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Integration of healthcare and social care

The direction the NHS is now taking is evidence that some aspects of NHS performance arise from fundamental design flaws.

The mistake was likely made in 1948 to separate healthcare and social care. Today, as care processes shift into the community and the early forces of consumerisation in healthcare emerge, the underlying separation logic is unworkable.

Unfortunately, tax funded healthcare and cost-shared social care (coupled with split jurisdictional authority) have proved to be an administrative and financing nightmare, but more importantly a complex disconnected experience for patients. While Beveridge had a good idea, its execution has proved to be seriously flawed (it was even based on the unrealistic promise that costs would go down). In contrast, the social insurance model bundled health and social care from the beginning and we can see that it produces better care integration and outcomes. Indeed, countries with direct access to specialists appear to have better oncology and cardiovascular outcomes. There may even be evidence that gatekeeping may be causing access problems and delayed diagnosis (up to 1 year for ovarian cancer, and 2 years for neurological disorders, plus more….); proposed changes here are upsetting the BMA which opposes direct patient referral for oncology testing. One wonders what they fear that other countries don’t.

Patients and users of the NHS have no ‘skin the game’ because they lack the ability to exercise choice directly to influence quality. Proxy measures are used instead to achieve this and draw on the standard NHS ontology of committees and panels and senates and similar decision processes. Any student of such systems would know that such proceses are invariably excuses for inaction and may simply act to protect vested professional interest groups through those who sit on them.

The Greater Manchester approach is in the spirit of service integration and could lead to better quality and care, but I fear it will simply replicate the complex administrative and bureaucratic overhang that bedevils the NHS itself. In the end, it may only be redistributing resources without real service delivery innovation. Of course, if they were to replicate the Swedish approach, then perhaps there might be light at the end of the tunnel, but the funding model is wrong for that.  Simply lumping things together requires the creation of coordination systems, which will, in the end, direct managerial attention to the performance of the coordination system, and not on quality, service delivery and patient care. Keep in mind that only the patient has direct experience of the care pathway, and where it fails to integrate.

However, I have no problem with decentralising and localising services and doubt the word “National” also meant uniform services at the lowest common standard; such thinking has led to mediocre service quality, unacceptable waiting, delay and political confusion. Excellence should be allowed to flourish as evidence of how good care can be; unfortunately, localised excellence is often rubbished and characterised as post-code lotteries and multi-tierism, and ends up being used as political hay to undermine innovation.

Healthcare: an election football

Political manifestos that promise to spend more money are failing to grapple with the powerful underlying forces at work in healthcare. Indeed, they may be ignoring these in order to score (cheap?) political points with voters.

There is clear evidence of failure to use good practice, of time-wasting clinical workflow and excessive political and bureaucratic overhang. Granted the UK state (in its components) is justified seeking a form of accountability for the vast expenditure of public money, but this does not necessarily entail control of how the money is spent and this particular debate is questionable given the performance of other countries’ health systems (e.g. the Dalton review). Historical evidence would show that public control of expenditure in many areas leads to “rent-seeking” behaviours by public servants at the expense of service quality.

Governance arrangements such as proposed at Greater Manchester look little different from the NHS as a whole and I fear will lead to excessive wasteful bureaucracy at the expense of front-line service quality (seen from the patient’s perspective not the bureaucrats).  I wonder if they will achieve the same degree of performance as the Swedish county councils.

The power shift that is underway in healthcare, with its consumerisation through digital technology, publicly accessible performance information, and priority on value-for-money (which are not bad things) wrong-foots policy positions that seek to exert the role of the state at the expense of individual patient control and choice. And going forward, it is hard to justify disenfranchising patients from control of their healthcare when so much of their lives is under their control.

Whole Person Care as a Labour political slogan may play well in the press, but creating it requires thinking about how whole systems of care integrate and this will challenge the dysfunctional fault line running through some parties’ politics on the role of the private/independent/voluntary sectors.

This thinking is absent (at this stage) from the Greater Manchester MOU, meaning the capacity of the private and independent sectors is not included in their total health system capacity planning. But failing to grasp the needs of other than NHS organisations is not limited to this, but extends to workforce planning, which must also satisfy the needs of the private sector across a wide range of workplace settings. One may not like private healthcare, but it is irresponsible to ignore its existence.

