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The problem of failing NHS hospitals and a way forward

Once again an NHS trust is highlighted as having poor, if not dangerous, care. See this item in the London Telegraph.

Are the problems a result of design flaws in the way the NHS organises itself to deliver care? Some basic elements of the UK’s NHS that are relevant to the argument I’m going to make:

  1. consultants/specialists have contracts of employment and clinical duties are agreed annually in “job plans” in use since 1991
  2. doctors, once qualified, and registed with the GMC, the professional regulator, are immediately employable in the NHS; their authority to act rests on this
  3. performance improvement and clinical professional development is still work in progress in the NHS despite GMC efforts over the years
  4. junior doctors in training rarely fail and marginal clinical performance is not recognised as such
  5. the Royal Colleges act on behalf of the interests of doctors, not in the public interest as that is the job of the General Medical Council, though they no doubt would argue otherwise.

One starting point is that CQC (Care Quality Commission) inspection may identify the problems, but hospital doctors, other clinicians (nurses, OT, etc.), managers and the board have a collective duty to clinical quality. CQC is not a system of accreditation, and so failing hospitals continue to be protected from the consequences of their actions. The only options are bureaucratic and invariably political (merge the hospital with another, shut the hospital), but this does not solve the problem of failed oversight and management. There is good evidence that hospital quality control systems are weak and rigourous quantitative methods are still needed. I have separately argued that hospitals need in-house operations management capabilites to model clinical care systems, for instance — exemplary hospitals providing high quality care use data-driven analytics in improving clinical work flow and patient outcomes. The Francis report is what I would say is a ‘team hug’ approach recognising individual and cultural factors. I’ll also take a starting point that job plans are not working to uphold standards of care. Putting all this together, we might conclude that we have either the failure of hospital management systems, or the absence of the right type of control system.

My suggested solution is that the NHS should introduce a system called “privileges”, by which appointments/employment and clinical work are subject to prior agreement and degrees of supervisory quality control and oversight. This is an evidence-informed quality control system:

  1. The responsibility of clinical quality rests primarily with the hospital, not the NHS as such, and hospitals need to put in place quality systems that check the quality of clinical work. The quality of clinical work is the responsibility of the hospital Board, as advised by the Medical Director
  2. Medical job plans of NHS employment should include explicit use of privileges or contracts should include privilege as the fundamental determinant with respect to the scope of practice in these job plans.
  3. Appointments to a hospital’s medical staff would require a review of credentials, training, fellowships, previous work undertaken by a medical committee with a recommendation to the Medical Director (and then to the Board, which would be the body granting privileges).
  4. The privileges system would introduce a system of control over what clinical work the individual doctor is recognised as qualified to do (say knee surgery but not hand surgery)
  5. Changes in what a doctor has privileges to do would require the doctor to produce evidence of specific training to establish their ability in the required area.
  6. All new medical appointments, regardless of their total time practising since being licensed, would be supervised in their first 6 months to a year, by a senior colleague acting on behalf of the hospital. At the end of this probationary period, privileges would be confirmed.
  7. Privileges are not forever, but are reviewed for substantive changes on an ongoing basis, and fundamentally reviewed every so many years.

I like the idea because I’ve worked in a system that used privileges, where I’ve seen how it acted to improve clinical quality and worked to the benefit of the doctors themselves. It brings order and structure to clincal work within the hospital by better aligning case mix with skill mix. New hospital appointments would be supervised, while monthly notices kept all clinical staff, importantly nurses on the wards and in the operating theatres, up to date to changes in privileges (who had an area added, or dropped).

Interestingly, the private hospitals in the UK use a system akin to privileges to decide whom to appoint to their medical staff, but it lacks substantive quality criteria or credentialling apart from the requirement of having an NHS appointment!

Some additional potential benefits:

  1. It would create a level clinical playing field between the public and private systems, now that the private or independent sector is becoming more important and perhaps better integrated into the care system in the UK;
  2. Thinking of the future, the privileges system would decouple to some extent doctors’ employment and the work they do. This might increase the likelihood that new ways of organising clinical services in the community, for instance, might become more common.
  3. Patients would have clear evidence that quality and clinical work are connected.

