They are not really something on the way to something else but stand for themselves from which I get ideas for other pieces. These examples are all about 30 cm on a side, but I have sheets of Japanese paper up to 2m in length to explore when I’m feeling more courageous!

         

Japanese ink on rice paper

Japanese ink on rice paper

Japanese ink on 300 gsm paper

Japanese ink on rice paper

Japanese ink on rice paper

On exhibitions

The visit to Bozar in Brussels was useful in two respects. The Japanese expressionists presented works that were more gestalt in nature (all over abstraction). Mixing the paint on the wood with paint scrapers, I used more curves than I’m used to, producing “Investigation of an idea under suspicion”.

The Avant-Garde show had me asking what makes a work Avant-Garde and not something else; indeed, the demarcation seems unclear and I wondered what made the AG, apart from self-description; perhaps that is the historical point. Eliasson’s Ventilator was shown; he says it is a work viewers need to complete (co-produce); doing this is also an objective in my work. However, I found the work a bit empty in the co-production sense. If the point of AG is to make a break (rupture appears to be the preferred word) with what is taken as received wisdom, I wasn’t clear how this worked. The show positioned AG in military art, and a fascination with technology, invention, machines, as well as war, weapons, positioning them as the hinge points or watersheds; this is a particularly aggressive interpretation of the work, and may indeed exclude wider logic. I left still wondering how AG is to be played out today, despite a suggestion of apocalypse and prophecy. Is that an interesting, intelligible and even accurate proposition? I worry about claims like this lapsing into empty commentary (much of the exhibition catalogue is unintelligible). Can one really be an Avant-Garde artist any more?

The Turps Diaries: October 2016

I try to position my work in the ‘here and now’; our brains see things before ‘we’ are aware of them, so I’m trying to get at that point in my work. The locus of attention is on the immediate. This is, as you note, risking a theosophist or mystical position, but I am trying to get inside the cognitive rather than euphoric experience. I read Klee, but had not read Kandinsky. I had found Malevich’s ‘The Non-objective World’ thought-provoking.

You ask how I build a painting. I don’t sketch much, at least specific paintings are not sketched in advance and then produced like taking dictation from the sketch. I start with a mark, “I start here”, and then evolve the image. I mix on the surface as a rule. At a certain point, completeness beckons, so I stop. I think I do this partly because of time constraints with other activities. I want to get my hands dirty quickly, to engage with the materials and the ideas more directly, with as little intermediation as possible. Upon reflection, I think to sketch would remove me from the here and now. I do have some sketches of ‘ideas’, and I use my photography portfolio as well for ideas. I suppose I don’t understand the purpose of sketching. In Marion Milner’s book, ‘On Not Being Able to Paint’, she sketches in her psychoanalytical journey, but I think to no end. I used to go the Albright-Knox in Buffalo to see their collection of abstract expressionists, particularly Clyfford Still; I suppose there is a lesson in how he integrated his sketching into his primary works. [added comment 12 Nov. I had a handmade paper sketchbook of watercolours; a visitor to my studio asked if I would sell it to them which I did….]

I’ve also tried to make sense of the art/science connection. Your commentary on the illustrations was interesting. I have gone to shows at the e.g. Wellcome Trust and come away a bit underwhelmed. In Arthur Miller’s “Einstein, Picasso: Space, Time and the Beauty That Causes Havoc”, he observes that Cubism was Picasso’s way of visualising relativity theory. I don’t see in the art/science collaborations visual power of that order. I guess I’m hoping that artists will get beneath the ‘surface’, perhaps try less hard to work from the obvious scientific imagery, and grasp the underlying and perhaps more relevant dynamics. The physical world actually does not exist but is made of fields; we just think the table is solid.

While I like the early art, right back to the cave paintings, I am moved by the abstract expressionists, and see relevance as a mode of thinking rather than a ‘style’ or an ‘era’. It is just the historical bit in between that I understand less.

You observe that I use a variety of approaches. I worry that this shows less commitment to a particular form of expression. How do artists balance the authenticity of their own endeavours to explore, with work that expresses their personality if methods keep changing, or is that just me worrying it is a weakness?

You wrote: “It may be particularly important in view of the fact that you are engaged in an ‘abstract’ (for want of a better word) idiom. Since abstraction does not directly reflect (or maybe it is better described as directly copying) the ‘nameable’ world around us, there is an imperative for a cogent thought process to drive the visually creative side: To work objectively from the concrete world around us puts certain demands on how we make work, how we measure its success or otherwise. With abstraction though the demands are not external and that means we have to establish our own set of exigencies.”

That made me think about the comprehensibility of my paintings and whether they were ‘successful’. Kant has a term, ‘ding an sich’; I want my paintings to be the thing itself, but while not about a nameable reality, they are about one with referents and meaning that can be known. I would not want my pieces to be mute (or indeed have that “Narcissistic echo of self-reference”). I accept that the painting itself is an object distinct from what it depicts.

Taking all that together, I’d propose that in the TURPS course, the challenge is to identify my set of exigencies, understand the visual lexicon I’m using and how it might evolve, and produce art from that learning.