We know that quality may be poor and performance reporting and information virtually impossible to obtain from private providers but there are reasons for this. From the position of a patient, NHS commissioners should be agnostic on the fitness of a provider and this would have the benefit of integrating care and quality across the patient treatment pathway and incorporate all possible sources of capacity and service delivery. It is the failure to normalise the role of the private and independent/volunteer sectors within total health system capacity that causes considerable fragmentation to patient care, and contributes to political posturing on the back of patient care. It would be wrong to assume failure is unique to the private sector and no political party can ignore the failures of the NHS (Bristol, Mid Staffs, and so many others).

In part this has been caused by the Department of Health traditionally insulating NHS providers from quality reporting and the consequences of failure. All governments have a problem to imagine the failure of publicly funded organisations (in any sector), but they do happen and require serious action to fix. Regretfully, there is evidence that local authorities exhibit the same behaviours.

In the end, the disinfecting light of public scrutiny is the solution, not more money. The NHS still avoids formal provider accreditation, instead opting for a (complex and troubled) inspection system through CQC which only now appears to be understanding the importance of provider failure — but failure in a complex care system is about people failing to act, of systems that are dysfunctional, and yes, driven by a focus on wrong-headed targets and a focus on pleasing political masters.

Want to know more?

On the quality of private care, this report is useful, but flawed: Centre for Health and the Public Interest, “Patient safety and private hospitals” in August 2014

Health Literacy and E-Health

Health literacy is moving up the political agenda at the European level, and the hope as always is that the direction of travel is truly empowering for citizens.  Having been involved in launching the world’s first digital interactive health channel for public access, in the UK in 2000, one thing I learned is not to assume that everyone is alike, that people make choices and that services need to respond to these choices. I also advised the Council of Europe on work on patient access to information over the Internet.

Much energy will no doubt go into health literacy, but there is little understanding of patient empowerment apart from the use of the words themselves. Health literacy, too, sounds like we ought to know what it means but when dealing with organised provider interests and risk aversion by public funding bodies, caution is required.  Much energy has already gone into e-health, with little services for the public to show for years of research and pilots. So we have a weak starting point.

Healthcare systems are poor doing what retailers take for granted, namely the segmentation of their users so they can create a range of service offerings that meet a broad range of people. Compare your hospital to Carrefour. When we launched the digital interactive TV channel, we worked with a simple framework drawing on work by the California HealthCare Foundation, “Health E-People” report. This helped us understand that there were different types of users with different needs, and that in developing content and services we needed to be mindful of this; we also conducted the first and most comprehensive ‘audience user study’ of the British health consumer ever undertaken, using media models to understand how people sought information, what they wanted to use it for and what the barriers were to its use for them. Recent work by the Pew Internet Project has identified the “9 Tribes of the Internet”, which has usefully taken our understanding into population segments based around how people use mobile and Internet-based technologies.

Many of the assumptions of literacy will focus on how people use health information in various forms.  But the wider use of technology, including wireless devices, is seen as a critical element of the future of healthcare.  So I have combined these two taxonomies to identify what I think are the key health literacy challenges for the 21st century for e-health.  I have only sketched out some relationships in the table below (it is not complete as this is a blog entry not a full blown report) but it gives an overview of the sort of considerations that are important.

There are also lessons for policy makers and people concerned with health literacy:

1. Eventually, the individual will have to own their own health record, and decide what to do with the information in it, with whom it get shared, and those who use that information will be accountable to the patient for the use of that information. Health literacy also requires control otherwise there is no reason for me to be engaged — others will help me if I get into trouble. The table below shows that some people will have trouble with this when technologies are a key element.

2. Not everyone will be digitally enabled. This is NOT a digital divide and is NOT evidence of social exclusion, but is a personal choice of people to lead their lives as they wish in a pluralistic society; this is hard for some policy makers to understand and the term ‘social exclusion’ is frequently used without an appreciation of personal choices. The key implication is that services will need to move very slowly to adopt technologies with some types of people. In time, perhaps people may adopt low level access and interactivity, but for many people technological interactivity will remain at best an option not a preference. Perhaps in some future world things may be different, but even today many people do not adopt common technologies, and with rising concerns about energy use and changes to personal lifestyles, we cannot assume the emergence of a uniform technologically based society in the next 5 years.