I acknowledge that much is done to create a quality environment within the publicly-funded NHS, and this is not ignored in my comments, which in no way need undermine efforts at team working, or cost control. Job Plans in NHS contracts do not discuss clinical focus in detail and actually spend more space on dealing with private practice and academic appointments than on direct patient care; in essence, they are only workload management plans. However, as employment contracts, they focus on the dimensions of employment (e.g. car allowances, maternity leave and employer responsibilities such as providing the necessary tools for the work to be done).

In my view, the problems have a genesis in these aspects of the system that taken together do not produce the desired outcomes when there are problems, and may actually mask poor quality care. Considering a system like privileges may serve to focus attention on what is really important.

Additional Notes

There are types of privileges: admitting, surgical, courtesy.

Hospitals can add conditions to privileges such as living nearby so the doctor can get to the hospital quickly in an emergency.

Hospitals would revoke or suspend privileges where there is evidence of danger to patients, unethical conduct, and disruptive of hospital operations (that last one’s tricky).

Is Simon Stevens the new NHS Wizard?

It is no doubt reassuring for many in the English NHS that Simon Stevens, the new CEO of NHS England, comes with new ideas — they don’t have to think so hard. I guess people have forgotten their criticisms when he left the UK to work for a commercial provider: UnitedHealth, in the US.

What apparently has happened while he was in this rather different environment is that he has returned to the UK with a box load of fresh thinking.

However, he must be wondering why all those people concerned with improving healthcare services had not thought of them already. Why he has to do this is really worrisome as it is just further evidence that the NHS is a permission-seeking culture that takes ages to innovate even the most mundane improvements. I have no difficulty with what Stevens is saying, and I hope he legitimates even more radical initiatives, if all it takes is for him, like in Star Trek, to wave his arms and say “engage!” for people to get on the with jobs we all thought they went to work everyday to do!

We’ll hear a lot about the small hospitals idea now that it has been reignited as a ‘big idea’ (little idea?). People will now say that it is a good idea, timely, insightful. Or as one person on the news said today, that this is recalibrating what the NHS does. Hmmmm. Methinks the lack of insight into the problems that Stevens highlights with his comments is not reveletory, but just more evidence that the NHS eats its young. Perhaps we should listen less to the economists who are trying justify expenditure models in the Department of Health, and more to people with imaginative ideas to improve healthcare with the money they already have.

What Stevens seems to have learned from his time outside the UK and in the US (and I expect he’ll pepper his comments with examples from other countries, but the US is the innovation engine of note) is the need for healthcare providers and payers to be able to use their respective roles to improve care. So-called Obamacare mandates payer-side reform with a pluralistic perspective yet the English NHS has limited payer-side instruments to really drive reforms (despite CCGs). The ability to repurpose money is really important.  Providers for their part are struggling with health reform in the US but it is driving innovation. What is stopping NHS Foundation Trusts??

Some examples from the US:

1. Virginia Mason Medical Center worked with Intel to develop a totally new approach to organising care with a focus on creating “the perfect patient experience”. The underlying logic builds on Toyota’s Production System and was used to rethink clincial work and patient care processes. (see Kenney’s Transforming Health Care, CRC Press. Forward by Don Berwick by the way.)

2. The Mayo clinic has been working on the focused factory/solution factory model to rethink the alignment of patient case complexity and clinical organisation. Given work I’d been involved in the late 1990s was the first structured patient segmentation model ever used in the UK, moving toward a segmentation model is hardly rocket science anymore. (check out the May 2014 issue of Health Affairs, article on cardiovascular surgery by David Cook and colleagues at Mayo).

3. Michael Porter, of Harvard competitive strategy fame, is applying his considerable analytical models to healthcare. He wrote a great book, Redefining Healthcare, about the US, and did a powerful critique using similar models on the German healthcare system. I just wonder why he hasn’t done the UK….