The Turps Diaries: introduction

Between 2016 and 2017, I participated in a distance-learning mentored programme to improve my painting. The course is offered by Turps Art School in London. I had to submit a portfolio to be accepted, along with about 40 other painters from around the world. I was thrilled to be involved and kept a diary which I’ve now posted to my blog.

There are 5 review periods, and I’m only sharing my own comments until I secure permission to post the comments of the mentors.

UK and the EU: Brexit as failed ideology

Dr Tim Oliver posted on the LSE Blog a thoughtful item on the various ways to understand the negotiation structure of Brexit [link to item]

He puts forward four key ones, and what I want to do is briefly comment on each.

Neoclassical Realism: This is about power relationships. The UK’s position within the EU has been weaked  as a naysayer of much of the European agenda. Externally, it is a full member of the UN security council and a member of NATO but both of these are immaterial to the Brexit outcome. As a card to play, they carry very little weight in negotiations as for the UK to abrogate its security responsibilities or use them as a bargain chip would actually signal weakness. In response, NATO would see the UK as an unreliable partner who would trade collective security for self-interest. As a global power in its own right, I suspect the evolution will be continuing geopolitical decline and loss of global influence. While we may see new alliances, for a realist, the international anarchy of inter-state relationships will become a factor in dealing with the EU and the UK will be the weaker for opting out of power relationships, for a delusional view of national power.

Constructivism: This is about norms and rules. The Brexit leave logic is that the UK can forge new relationships more productively outside the EU than within. Trade is a proxy for the power of nations to abide by norms or construct rules. As a nation among many, trade migrates to the larger blocs and the single actors take what they can get. The UK will become a rule-taker outside the EU. The test will be the deal with the EU. If the UK can’t agree a good deal with the EU, that would signal the UK can’t be negotiated with unless they get their way. This is of course silly logic at one level since the UK is leaving a trading bloc where it was a rule maker. Only fools and deluded politicians believe rule taking is preferable.

Bureaucratic politics: This is about the behaviours of bureaucratic systems. The UK has viewed the Brussels bureaucracy in some respects as a distraction from domestic affairs. The EU relationship was managed through the “Foreign and Commonwealth Office”, a strong clue on how the EU was viewed (viz. foreign). In terms of civil servants building careers, postings in Brussels were not seen as career enhancing (unlike working for the Home Office for instance); this led to very good individuals pursing careers at the Commission to the detriment of their domestic career progression. Indeed, expertise in European matters was frequently dismissed. This sorry state of affairs of course played out through the removal or departure of key individuals with expertise in European affairs. That they might have gone ‘native’ is a concern all governments have and is one reason diplomats are routinely rotated. But the EU requires deep expertise both because it is a unique body of law but also because the UK was a key actor in that system. I suspect that the current negotiations are being handled badly partly because the UK team lacks the ‘native’ understanding; this may explain why the government is afraid of civil servants with strong EU views; like Orwell’s 1984, this doesn’t fit with the mind set in government. The consequence is more about failure for the UK from incompetence than from bad bargaining.

Cognitivism: This is about ideas and mindsets. The UK has seen the EU as simply a trade arrangement, consistent with years of free trading. The EU sees itself as an idea, in the same was the US sees itself as an ideology. There is nothing wrong with that. The weakness is the UK sees itself defined through trade and not as a national idea called the UK; indeed it not sufficient to argue the UK’s ideology rests on notions of sovereignty and taking back control as this flies in the face of the fact that all nations are constrained by treaties of one sort or another should they choose — what Brexit does signal is the UK can abrogate a treaty obligation and may be prima facie unreliable. The Brexit debate has shown how poorly prepared the UK politicians on the government side are, and who actively avoid discussing the social dimension of the EU — indeed look very uncomfortable discussion the rights of 3 million EU citizens within the UK. Social Europe is made up of academic networks amongst research institutions, or families brought together across borders, of young people experiencing another culture through Erasmus exchanges, even of duty free wine and beer, freedom to travel, enjoying the security the European Health Insurance Card brings and so on. As an ideology, the UK dismisses this as a ‘project’ and emphasises that all things about money matter more than people. Barnier and colleagues emphasise the primacy of people. This is consistent with the ideological basis for the EU’s bargaining position. The result is incomprehension by the UK of the EU position, while the EU knows the UK position well as it has played out over 40 years of opposition to social Europe.

From a decision making perspective, I concur with Oliver that each in some way is being played out. The salience of the various issues is rising for those who voted in the referendum and showing the problems that were indeed well-known beforehand, by experts of course. But rising public salience will constrain politicians’ actions as technical issues evolve into political ones. For instance, cross-border access to healthcare (1708/71) is full of technical details, but the public salience will be loss of healthcare when they travel. The departure of EMA from the UK looks like a technical issue of moving offices, but its salience lies in drug companies deprioritising the country for launching new medicines, with possible diminution of research infrastructure. Inside each technical issue that can be hammered out by civil servants, lurks a political issue that can only be resolved through public discussion.

What Cognology would say.