3.The benefits of technologies in the traditional health technology assessment model will need to pay much greater attention to the segment of the population likely to be involved as their distinct patterns of use and preferences suggest that a one-size-fits-all approach would never work. This means that designing and implementing e-health services, and other health technologies will need to be far more flexible when it comes to the structure of service delivery. This is hard for health systems to understand as they work on the basis of uniform service delivery, paying little attention to unique local or individual requirements. It is a provider dominated environment, not a consumer-centric one.

4. The tribes model suggests that even within health service organisations not everyone will necessarily buy into the technology revolution. Many people work in healthcare precisely because they want to have personal contact with people, and not through intermediating technologies. Since many patients also would have that preference, organisations may need to structure services and staffing to ensure the right mix of people service the public.

5. The great challenge of patient compliance, concordance, adherence (whatever the current term in vogue) may become more dependent on the features of the technologies, their design and ease of use, than on the willingness of the patient to follow a particular care regime. Helping people understand their limitations in using and working with technologies as matter of personal preferences will become very important, which increases the focus on personalisation of healthcare. Similarly, device designers and makers report they see their customer as the doctor (yes, just the doctor) as they specify what technology the patient uses; they do not see patients as customers, and therefore, may need to be encouraged to design technologies that patients and informal carers may use. There is a design revolution waiting here! (where are you Philippe Stark?)

The current approach to health systems in general, especially where the state is the main source of funding, leads to omnibus systems of service delivery, which largely ignore individual preferences — it is a system truly structured to favour provider interests. It would be a mistake to assume a similar approach with e-health and similarly with health literacy. Instead, we should be encouraging approaches which are sensitive to the preferences and usage patterns of individuals and which accommodate to their different literacy styles. In this way, too, we may actually see ehealth services being offered that people will value and use. And that will be a reason for people to become more health literate.

The 9 Tribes of the Internet
(% of US population data)

What each tribe wants from technology

Type of Health Person and their specific health expectations using technology

The Well

The Newly Diagnosed

Those with Long-Term Health Conditions

Digital Collaborators (perhaps 8% of population): always connected through broadband or wireless

a place to jack into the grid

tools for collaboration

want to be involved in experiments to enhance grid services

expect access to health information

symptom-checking and self-diagnosis

smart devices (e/m-health)

access to other people like themselves through social media

mobile and telehomecare in the smart home

expect electronic prescribing, test results, electronic appointment booking and access to their health record

expect email/text based links with care providers as a normal feature

Ambivalent Networkers (7%): use mobile technology selectively, but feel obliged to be connected

need help navigating information overload

may be non-compliant with services that are only digitally provided

offer choices between traditional and technologically enabled services

Media Movers (7%): engaged in sharing content online; but it is not about creativity or personal productivity

offer help to share their ideas, creations and content

offer social networking and opportunities to make connections

access to health information resources, directories and ability to personalise

access to social networking like-minded patients

opportunity to connect quickly and drive content

grid-based communities, and opportunities to drive content

Roving Nodes (9%): actively use mobile devices to organise their social and work lives

help them be efficient, especially as a parent as the majority are female

offer technologies that help them check up on things, particularly using cloud technologies

expect electronic prescribing, test results, electronic appointment booking and access to their health record

symptom-checking and self-diagnostic services that are very user-friendly

use push alerts and reminders for medicines, appointment, treatment plans

provide service options that do not require users to be adopters of the technologies but only of its functionality

Mobile Newbies (8%): really like their mobile phones, but don’t use internet much

offer how-to and coaching material

offer technology support

provide pathways to make finding information and services easy

mobile (on-demand) health information services

offer choices between traditional and technologically enabled services

make sure technologies come with a support service

focus technological support through the mobile device, not the desk-based computer

Desktop Veterans (13%): early internet adopters are happy to work from a desk to search for and access services and information; mobile phones are used to make phone calls

offer good technology and connections

highly self-sufficient searching for services, so offer self-service options

would value tutorials to help them engage in social media

expect electronic prescribing, test results, electronic appointment booking and access to their health record

symptom-checking and self-diagnostic services

may require accessibility technologies to meet their at-home preferences, rather than mobile health

may become an adopter though as long as it meets their self-sufficiency expectations

Drifting Surfers (14%): infrequent online users and users of mobile services; use technology for basic information gathering and would be unlikely to miss loss of internet or phone

don’t force technologically based applications at this group

most likely to drop technology that is hard to use

offer traditionally structured services

make sure any technologies are easy to use, as compliance may be more a function of the technology than the patient’s willingness to comply with a care regime