4. Patient activation is on the agenda in the UK, following a recent paper from the King’s Fund. But why did it take a decade for them to discover something that is old-hat as an operational strategy to patient adherence. The problem in the NHS is that there is insufficient priority to spending money to anticipate care needs. I had a project to assess a project on how weather impacts acute exacerbations of COPD; all it took was a telephone call to tell people with COPD risk to stay home on days when the weather was for them risky. This sort of good thinking wasn’t continued, despite evidence that it worked. Oh well.

5. Berwick’s work, first published in Health Affairs, on the “Triple Aim”, is coming up to 8 years old, and it seems Wales and Scotland are using it, and Darzi and colleagues did write about it in a recent issue of Health Affairs, but it wasn’t published in the UK (perhaps the UK is poorly served by academic researchers or are publishing in obscure journals with paywalls to ensure dissemination is limited to subscribers). Triple Aim is a powerful analytical model to probe wasteful, dangerous and unsatisfactory care. I’ve been using the Triple Aim in my own work constructing decision architectures of patient treatment pathways, but the ability to convert the results of the analysis into action remains the sticking point. Payers haven’t been commissioning the work, and they are really the problem owners as much providers.

6. The Evercare programme, which Steven’s ex-employer runs, has been around in the US for over 30 years and involves, in part, specialists visiting at risk people at home and works well. The NHS tried to translate it to UK practice, but the key benefit, of home-visiting specialists, was implemented. The results was sub-optimal and probably a complete waste of time and money. Gravelle and colleagues produced an evalution in 2007, published in the BMJ.

Don’t misunderstand, many people working in the NHS want to make things better. The problem I have is why good ideas need to be permitted. I guess it is all about the politics of healthcare, but I thought the new model NHS was supposed to bury the supertanker logic and create bureaucratic distance to allow that.

The NHS solution to challenges is to bureaucratise them (create entities and bodies with mandates) and issue guidance, which perpetuates the permission-seeking culture.

Having experienced healthcare in other parts of Europe, there are many important alternative approaches which do not require new bureaucratic organisations. A looser more flexible approach to pursuing innovation may be the trick. Oh sorry, the NHS tried that with the Innovation Institute for something or other full of people running around the country with powerpoint presentations.

Just think of Sweden — healthcare run by the local council, and with co-payments!

The logic of reform

Domino Spiral

Death spiral or solution? (Photo credit: FracturedPixel)

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

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

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

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

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

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

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

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

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

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

Conditions for good research

Just about every country has identified life sciences in some form or other as a priority for academic and commercial development. But what will characterise the countries that may in the end prevail?

  1. The research community needs a high degree of autonomy. The European University Association released an interesting study, University Autonomy in Europe II: the Scorecard, in 2011, assessing the degree of institutional autonomy universities in the various EU member states enjoyed. The countries with the greatest university autonomy were from northern Europe: Denmark, Ireland, UK, Finland, Sweden Latvia, Lithuania. Those with highly regulated and state controlled systems were from southern Europe, or had systems where the state just likes to intrude: France, Luxembourg, Greece, Italy and others. To be fair, some countries were more or less autnomous on different indicators, but the rough distinction can be drawn. Surprisingly, at least to me, was the middling performance of countries like the Netherlands, Austria and Germany. No doubt various higher control states will endeavour to justify why the state needs to be so intrusive, but as evidence that this is perhaps an unhealthy state of affairs, we see the highly instrusive French state over the past year moving to create greater diversity and differentiation in funding for its universities with greater autonomy (see this news item for instance). Clearly, greater autonomy necessitates greater diversity and differentiation and in the end some will need to become better than others. While we would like to think that all universities are essentially the same, reality suggests that the only real equality lies in the extent to which they all meet minimum standards, rather than all trying to meet some arbitrary ‘gold standard’.
  2. The second point is that the bulk of significant research results in life sciences arise from centres known as academic health science centres (AHSC). This is a theme I warm too, as it provides an organisational model that drives innovation from the clinical user end, rather than from the research end. Yes, more research funds are always needed, but we also need solutions. Efforts to operationalise translational medicine are doomed to fail if the driving forces are not coupled to the clinical user and innovation policies in general need to start with problems needing solutions, and hence a factor more likely to be evidenced. Only a few countries have AHSCs — such as US (over 50), Canada (about 14), Sweden (1), Belgium (1), Netherlands (8) and the UK (5). Germany arguably has at least one as does Italy. France has none, and one will need to see whether changes in their higher education system are likely to lead to formal establishment of this approach. The challenge (and this was the subject of a paper I presented, see the previous entry below), is that while universities are more likely to enjoy degrees of autonomy, hospitals are less likely to. The UK was only able to move toward establishment of AHSCs when the state control of the hospitals was relaxed through successive periods of NHS reform. The Netherlands model built on existing relationships. Countries without AHSCs, though, will confront the twin challenge of institutional autonomy of both universities and hospitals.
  3. The third point is that not all countries will be able to do everything in life sciences and therefore will need to set some priorities. National priorities are hard to conceive, because countries usually think of themselves as being able to do everything and so efforts for instance, get diluted and underperform. Cash is tight these days (think debt) and governments just cannot afford everything, so the most difficult challenge is establishing priorities.