Intelligent application of game theory in complex areas such as Brexit would have revealed that perhaps there are/were more options than assumed. The driving anti-intellectual logic of “red lines”, which signalled boundaries within negotiation, is always a bad thing. In the case of Brexit, it probably guarantees a bad outcome at least for the UK. I think smarter negotiating would have done a better job early on modelling or gaming the likely scenarios. What we are left with is political egos, hardly something noted for intelligence.

Intelligent medicines optimisation

A central feature of any high performing healthcare system or organisation includes best practice in medicines use and management. As all aspects of healthcare are under varying degrees of financial stress these days, cost controls and appropriate use of medicines must support the highest standards of clinical practice and safe patient care.

Medicines optimisation is one strategy as the use of medicines influences the quality of healthcare across the whole patient treatment pathway.

Failure to optimise the use of medicines across this pathway may arise from:

  • misuse of medicines (failure to prescribe when appropriate, prescribing when not appropriate, prescribing the wrong medicine, failure to reconcile medicines use across clinical hand-offs;
  • “clinical inertia” and failure to manage patients to goal (e.g. management of diabetes, and hypertension post aMI) [O’Connor PJ, SperlHillen JM, Johnson PE, Rush WA, Blitz WAR, Clinical inertia and outpatient medical errors, in Henriksen K, Battles JB, Marks ES et al, editors, Advances in Patient Safety: From Research to Implementation Vol 2: Concepts and Methodology), Agency for Healthcare Research and Quality, 2005];
  • failure to use or follow best-practice and rational prescribing guidance;
  • lack of synchronisation between the use of medicines (demand) and procurement (supply), with an impact on inventory management and
  • loss of cost control of the medicines budget.

The essential challenge is ensuring that the healthcare system and its constituent parts are fit for purpose to address and avoid these failures or at least minimise their negative impact.

Medicines costs are the fastest growing area of expenditure and comprise a major constituent of patient treatment and recovery.

The cost of drug mortality was described in 1995 [Johnson JA, Bootman JL. Drug-related morbidity and mortality; a cost of illness model. Arch Int Med. 1995;155:1949/56] showing the cost of drug mortality and morbidity in the USA and costed the impact at $76.6 billion per year (greater than the cost of diabetes).

The study was repeated five years later [Ernst FR, Grizzle A, Drug-related morbidity and mortality: updating the cost of illness model, J Am Pharm Assoc. 2001;41(2)] and the costs had doubled.

Evidence from a variety of jurisdictions suggests that drugs within the total cost of illness can be substantial, for instance:

  • Atrial fibrillation: drugs accounted for 20% of expenditure [Wolowacz SE, Samuel M, Brennan VK, Jasso-Mosqueda J-G, Van Gelder IC, The cost of illness of atrial fibrillation: a systematic review of the recent literature, EP Eurospace (2011)13 (10):1375-1385]
  • Pulmonary arterial hypertension: drugs accounted for 15% in a US study [Kirson NY, et al, Pulmonary arterial hypertension (PAH): direct costs of illness in the US privately insured population, Chest, 2010; 138.]

Upward pressure on the medicines budget include:

  • medicines with new indications (be careful, some of this is an artefact of drug regulation gamed by manufacturers)
  • changes in clinical practice which has an uplift effect on medicines use (especially if guidelines are poorly designed)
  • increasing the number of prescribers (keep in mind that prescribers are cost-drivers)
  • medicines for previously untreated conditions (this trades-off with reduced costs in misdiagnosis, mis-/delayed treatment)
  • therapeutic improvements over existing medicines, and
  • price increases (think of monopoly generic manufacturers, for instance).

Downward pressures include:

  • effective procurement methods (e.g. avoid giving winners of tenders ‘the whole market’ and ensure that rules enable generic competition)
  • use of drug and therapeutic committees and drug review processes (it is all about knowing where the money goes for improving value)
  • use of prescribing and substitution guidelines e.g. generic substitution (oh yes, enforcing it, too; it also helps to ensure OTC medicines are not reimbursed by insurance as this adds to competitive pricing pressure and improves patient choices)
  • positive and negative hospital formularies (yes, hard choices)
  • pro-active clinical pharmacy services engaged in both business and professional domains, (this means ensuring the expertise of pharmacists are central to decision-making) and
  • reduction of waste (you don’t want to know how much drug waste there is but estimates are up to 30% of expenditure is waste).

Additional sources of pressure in either direction come from:

  • population case-mix (that means paying attention of the health of the nation)
  • changing prevalence and incidence over time (also paying attention to the determinants of ill-health, particularly avoidable causes and effects by age cohorts)
  • performance and efficiency of clinical workflow across the patient pathway (this is where money gets wasted at light speed and where it can also be saved; clinicians are in control of workflow so engaging them in areas where they can make a difference matters a lot)
  • medicines payment and reimbursement practices including patient co-payments where they exist and the structure of hospital budgets or financing, (do we want to discuss the unintended and perverse consequences of the payment system?) and
  • healthcare system regulations (yes, where many problems are caused in the first place).

What Cognology says.

Many of the drivers of problems can be addressed through a combination of professional staff development, better use of information, particularly within decision-support systems to support guidelines and prescribing compliance, and organisational interventions.