Information Encumbered (10%): see no great benefit from technology in their lives and are firmly rooted in old media

don’t force technologically based services or solutions at them

help them find information, navigate to services

make sure information is organised for easy use and access and not from multiple sources (will value a single authoritative provider)

offer choices between traditional and technologically enabled services but may be non-compliant with services that are only digitally provided

Tech Indifferent (10%): not heavy internet users, and don’t use mobile phones much and generally don’t see their value

technology is seen as not having any benefit to their lives

value public access facilities if they need access to digitally based services as they unlikely to have the necessary technology

depend on traditionally organised health services in physical locations

are more likely to think of high tech healthcare as low touch, as they associate care with people, not devices

May be prepared to learn to use technology, but it must work easily, and not require special expertise, and not detract from interaction with people

Off the Net (14%): do not use the internet or mobile phone and do not possess the technology, but may have in the past, but found it didn’t offer them anything of value

traditional services are most useful

community-based activities and social venues

may be influenced by baby steps internet courses

depend on traditionally organised health services in physical locations

are likely to be reluctant users of specialist health technology devices, but if required to may have difficulty even with relatively simple procedures

are more likely to think of high tech healthcare as low touch, as they associate care with people, not devices

Want to know more?

There is more heat than light in the e-health technology area, but I have found some material useful. E-health services don’t really exist as a general feature of healthcare systems, as most are still anchored around the telephone, or simple appointment booking and some electronic prescribing.

To get you started, it helps to think not so much about technologies but what they can do and why that is important. These two European reports may be a way in, though the reports may overcomplicate. There is a tendency for e-health to be seen from a service provider’s perspective and less so from the end-user/patient perspective.

Braun A, Barlow J, Borch K et al. (2003). Healthcare Technologies Roadmapping: the Effective Delivery of Healthcare in the Context of an Ageing Society; this document has a useful taxonomy of health technologies.

Cabrera M, Burgelman J-C, Boden M, da Costa O, Rodriguez C (2004) e-health in 2010: realising a knowledge-based approach to healthcare in the EU; this document outlines some of the skills needed for different groups of people who might use e-health technologies.

NOTE: Use a search engine to fine more or email me for a short bibliography.

Forecasting the present to improve healthcare

Internet Splat Map

Real-time data with hidden patterns

I once wrote about “on-demand, real-time, location-independent” healthcare. Today, we often think of this in the context of e-health or telehealth. The essential capability behind this string of terms was to capture the way that the ‘information value chain’ (digital information technology) could influence how healthcare is delivered. An interview I gave in Euractiv added that such technologies could be productively disruptive of cozy working practices in healthcare, by shifting the focus of healthcare decisively to the end-user, and away from provider interests.

For years we have seen investment in e-health technologies, but few services, and bold statements from the European Commission on the potential of e-health to bend the cost curve down. Now everyone wants to bend the curve down; most approaches, regretfully, rest on reducing activity within existing ways of working rather than adopting new ways. One difficulty here is obviously that with disruptive innovation in healthcare, healthcare work will change and that will have an impact on professional practice — when was the last time a health profession was made obsolete by technology. For some types of surgery, radiologists may become obsolete through interventional radiology which integrates real-time radiological technology into surgery. Something to think about, perhaps.

These thoughts bring up one important aspect of the use of information technology in healthcare, the ability to understand the present better in order to use resources better. Hospitals are notoriously bad at forecasting real-time demand for healthcare. They make various predictions that demand for emergency services may follow the cycle of the full-moon (true), and may correlate with large public events, but run-of-the-mill day to day capacity and resource management treats on-demand healthcare as an emergency

There is a technique used in some areas called ‘now casting’, an effort to correlate real-time information with short-term modelling of resource use, and to anticipate short-term demand.  The European Centre for Disease Prevention and Control, in a June 2009 report on surveillance during a pandemic, includes amongst it various methods the use of now-casting. Weather forecasts are a weather model which is continuously updated with real-time data. We may also be familiar with public health surveillance and digital technology has improved the quality of our models.  But real-time techniques (such as mapping) takes us into a new realm where demand can be better understood, to avoid inappropriate queueing and service rationing. For Europe, such capabilities to track information would be important, as information, like viruses, doesn’t respect borders; and real-time information healthcare capabilities for one member state would be capabilities for all.