UK Balance of EU Competencies Review of Health: first thoughts

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

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

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

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

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

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

“Triple Aim” for regulation

We are awash with regulation. Healthcare and medicines are particularly affected.

For instance, in their wisdom, European lawmakers have deemed it inappropriate for medicines to be advertised. And this in the 21st century, with open information access, calls for transparency and the empowered and informed patient. Of course, the logic of such restrictions reflect real-world anxieties, but they also reflect the anxieties of another age. If we examine regulatory practices, we’ll find that in the main they use instruments that would have been popular in the 1950s and 1960s. Today, more subtle and information rich tools are available.

We regulate to coerce people and organisations to behave in certain ways that they would not, of their own volition, otherwise do. This coercion is legitimate if it arises through due process and democratic accountability, and not just the whim of the regulator or government. Sometimes this coercion has perverse consequences, such as with medicines where the legitimate manufacturer of a product is prohibited from publicising a product, but all manner of snake-oil salesman can make all manner of inappropriate claims for medicines, each pits or peanut butter as a sunscreen! The truth lies somewhere but regulations make truth-telling more difficult and not always in the public interest.

What I want to propose draws its inspiration from the US, with Don Berwick and colleagues suggested Triple Aim tool for determining high-value intervention targets (the three are: quality of care, patient satisfaction, and cost).

The Regulatory Triple Aim would comprise three tests, the simultaneous failure of which would indicate that the proposed regulation should not be considered further.

  1. Will the regulation produce poor quality or substandard outcomes? This is likely to be measured through evidence or insight into perverse consequences, weak enforcement, lack of suitable performance data, etc.
  2. Will the regulation produce dissatisfaction amongst the regulated? This is comparable to the patient satisfaction and goes to whether the regulation is appropriate and proportionately coercive and will it enjoy high degrees of compliance.
  3. Are there avoidable costs associated with the regulation? This is an interesting test as it actually asks two things: [1] is there an incremental burden of costs associated with regulation and [2] is the cost proportionate to the benefits.

As a formula, we have Quality (#1) + Satisfaction (#2)  divided by Costs (#3) = Value for Money.

We need ways to sharpen our focus on regulation, and we need to ensure that there is not too much of it for the value we seek to achieve.

Let’s test it with the regulation that was intended to control refillable olive oil containers or pots in restaurants, something that more insightul minds eventually decided was a silly thing to do (I’ll wager though that has just gone into hibernation while a study is commissioned to find evidence that such refillable containers are full of fake olive oil or somesuch and then it will re-emerge), but it did get a long way along the regulatory process without anyone (group think?) challenging it — are people really that dumb? I wonder how that happened — did no one apply a Wilson matrix to this to see if the distribution of costs and benefits was properly understood? Anyway, back to Triple Aim.