The problem we have is that we are generally good at looking for things we know about, but not for things we don’t know about, and therefore are unable to anticipate. So our public health pandemic systems are surveillance systems, which focus on things we already know about; they cannot identify short term changes with emergent problems — unless we are looking, we won’t see.

A robust real-time healthcare information system would be agnostic to specific issues, as it would work to identify emergent patterns, and provide a picture of the situation to enable shorter-term or immediate responses.  We aren’t yet that smart to know what to look for — people have predicted the end of infectious diseases, the end of history, the end of poverty. The advantage of digital information technology is its ability to search for emergent patterns, to correlate perturbations as potential precursors of something to come (like monitoring a heart patient at home to detect early tell-tales, so the ambulance can be sent the day before the heart attack).

The advantages would be immediate, from better hospital resource management, to tracking emerging infections, to improving the ability of front-line services to be in the right place when they are needed.

Do you have suggestions?

Comment on this post with your suggestions on areas where improved data management in real-time could both drive down costs and improve healthcare. Also comment if you are already doing this.

Want to know more?

Mapping of influenza using real-time data feeds has featured on Google; a Canadian firm also does health mapping: Infonauts.

Use of now-casting in weather is used by meteorologists; the UK’s Met Office explains how it works here.

Nowcasting consumption using Google data is here.

Here’s one from 2004! using nowcasting of air quality to issue health alerts; linking this data with hospital admissions data for, say people with COPD, might offer improved real-time responses, perhaps even an anticipatory capacity to tell people to stay indoors. A UK project does this (this link is a Wikipedia entry on the project).

On the difference between truth and fantasy

Negative prediction value in binary classification

As we search for the solutions out of the recession, toward a better future and more competitive post-Lisbon (jargon!) economy, it is worth recalling some of the dumb things people have said that has often acted as a brake on progress and change. In healthcare in particular, prediction has a big role as models of the future are driven by the relentless march of demography and various assumptions about the progress of science and technology.

Equally relevant is the meaning of policies designed to drive forward change into the future based on the advice we take from people.

Bringing substantial change to healthcare (or education or whatever interests you) can be frustrated by people, who often from positions of authority, spout nonsense.  And while the items on the list below are famously wrong-headed, other commentators have said things that did make sense (and whose advice we did or did not take, like the few who worried about cheap housing in the US), but the problem is are we are just not very good at telling the difference.

Herewith a few gems (from a regretfully much longer list sourced from various documents); we can be glad their words were generally ignored. If nothing else, the list is testimony to hubris.

  • “…so many centuries after the Creation it is unlikely that anyone could find hitherto unknown lands of any value.” Committee advising King Ferdinand and Queen Isabella of Spain regarding a proposal by Christopher Columbus, 1486.
  • “What can be more palpably absurd than the prospect held out of locomotives traveling twice as fast as stagecoaches?” The Quarterly Review, March, 1825
  • “If a train speed is more than 180 km/h, passengers will suffocate” D. Lardner, Professor at the University of London, 1850
  • “Louis Pasteur’s theory of germs is ridiculous fiction”. Pierre Pachet, Professor of Physiology at Toulouse, 1872
  • “The abdomen, the chest, and the brain will forever be shut from the intrusion of the wise and humane surgeon”. Sir John Eric Ericksen, British surgeon, appointed Surgeon-Extraordinary to Queen Victoria 1873
  • “The Americans have need of the telephone, but we do not. We have plenty of messenger boys.” Sir William Preece, chief engineer of Britain’s General Post Office, The Economist, 1876
  • “Heavier-than-air flying machines are impossible.” Lord Kelvin, president, Royal Society, 1895
  • “Airplanes are interesting toys but of no military value.” Marechal Ferdinand Foch, Professor of Strategy, Ecole Superieure de Guerre.
  • “Everything that can be invented has been invented.” Charles H. Duell, Commissioner, U.S. Office of Patents, 1899
  • “There is a low probability that we will one day master the atomic energy” Robert Millikan, Nobel Prize in Physics, 1923
  • “I think there is a world market for maybe five computers.” Thomas Watson, chairman of IBM, 1943
  • “We have a computer here in Cambridge; there is one in Manchester and one at the National Physical Laboratory. I suppose there ought to be one in Scotland, but that’s about all.” Douglas Hartree, Physicist, 1951
  • “The world potential market for copying machines is 5000 at most.” IBM, to the eventual founders of Xerox, saying the photocopier had no market large enough to justify production, 1959
  • “If I had thought about it, I wouldn’t have done the experiment. The literature was full of examples that said you can’t do this.” Spencer Silver on the work that led to the 3-M “Post-It” Note
  • “We can close the books on infectious diseases.” William H. Steward, Surgeon General of the United States,  1969; speaking to the U.S. Congress – cited in The Killers Within: The Deadly Rise Of Drug-Resistant Bacteria by Mark J. Plotkin and Michael Shnayerson, 2003
  • “There is no reason anyone would want a computer in their home.” Ken Olson, president, chairman and founder of Digital Equipment Corp., 1977
  • “Satellite TV in Britain will be a flop.” Michael Tracey, head of the Broadcast Research Unit, Sunday Times (London) 1 December 1988

And to give us renewed vigor and energy, keep in mind what these sensible Europeans said the next time you are confronted by policies that don’t make much sense:

  • “The probable is what usually happens”. Aristotle  [Policy people often have trouble understanding that some things happen despite their best efforts to exert control; healthcare systems are complex and adaptive, but does policy consider that? The world is wicked.]
  • “It is a truth very certain that when it is not in our power to determine what is true we ought to follow what is most probable.Descartes, Discourse on Method [But policies are pursued frequently with little regard for the real world and a greater eye to political compromise; I doubt Descartes would have been employed as a policy advisor today.]
  • “It is remarkable that a science which began with the consideration of games of chance should have become the most important object of human knowledge. … The most important questions of life are, for the most part, really only problems of probability”. Laplace, Théorie Analytique des Probabilités, 1812 [It is perhaps worthy of further reflection as slavish pursuit of evidence-based policies ignore the fine print that says the evidence is only as good as the research behind it and much of that has varying degrees of statistical reliability.]

On noticing and not noticing — the challenge of wicked problems

Violinist Joshua Bell att...

In Washington, DC, at a Metro Station, on a cold January morning in 2007, a man with a violin played six Bach pieces for about 45 minutes. During that time, approximately 2,000 people went through the station, most of them on their way to work. Few paid the violinist much attention, either pausing briefly to listen, or tossing money into his hat as they rushed past — he made $32.00 for that hour. When he finished no one applauded, no one noticed.  Two days earlier, the violinist, Joshua Bell, a world-class musician, had played to a sold-out audience in Boston, where patrons had paid $100 per seat to listen to him play the same music

This event raises important questions, such as whether we recognise talent in unexpected situations and perhaps more importantly, how do we notice things.  What lessons can be drawn from this for Europe?

When we think about the complex challenges we face in our society, what stops us from doing the important, rather than the merely urgent?  After all, the Washington commuters felt compelled to respond to the urgency of their travel, and failed in their urgency to notice something different.

Instead of commuters, do we have Euro-crats and functionnaires rushing past the real problems on their way to solving small, but more easily managed problems and challenges? Do we have policies and governments that grasp the urgent and unimportant but miss the urgent and important?

Addressing the complex wickedness of contemporary challenges will never be easy. They are embedded in the very fabric of our world, and indeed, much of what passes for policy frequently exacerbates these problems, by being simple-minded, linear in analytical focus, and failing to grasp interconnectedness.

This is surprising given that the one key cause of the recent (and still rumbling away) financial crisis was the tightly coupled nature of financial institutions, a closeness that meant that it was virtually impossible to insulate one area from contagion from another area.  Not noticing this tightly-wound system is bad enough. Failing to ensure that future financial systems are more loosely coupled would be almost criminal. Instead, we are probably seeing even tighter winding of systems.

But the people who failed to notice problems are frequently the people asked to solve them, but they are trapped by their lack of noticing — they would walk past the violinist on the metro on their way to the concert. Of course, they would argue that the chances of another world-class violinist on the metro is close to zero, so they don’t need to be vigilant, but of course the next thing they won’t notice is something … they won’t notice.

And we will pay the penalty for that lack of foresight, thoughtfulness and insight.

We need people who can approach the world with an open and uncluttered perspective. Such people may not behave like the people we are used to as they notice things others don’t, link things others don’t. I’m also suggesting that recruitment practices themselves may be a source of systemic policy error.