Olive Oil in Refillable Pots or Containers

Would regulating olive oil in refillable pots or containers …

1. … produce poor quality or substandard outcomes?

2. … produce dissatisfaction?

3. … create avoidable costs?

Triple failure, meaning answering YES to each question, would suggest this would not be a good idea.

Post your assessments and comments. Obviously, if you’ve got better examples, (such as regulation of clinical trials or whatever) please feel free to expand the scope.



Will baby boomers with the help of Gen X, Gen Y and Gen Z fix healthcare?

A recent report from the Royal Bank of Canada on baby boomers (2013 report) got me thinking about whether generational factors will drive health system reform; this report notes that baby boomers are more likely to worry about their health than their finances. What might that mean if we generalise our thinking to embrace generational profiles of the world that baby boomers have grown up in and the expectations of Gen X, Y and Z?

And what a brain it is!

Think (Photo credits:

Let’s start with the boomers. Apart from the critical view that baby boomers have had it really good, they did invent much of the world we see today, and which the next generations are driving forward.

Baby boomers have become accustomed to things like one-stop shops, not waiting, being kept informed, and prepared to pay for both  quality and service. They are unlikely to sit around waiting for home care to decide when it is convenient to show up, they are impatient when their appointment with the doctor is delayed. They are not used to be told what to do and are problem solvers because that is what baby boomers had to do with some of the stuff left behind from the 1950’s and 1960’s.

Gen X, Y and Z are inheritors and translators of that tradition. What came before the boomers is the problem.

Why hasn’t this translated to healthcare?

Regardless of institutional and political inertia, Integrated care is a response to disruptive patient expectations that healthcare meet their needs.

Our healthcare systems were designed with notions of structure and function that date back to at least the 1920s (hospital management) and use policy instruments popular in the 1950s and 1960s. Countries that are modernising today, have different notions of healthcare and have not adopted the European-type social models, despite hyperactive people pushing this logic at them. We don’t live in that kind of world any more. Baby boomers who have seen substantial economic and social change certainly understand that, while the Gens are growing up without that sort of historical millstone.

Tired nostrums and the moaning of healthcare managers are hardly useful, when we see entrepreneurialism all around us. There is a Silicon Valley of healthcare but where is the Silicon Roundabout of healthcare?

A note on the Gens

Gen X, born between 1966 and 1976 experienced the trials and tribulations of divorcing baby boomer dual income parents. They are sceptical but very well educated. They are more pragmatic and cautious, given what they have been through, but will have little trouble with unstable systems as long as they understand how they work. Not afraid of chaos perhaps? And healthcare is a complex adaptive system, a.k.a, a system characterised by chaotic behaviours.  Policy is uncomfortable with disruptive chaos, yet it is that which creates the seeds for health system reform.

Gen Y, born betwen 1977 and 1994 are the largest population cohort beside the baby boomers. Very technologically sophisticated, they’ll certainly wonder why they can book a doctor’s appointment off an app! Apparently, they are not very brand loyal according to advertisers, so perhaps they not going to worry so much about sacred cows of social institutions, but look beyond that to the fundamental purpose of these institutions. I like people in this group a lot for their unconventional thinking and lack of faith in tried and test solutions and willingness to think new thoughts.

Gen Z, born between 1995 and 2012/now are growing up a world that is digital, connected, always on (McLuhan would understand). They expect things to be customisable, not one size fits all. That sounds like they’ll not be happy with being regimented through a care pathway that doesn’t work for them. Twenty odd years from now when they start to take the reigns of power, I would be very surprised if they didn’t engineer radical rethinking of healthcare. I, for one, would like to get inside that room today to see why we can’t think those thoughts today.

Driving Integrated Care


A model of integration — ants do it

Two items in the publication, Public Finance (pledge to integrate care and integrated care a long way off), illustrate the frustrating nature of health system reform in the NHS.

Is integrated care hard to do? Are there perverse incentives in the system (things like free-riders and moral hazard, even NIMBY) that work agains effective change in healthcare, and in particular the neverending saga of the NHS? I suggest the problem lies in the methods chosen to solve the problem of integrated care, rather than the value of the goal itself.

  1. Over the years, the NHS has made great strides improving the quality of managers (I used to teach them and co-direct an MBA full of NHS managers) but many appear to be unwilling to speak ‘truth to power’ and take full responsibility for dealing with, in this case, integrated care. Instead, we continue to seek both permission-seeking behaviours in the executive suites of the providers and purchasers (just hate the commissioner language, so gutless), and reluctance to challenge the status quo, perferring the herd mentality.
  2. Foundation trust status has done wonders for improving institutional governance, but operational performance (as we know from Francis) is still uneven. I believe this is in part due to NHS organisations being incredibly weak in terms of their analytical capacity (working with data, modelling etc.) to understand and respond to day to day challenges, which undermines the ability to plan and structure strategic direction in response to changing health dynamics.

Integrated care is not hard to do but does require understanding the patient journey through the system and how best to organise the bits. So where does the NHS go wrong is solving this particular problem?

The models used, and the two articles evidence this are broken. What models does the NHS use? It uses approaches which I liken to ‘team hugs’ and ‘pass the teddy’, feel-good leadership approaches, which do not focus on the outcomes to be achieved, but processes, which may or may not lead to a solution. The result is an overuse of:

  1. “joined up care” rhetoric continues to confuse, yet we still don’t know what it means though it sounds like something we would want; I think it is what we thought we were paying for all along!
  2. “commitments” by those involved become contractual type language of agreement, and which are used to “clarify” what can and cannot be done. But again we see no focus on the problem, but on regulatory and other controls, which if they need clarifying, are perhaps useless if not actual barriers, so why do they exist in the first place? When do we bell this cat?
  3. “ambitous plans”, which is code for more paper which no one will read but which will clutter people’s diaries with meetings about meetings about meetings….
  4. “examples” of what can be done is supposed to demonstrate to people that what they want to do can be done; but if these folk are truly in charge of their organisations and have taken ownership of the problem, would already be probing the possibilities
  5. “pioneer status” is code for people who get to the early money first and get to take one of the examples and try it out by developing a plan which people can talk about, and around we go again.
  6. “top-down” is to be avoided, but is said as a reminder that ‘you are in charge’ just in case you were confused, but given the wider context, you actually aren’t in charge as if you were, we wouldn’t be having this conversation.

The reliance of policy-based tools, though, drives a logic that may not be as flexible as possible to achieve integrated care. If it is such a good idea, what is stopping people?

Integrated care can be driven on the purchasing side by, for instance:

  1. Incentivising providers through bundled payments for whole packages of care that cross institutional boundaries;
  2. Incentivising the emergence of new types of providers to achieve care integration;
  3. Tracking outcomes for processes of care.

Integrated care can be driven on the provider side by, for instance:

  1. Pursuing forms of vertical or horizontal integration that achieves a measure of care integration for specific populations of patients, by avoiding the problems of inter-institutional referrals;
  2. Creating new units of care activity that overcome internal organistional barriers, such as bolting on primary care onto the front-end of the hospital, using step-down units and other alternative provision for different strate of risk;
  3. Ensuring the urgent does not wag the dog and draw resources away from better service stuctures — why does is emergency service so overwhelmed yet the capacity of the system to anticipate and predict so weak?
  4. Bridging skill mix cartels and protected working practices embedded in professional regulation to enable flexible working.
  5. Did I mention working 7 days a week and running at least 18 hours a day? An example of the failure of integrated care is a hospital not discharging a patient on a Friday because [1] the lab doesn’t work late or [2] social services won’t start home care on a Friday afternoon. Integration means doing things when they need doing, not when it is convenient to do them.

It all comes down, in the end, to how you solve a problem. The NHS continues to use methods that have failed in the past, yet these tools continue to be trotted out over and over again.

There are better ways. Email if you want to know more.


Pathways to markets: beyond mere price

The title it a bit obscure, but makes the distinction between people who pay for medicines and those who prescribe them.