The most important job for governments, the Commission, the Parliament, everyone, is to ensure openness (what I call porosity) to the wicked interconnectedness of the world, so they can avoid reducing real-world complexity to a series of simple-minded, linear, and probably in the long term, wrong-headed policy fixes.

And one thing is certain, we need to know if we are walking past something important on our way to somewhere else.

Time to stop unpaid internships

The Treaty of Rome signing ceremony, at the Pa...

Unpaid interns taking notes?

I was looking over a list of jobs with various agencies in Brussels. A large number of these sought ‘interns’, for unpaid positions. The UK’s Tatler magazine recently had an article called The Interns: Never have so many battled to get coffee for so few.

The Tatler article puts the issue into a social context, as the only people who can really afford to be an unpaid intern are those who already have some financial backing (from more affluent parents, usually).

The longer term impact of the unpaid use of people in this way is to make it harder for people from less affluent backgrounds to get their foot on the employment ladder. And in the end, that is a loss not just for that person, but for us all and our general sense of fairness suffers.

It is now time to stop the use of unpaid interns across the European Union, and in particular its practice in Brussels where a vast army of such people go to ‘work’ everyday right under the noses of the very people who should be most concerned.

The many agencies and firms, and they know who they are, should be held accountable for the use of unpaid individuals in this way which could be seen as bordering on exploitation.

Clients of these firms should similarly beware of the implications of the use of unpaid expertise, for which the firms in the end are paid, but the benefits of which are not passed on to the interns.

And what about the interns themselves, who are exploited in this way, as they try to establish their careers? It is hardly a good introduction to the world of work.

Active steps people can take:

  1. Firms that use interns should be required to identify their use in contracts with clients and identify the economic value of these individuals and whether interns were paid or unpaid; clients can then decide whether to engage these firms knowing that some of the work will be done by people who will not be paid.
  2. Any contracts awarded by official European agencies should require an ‘internship disclosure statement’ identifying the use of interns in the work, and whether any were unpaid; this would apply in particular to reports and studies prepared by agencies for official European agencies and the Commission where interns may have undertaken research or similar work.
  3. The Member States  should consider requireing that official European organisations and the Commission do not permit the use of unpaid interns who are citizens of a Member State in any work commissioned by those official bodies from suppliers located within the European Union.

There are other actions possible, for instance to disclose workplace protection and support to unpaid individual, their care and welfare while unpaid but on company business, and so on. Careful thought will no doubt produce a productive way forward to ensure that individuals can still start their careers through internships, but do not suffer from any corresponding exploitation. We must ensure that if internships are to be of value, they actually contribute to career development in a meaningful way.

Comment on this post with your experiences  and thoughts. Or email me in complete confidence.

Hospital as Nexus of Innovation

Alex Kosmas's nexus

Alex Kosmas "nexus"

The ERRIN innovation event, The Hospital of the Future, 2 March 2010, explored the future of the hospital as a recipient of financially and environmentally sustainable investment.

The key outcome for me, as one of the moderators of the event, was the emerging view of the hospital as a major innovator within their local/regional economies.

Hospitals are both producers of knowledge and consumers of it. They in effect sit on two sides of the great chasm that separates a great idea with its commercialisation — this chasm is fondly referred to as the ‘valley of death’, and many good small start-ups go there to disappear and their potential benefits lost to society.

We may not think of hospitals in this particularly entrepreneurial manner, but perhaps within their social mandate to provide healthcare, they may be one of the few institutions that are best suited to be research translators.

There is much concern about the general poor ability of universities to commercialise their research. Perhaps we should focus our efforts elsewhere — universities are not really consumers of what they produce; indeed, they can be seen as some of the least innovative institutions in modern society, reforming slowly, adopting novel approaches to teaching as a leisurely pace, and often quite disconnected from the real challenges facing policy makers and decision-makers on a day to day basis. They were innovative when they were invented, but times change (for a take on this see Louis Menand’s The Marketplace of Ideas, reviewed in The Economist)

For healthcare, it may be more sensible to concentrate on building entrepreneurial capacity with institutions that are heavy consumers of innovation, in effect to pull the bench-side research to the bedside, rather than continue to try to turn academics into real-world entrepreneurs.

That means of course that consumers of research need to be freed up to be more innovative and entrepreneurial in order to accelerate the research translation process. Hospitals seem to me to bring together key elements to achieve that goal better than we may have realised and that therefore, the hospital of the future, starting today, should be a nexus for innovation and entrepreneurial activity.

Building confidence for Europe’s entrepreneurs

A rural shed

Entrepreneurs all start somewhere

I had the distinct honour of speaking at and participating in a panel discussion at the European Foundation for Management Development conference at Advancia, in Paris recently. An informed group assembled to hear from entrepreneurs and academics.

I was impressed with the work of Advancia and the support it gets from the Paris Chamber of Commerce. This is an important twinning of interests, and I think a model for other countries. I like institutions that enjoy considerable independence and can forge unique approaches to the challenges of the modern world. Education for entrepreneurs is a major concern and the role of Advancia is to be applauded.  I would only add that entrepreneurs also need start-up capital, cash-flow financing arrangements with banks, and of course customers keen to buy from innovators.

That Europe is often compared unfavourably to the US is unfortunate, and perhaps betrays the belief that the US gets it right while the rest of us just muddle along. My view is that Europe has unique strengths (and some worrying weaknesses) that should enable distinctive European approaches to developing entrepreneurs and supporting innovation. Rather than copy Silicon Valley, create another model entirely. I didn’t hear much about how Europe can do this, but I left the event feeling there was life on Planet Europe!

My thoughts coming out the conference are that Europe must be mindful that it not kill off small businesses with heavy-handed social regulation, that drains start-up capital.  We hear a lot of talk about jobs and employment, but small and medium businesses are jobs engines and from these small firms grow corporate oak trees. We must also be mindful that while Europeans may feel a perhaps smug complacency at holding the moral high ground on many pressing social issues, this does not help when unemployment is high, with its corresponding economic, social and personal costs.

Whole emerging industries are waiting to be developed, yet more nimble economies may indeed snatch any advantage Europeans may have.  Three sectors come to mind: 1. green and environmental technology, 2. electric vehicle technology and 3. sustainable models of industrial growth. No doubt there are many others.

The fear is that even when Europe is ahead, other countries act more quickly to create the sense of urgency needed to fund commercialisation and market adoption of new technologies and services, and once again, Europe may fail to build another global gorilla. Entrepreneurs have a sense of urgency, but systems we design to foster innovation can in the end be bureaucratic and lack timely responsiveness — we do not normally associate entrepreneurialism with the public sector.

I also worry about the need, particularly at the Commission level, to be fair in allocating grants or funding in general. Capitalism, economic development, innovation isn’t really fair and we can’t always back all the winners and ensure there are no losers. While I endorse fairness as a social good, in matters of investment of innovation, you back winners, and no one really knows which are the winners to back and certainly there is no divining rod in government funding that can accurately ensure funding goes to winners. Losers are inevitable — and we heard of important work at Advancia on bankruptcy law across Europe. We need to learn to tolerate failure if we are in the end to build a Europe fit for the 21st century and more.

Grandes Ecoles: For whom the bell tolls? It tolls for thee.


time to try something new?

Writing about health issues also means thinking about how people learn — we all want our health professionals to be highly trained and educated. We are also generally mindful that talent should prevail over privilege. Such appears to be an issue for President Nicholas Sarkozy of France and the elitist Grandes Ecoles that enable the French elite to reproduce their status and privilege.

It is with some disgust that one learns that these institutions of knowledge are fearful that their standards would decline if they admitted people from poorer social backgrounds, and this in the land of equality and fraternity — perhaps these institutions need a history lesson.

It is a tired and dated rhetoric that income and social background should be determinants of future success. That such institutions in a country with such a commitment to intellectual debate should be fearful tells us more about them, than about France, itself.

As institutions funded from public sources, perhaps even more generously than the underfunded French universities, this should bestow upon them an even greater public duty to find the best and brightest in the land.

Le Monde is undoubtedly right when they say the Grandes Ecoles have had their day. Whether it is right to merge them with weakly performing universities may not be as wise, but redefining their admission practices to better help France meet the needs of the 21st Century would seem to be a priority.

This can be accomplished. The evidence from highly selective institutions of higher learning is to be blind to social factors and sharp-eyed for the bright and talented. Perhaps the continuing decline of much of value in France comes from its ossified system of higher education, which rewards the status quo, and discourages innovation — didn’t someone say the French don’t have a word for ‘entrepreneur’?

I weep not for those who covet privilege. In the end, it is worthless currency and those who seek it will become objects of ridicule.  I can hear the bells now.