There is a pathway for new medicines into markets, and increasingly it is not by marketing to doctors. The pharmaceutical industry to a great extent still sells medicines like the Avon sales person, or the old Fuller brush salesman. It feels almost door to door, and for the pharmaceutical reps, it is doctor’s door to doctor’s door.


But let’s think about this again. A medicine may be priced per-pill, and perhaps that is the essential cost to patients paying cash or with a co-payment. To the payer — the insurance company or government — it is that unit price times the number of patients perhaps taken over 5 or 10 years. I prefer to think of medicines costs in that way as it better captures the longer term population level investments and costs that are involved. Granted there is the selling of the clinical benefits of a new medicine, but increasingly this is an evidence-informed decision making process involving such analyses as health technology assessment. By using my model, the numbers get big and scary really quickly and illustrate the real boundaries of decision making and the adoption of a new medicine.


That means, medicines need to be brought to market as a structured offering, costing perhaps a few hundred million dollars over say 5 years, with associated clinical and outcome benefits to patients and incprporating true value and not just price. In that respect, this will better capture the challenges facing payers, who must weigh out the pros and cons of particular health investments.


In a recent interview by the McKinsey Quarterly, Chip Heath, co-author of a new book on decision-making notes “The typical Fortune 500 manager will run projections from the market data. …  The entrepreneur’s reaction is, “I’m gonna experiment. I’ll find my way into the market as opposed to project my way into it.” The entrepreneurs’ impulse to experiment is right.”


Now, this is quite interesting, and echos Clayton Christensen on the dilemmas of innovation. Running the market numbers does not capture the essential challenges new medicines


English: Example of promotional "freebies...

face and I believe inappropriately positions new medicines as commodity products, rather than what in many cases are true innovations. Mistakenly, companies price new medicines to compete against incumbent products on the market, as though this product had got the price/value equation right. The way forward is to examine the essential cost drivers of payers and linking pricing to these challenges — engage with a payer on the real value and benefits of medicines, taking account of patient and clinical adoption, patient adherence, and longer term value.


So it is time to stop selling and marketing medicines in the old way. Time to move beyond advertising blitz, to true value pricing. One benefit will be smarter discussions between industry and payers. But that will necessitate companies overcoming their own highly fragmented market-facing organisational structures.


Just a word of caution: payers must become more sophisticated buyers of medicines as they will frequently fall into the trap of asking for a discount, rather than negotiating for more value to patients. By the same token, industry may fail to present what today are the essential value drivers of their products. This of course means that in most countries the reimbursement/pricing models are broken or nearly broken, and has not been helped by the sloppy decision-making where austerity is concerned.


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Could the medicine you don’t take properly kill you? It may depend on your age.

The lost of my trilogy picks up on medicines again.

In the US, not taking medicines correctly is thought to be the fourth leading cause of death – could this be true?

WHO data on mortality captures medicines use in a variety of categories. I ran the data on the categories concerned with medicines-related harm (ICD-10 codes: X40-X44,X60-X64,Y10-Y14,Y45-Y47,Y49-Y51,Y57). It is less than 1% for any European country for the whole population, but breaking it down by age cohorts reveals interesting results that show at different ages, in different EU countries, there are age-related variations in cause of death, rising with age. None, however, emerges as a leading cause of death on its own.

However, medicines use sit within a system of patient care. Therefore, medicines misuse and medication errors may create conditions for a co-morbidity to assert itself. And of course, whether the drugs were toxic for the patient at a particular dose (keep in mind, pills for instance come in standard sizes and may need to be cut in half or so to get an accurate dose for a patient). Working through this data, though, does highlight areas to pay attention to, and in particular countries where there appear to be noteworthy higher risk. I’d like to see better analysis of medication errors.

Once again, before we target the drugs bill as being out of control, let’s get a better understanding of the dynamics of medicines use itself. We may be spending money foolishly or carelessly. What are the incentives in health systems that may actually encourage this sort of professional conduct?

The devil is not just in the detail, but in the data and in clinical practices.

Want to know more?

WHO datasets are here: