Tag Archives: “bad idea”

Why the proposed NHS Reinstatement Bill is a bad idea

Right now, there is the proposed NHS Reinstatement Bill, a lobby document which lays out a way to reverse many NHS reforms.

This lobby document, which is what is it, is familiar reading, and brings back various structures that in the past have failed. You can find information on it at this link.

What is interesting about this approach is the aura of respectability that it wraps itself in, by proposing the changes as a legislative draft, almost as though it were ready to go to committee.  This is, obviously, an influencing tactic designed to force debate onto the topics covered in the proposed bill, and disarm critics who don’t agree that the points in the lobby document are the right starting points. In that respect, the lobby document polarises positions, particularly against current policy direction.

The whole lobby document’s comments and notes identifies proposed changes to a variety of existing legilsation. What we don’t find, though is any evidence that the authors were in any way persuasive  or influential during public consultations at the time. We call that ‘sour grapes’.

Approaches such as this suffer from the following:

  1.  a belief that the fundamental values underpinning the health service can only be protected in a particular way and these are the ways things used to be.
  2. a belief that the changes that have been made have violated these values; moreover, that the solutions have made things ‘worse’ as they see it.
  3. selective use of academic research to support the positions that one wishes to avoid changing.

New PublicManagement as reform of government itself must sit uncomfortably with this regressive thinking.

For the authors, they would no doubt point to market failure logic to prove that the NHS should not be ‘marketised’ as they put it, forgetting that a greater fear is ‘government failure’, for which there is ample evidence, not just with the NHS but a whole host of other public initiatives and legislation that has wasted public money.

Healthcare systems are complex and by trying to overlay what they see as simple solutions to the problems they claim arise from the reform agenda of past years, they misrepresent what the actual problems are. As messy, or complex/wicked, challenges, the authors believe that by taking away that messiness, they’ll also take away the problems. But they know just as well as anyone, that their solutions will only create, perhaps even recreate, the very problems that led to reform in the first place, except now they will be today’s problems, not yesterday’s.

One might argue that the authors are committing a type 3 error, of unintentionally solving the wrong problem well, but that would assume that they have are not clear in their minds what they are proposing. Therefore, it appears they are do know better and are committing a type 4 error, of intentially solving the wrong problem well because that fits with their policy preferences, or prejudices.

That’s why this is a lobby document, designed to intensionally convince, (is mislead too strong?) others of their definition of what the NHS problem is.

Regardless, the lobby document and the authors are caught by a fundament policy trap: of solving the wrong problem.

Want to know more?

Government failure in the UK is examined in Anthony King and Ivor Crewe, The Blunders of Our Governments, 2013 (@Amazon) and in Richard Bacon and Christopher Hope, Conundrum: Why every government gets things wrong and what we can do about it, 2013. (@Amazon)

New Public Management was originally conceptualised by Christopher Hood, in 1991, A Public Management for All Seasons. Public Administration, 69 (Spring), 3-19. Some (Dunlevey et al) argue that New Public Management is dead and that governance in the digital era requires greater, not less, government. That may be the case for some, but if you actually look at the tools that are available to government in a digital world, you’d find that there is little reason for government to own or run very much. See Christopher Hood and Helen Margetts, The Tools of Government in the Digital Age, 2007. (@Amazon)

I have found Leslie David Simon’s book, NetPolicy.com (Woodrow Willson Centre, 2000) an early, and compelling way of laying out the digital agenda in a policy context really well. (@Amazon)

I would also recommend Vito Tanzi, Government versus Markets: the changing economic role of the state, 2011. (@Amazon)


Where to be an entrepreneur in Europe? Not France!

dead duck

A French Entrepreneur (Photo credit: Dave Malkoff)

A paper by academics Nadine Levratto and Evelyne Serverin, “Become Independent! The Paradoxical Constraints of France’s Autoentrepreneur Regime” (available here) shows the failure of this programme to generate entrepreneurial behaviours.

What went wrong, and why should other member states not copy France?

Since January 2009, when the autoentrepreneur category of working was first introduced, over 550,000 people have registered. They system differs from the also complex Regime Reel in France by taxing autoentrepeneurs on gross turnover (up to the allowed ceiling of €32100, at the rate of between 12 and 21.3%) rather than on revenue (turnover less expenses). People in this category discharge all their taxes by paying this amount, but do not get to claim expenses and do not need to do VAT accounting. In France, the very high national debt is driving lawmakers toward a regime that is levying the regressive social charges on everything from the first euro (!); this is evidence more of desperation than leadership — that entrepreneurs have been captured by this is not surprising.

Almost 50% of autoentrepreneurs in France had an annual turnover of zero, while 15% had a turnover of less than €1000. Only 500 autoentrepreneurs exceeded the upper threshold.

This regime fails because it is not about being entrepreneurial, but about collecting tax and creating bureaucratic barriers to success: more specifically:

  • autoentreprenurs can’t hire anyone — the authors speak of them as ‘lonesome’, working out their entrepreneurial dream on their own, forbidden to collaborate with others, even hire an assistant
  • they can’t recycle capital to build the business as it taxed away at the turnover level as there is no recognition of the extraordinary expenses of business startups
  • because of the structure of business, they are a bad risk for banks to lend to
  • two autoentpreneurs can’t collaborate as tax authorities would view them as a company
  • there is an excessive concern for employment law and insufficient understanding that entrepreneurial behaviours are not about being secure, but about risk, and therefore has little to do with employment law itself.

There should be no surprise that the system failed and people outside France can say simply on this basis, and with some justification, that the French don’t have a word for ‘entrepreneur’ as clearly they don’t seem to understand what the word means. Indeed, the authors note that the programme has been such a dismal failure, that the French government is rebranding it as better for second incomes, than entrepreneurialism.

What we need is an analysis of these failing efforts at entrepreneurialism by member states, certainly as a warning to others, but more importantly to establish a general understanding of how entrepreneurialism should be treated within member states from the perspective of taxation and law.

If I were forum-shopping for a member state to pursue my entrepreneurial dreams, I would be looking for a country with light-touch taxation, and flexible employment rules.  Start-ups have real problems with cash flow and locking them into high social charges and rigid employment laws is counterproductive.

What is worrying is that other member states, according the authors, have copied this regime: Portugal (recibos verdes) and Poland (samozatrudnierie). Others may be thinking about it. We should all be very afraid of this.

If you are entrepreneurial or have experience in specific member states, please email or comment. Which do you think is the best country in Europe to start a business or be entrepreneurial?

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Digital Maginot Line

Cloche GFM (Ouvrage de l'Agaisen)

Fear, not protection. (Photo credit: Wikipedia)

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

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

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

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

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

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

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

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

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

Or I can make them the centre of my world.



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Reforming NHS Reform

Steve Field was asked to lead the collective rethink by another group of vested interests of proposed NHS reform.  He apparently thinks, according to the Guardian, that the English NHS reforms are not workable. Apart from the rather pointless delay in getting on with reform, in the patient’s interest, rather than the interest of providers, he overstates the challenges faced by competition.

There is a general fear of what is called ‘creative destruction’ being applied to public institutions. But governments for years (think back to Thatcher, Blair) have tried to reform Whitehall, trim the scale of the public sector, and bring needed new thinking — the New Synthesis project is one example of people trying to rethink the public domain. Most of the changes in the NHS over the past two decades have been clearly in this direction, but regretfully, the Coalition failed to signal that they were tidying things up — who suggested all this needed primary legislation anyway as the SoS has enough power to do this anyway.  The push-back from entrenched public institutions can be unnerving to governments, in particular Coalitions, who need to keep their political dance partners happy.

So what to make of the comments in this interview:

  1. Head to head competition is unlikely across the bulk of England as integrated Foundation Trusts tend to be the sole and dominant provider in their areas. Major cities are the exception and the high operating costs, difficulty accessing services, and duplication of services is something that needs to be dealt with through targetted commissioning. Failure to do the hard bits will simply drive costs further skyward, and reward failure.
  2. There already is competition with the private hospitals, but they have their own interests, and launching a major assault on the NHS would be largely pointless — their customers are NHS consultants who provide their services to people who have taken out private insurance in order to opt-out of the NHS.
  3. So-called cherry picking is not a bad thing — aggregating similar cases in specialist units is clinically sensible as it produces better outcomes. Now why has the NHS resisted this sort of service rationalisation? If NHS providers are unable to sort out their clinical priorities they why shouldn’t a new entrant offer this service if they can do it better? I reviewed two hospitals once that duplicated services, and seemed unable to provide a single service between them. Outcomes weren’t good either.
  4. The ‘rules’ the Department of Health works with have rigged the market anyway in favour of incumbent NHS providers, whether they are providing a high quality service or not. There is real fear here in Government, but the patients’ priorities for a high quality service they can value may be more important than ideological considerations.  Perhaps we have to wait for the Facebook generation to start consuming health services for the mandarins to ‘get it’.
  5. Unbundling hospitals is something that can be done, but understanding the complex interaction of hospital-based services also needs to take account of the general shift toward out-patient services and increased focus on primary care, meaning hospitals aren’t going out of business soon, anyway. Field is right to point to shroud-waving, but misses the point that it was this shroud-waving that caused the panic in the Coalition.
  6. He uses the term ‘free market’ when in fact it won’t be, it will be a regulated market as there are very few free markets anyway (including in the US where there isn’t really a free market in their largely publicly/federally funded system of not-for-profits and loss-making hospital chains — try getting care from an HMO that you aren’t a member of).  The only existing health market regulator in the Netherlands seems to be managing just fine.
  7. Other countries have forms of competition between hospitals (France, Germany, Netherlands, Belgium, Spain, golly, this list could go on and on) and their systems haven’t crashed into some incomprensible quagmire of service chaos. Field overstates the problems, but it may betray some degree of fear that competition will unearth further underlying challenges that provider managers may be ill-equiped to deal with. There are some incredibly well-run hospitals in countries like the Netherlands, France, Switerland, Sweden, Belgium, not to ignore some of the best US hospitals but training in hospital management in the UK is not to world standards.
  8. That some NHS hospitals are badly run seems apparent, and something needs to be done about that, so removing motivation for an executive focus on financial and service performance seems a bad idea, at least to those who would be faced with the job of actually managing a hospital, and not just taking up office space.
  9. You don’t go out to tender for a trauma centre, as you need a catchment population in the millions to justify the necessary skills. Commissioners who don’t understand this shouldn’t be allowed anywhere near the NHS.
  10. There are examples where novel solutions to challenges have been inspired, my favourite being the establishment of five world-class academic health science centres; all we need now is for them to assume a leadership role in driving excellence in management and patient care through the wider system.

I find it interesting that those who have the greatest stake in maintaining the status quo are those who are leading the listening exercise; why didn’t the Department of Health select perhaps an international panel or empanel a group of people with alternative perspectives? The vested interests run deep in the corridors of power.

As for some of the pending conclusions:

  1. no problem reserving a spot for nurses, but what about pharmacists, occupational therapists, and a host of others? Oh dear, patients and users?
  2. why hospital doctors on commissioning bodies; aren’t they part of the system that most would keep services in hospitals. There is serious risk of provider capture here. Including them because they might feel alienated is plain silly. The most alienated part of the NHS is the patient.
  3. inclusiveness is running mad here, and would make any ‘clinical cabinets’ virtually unworkable — when will they all have their group hug? I think it will just make work for consultants in organisational dynamics, who will be needed to help develop them, and keep them from constant bickering. The NHS spends too much time worrying about emotional intelligence of managers and whether their leaders are getting enough cheese. The proof is in the pudding and the leaders aren’t leading.
  4. GPs can acquire skills to commission anything they like, and to say otherwise is insulting and perhaps other words might be more applicable.  This is a lame excuse, otherwise we would never get anybody doing anything because one could always argue that they don’t know what they are doing and someone else could do a better job. The NHS Commissioning Board isn’t needed; it is just the continuing felt need for ‘national’ bodies and will hoard expertise that should be distributed around the system, to avoid the problem Field thinks exists.
  5. I doubt plans to reform medical or other professional education will be affected. This the job of the universities anyway, and they should get on with the job regardless. If that were true, then the NHS has colonised the education field inappropriately.
  6. The levy on private hospitals is unworkable. Half of nutritionists don’t work in the NHS — should Waitrose pay for the nutritionists they employ, should self-employed physiotherapists reimburse the NHS, and what about the 25% of nurses that work in the private sector.

What is clear is that listening exercise has beneficially galvanised those who didn’t have a problem with reforms to point out that this is now delaying essential service innovation — not the NHS innovates at the drop of a hat! France recently reformed its system. Anyone notice. Quick and likely to be quite effective.

I look forward to their final report, to see what changes I need to make in my comments above.


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The UK’s NICE is a disguised authoritarian

The stop sign design currently used in English...

Something NICE needs to do

NEWS FLASH: Setting a minimum price for a unit of alcohol would help tackle Britain’s drink problem, health advisers are expected to recommend. The National Institute for Health and Clinical Excellence (Nice) will include the advice in its guidance on how to crack down on problem drinking. (1 June 2010)

This commentary is not on whether to set a minimum price for alcohol. This is a comment about expansion of the scope of NICE’s mandate.

What is NICE for and why are they now becoming involved in more fundamental health policy matters? Under the rubric of health excellence, one assumes they are pushing this as far as they can possibly go.

NICE is really a disguised authoritarian advisory body because of their lack of proper public accountability coupled with their privileged access to ministers in government.

NICE are not ‘health advisors’; they are a fourth hurdle advisory body with a focus on what works in healthcare service delivery, such as medicines and device technologies. By moving outside this, they are creating the impression that any area of health interest can be subjected to their methodologies. Indeed, that all matters of policy can be reduced to a QALY analysis and some economic modelling. No doubt at some point, they will pass judgement on the health impact of the national speed limit,  the salt content of food, the pub opening hours, as long as there is some way to tie the analysis to a health outcome. Invoking their brand of technocratic thinking to replace the fine art of public consultation is hardly the way ahead — that there is some evidence for the benefits or costs, does not lead inexorably to the conclusion that health policy should change.  Running health policy by the numbers in this way guts the democratic process for deciding social priorities.

This all-purpose extension of the mandate of NICE is not a good thing, for democracy or for health policy in the UK.

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When it pays to be second best: English NHS “preferred providers”

For all the reform and protestations that the public deserves a health system for the 21st century, the ongoing saga of health reform in Britain continues to amaze.  The Secretary of State for Health for England, Andy Burnham, has decided that NHS providers get to try twice to prove they are worthy of continuing public confidence.  As he has put it, the NHS is the “preferred provider”, apparently for itself.

Those not familiar with the reform of the NHS, and indeed those who are, must be wondering why mediocrity should be rewarded, and in these difficult times, why the taxpayer or the government should countenance circumstances that public public money at risk.

The NHS commissioners (purchasers in real world speak) are the surrogates for consumer choice, as while NHS patients do have some choice, commissioners in the end are deciding in which directions that choice can be exercised.  A bit like Henry Ford’s model T car: you can have it in any colour as long as it is black.

Why should this matter? The Minister has said that the NHS should not be agnostic about who provides healthcare service delivery but instead favour NHS providers.  But as a monopoly supplier of services, the NHS and the English Department of Health must be mindful of abuse of a dominant position and in particular favouring institutions that are in effect emanations of the state, on the one hand, and forcing the public to experience second-rate service on the other.

Favouring a failing provider strikes me as looking a lot like state aid.  It also does not appear to be a service contract either, as the reason for awarding the contract seems to depend on the ownership of the provider (and protecting their status) and not whether they can deliver the service to a quality standard (which is the purpose of the contract).  The clue that this is a policy fudge is that a failing provider gets another chance to be a preferred provider over a potentially more competent and higher quality provider.  Can you legally enter into a contract for a service to a quality standard, knowing in advance that the provider is unlikely to be able to deliver to the terms of the contract?

Hmm. So much for value for money and healthcare fit for the 21st century.  Do I hear the auditors stirring?

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Regulating internet pharmacies at the European level is necessary

Various prescription and street drugs may caus...

Available over the internet

It would be a serious mistake not have an EU-wide regulatory framework for internet pharmacies.  Not achieving one would be just more evidence of the politics that infects all discussions of cross-border healthcare to the detriment of the patient and health consumer.  Illegal drugs, fake drugs, reimported drugs, counterfeit drugs, substandard drugs, legitimate drugs — how is a consumer to tell the difference on the internet?

We need an EU-wide regulatory framework for a few pretty sensible reasons:

  • EU wide standards would ensure a common standard of practice, and European citizens should expect no less.
  • A key element of internet pharmacies is their cross-border character, and indeed whether they are inside or outside of the EU itself; the provenance of a medicine is integral to knowledge about its legitimacy and by breaking the information flow about specific medicines in a cross-border environment, the EU is putting people’s lives at unnecessary risk.
  • Price differentials within the EU actually encourage internet pharmacy sales, as it is these price differentials that make internet medicines attractive to consumers, and which create the risk of buying counterfeits in the first place. It is also known that the cash market in medicines underlies the opportunities for criminal elements to insert fakes into the medicines supply chain.  This will only become easier to do and harder to detect.
  • Cross-border trade in medicines involves a lot of repackaging, relabeling, etc., which destroys or confuses such information as batch numbers and point of origin.  This is essential core EU-wide information.

Leaving all this to different national regulators will simply play to the regulatory patch-work that characterises medicines regulation in the EU, and ensure that consumers will be confronted with varying degrees of protection, information and risk.

Despite protections from other EU directives on cross-border sales, medicines and the risk of counterfeits put the issue into a different situation as the efficacy of the medicines may only be determined after the patient has experienced the consequences to their health from the purchase of a fake medicine.

Member states are not that good at organising multi-lateral arrangements, so why should we expect them to be any better on medicines trade in a cross-border world?  The complexity of the EU will now be sustenance to those who would wish to contaminate the medicines supply chain.

I am obviously trying to decouple the problem from the issue of parallel trade, and focus on the core elements of cross-border regulation.  Parallel trade would be caught by a simple internet regulatory framework.

What would a solution look like?

Well, the opportunity to establish an EU Internet Pharmacy Imprimatur will be lost, as it would have been a key element in the solution.  It would have established basic information about the legal status of the internet provider, and its legal dispensing practices, including handling of prescriptions.  It would have given us pooled knowledge about all medicines, whether legal or not, with their origins and destinations being available in an EU-wide systematic manner.  With common regulation would come shared knowledge of all regulated and licensed firms operating in the very complex medicines supply chain; this information is not shared across borders, with obvious consequences.

The push-back from industry on the technological side is understandable but to be regretted.  it is possible to establish common technologies, and common data-gathering to make a sensible system work where costs are not onerous and patient safety is assured.  The outcome to be achieved is common knowledge across the whole medicines supply chain in a cross-border world. In addition to the much-talked about radio frequency tags, and barcodes, there are other methods available or in development which offer additional opportunities and are likely to alter the impact of costs on industry.  The current technologies are hardly longer term solutions anyway, but industry will need reasons to explore them.

A common regulatory framework for cross-border medicines trade over the internet is sensible, and does not really need the problem of counterfeits to be justified.  Industry resistance needs to understand that consumers, who will be in the main buying these medicines, need assurances of appropriate dispensing, quality of the medicines, proper shipping, and expiry dates,for example.  They also need to have named individuals if there are concerns, as mistakes can happen such as the wrong dosage being provided.  As well, there are naming differences amongst member states of similar medicines, dosages and methods of delivery differ (e.g. tablets, suppositories, soluble, all in the same medicine reflecting cultural preferences), and so on.

The McKinsey Report on the NHS: a song in the air? Not likely.

The leaked McKinsey report on the NHS, which endeavoured to provide a review of areas where efficiencies can be achieved in the face of declining public finances does not really offer anything we don’t or at least shouldn’t already know.

NOTE: This post does endorse the McKinsey’s report findings — only to express some surprise that it was not more insightful.  Of course, I have only read the leaked documents, and cannot comment more fully, but then if the Department of Health did want a proper (adult) debate, they would put it in the public domain for all to see.  Perhaps McKinsey would, as supposedly insightful strategy consultants, suggest to the Department the value of a wider social debate on the NHS priorities — but this isn’t their style.  The wisdom of crowds, or the madness of experts?

So on with the commentary.

As if at least 20 years of NHS reform meant nothing, OECD countries together are grappling with rising healthcare expenditure coupled with demand that seems insatiable.  The recession and its consequences has for many offered a useful policy window through which to drive changes that under more benign economic circumstances would be untenable.  Health, as always, is the last to face the music.

What actually is the NHS?  In the UK, it is 4 devolved publicly (tax) funded universal health systems (England, Scotland, Wales, Northern Ireland run their own show); McKinsey is writing about the English NHS.  The “NHS” is often described as one of the largest employers in the world, but then healthcare systems are generally large employers, usually about 5% of a country’s workforce, consuming around 9% of GDP.  The whole health industry is usually about 15% of GDP, employing perhaps 7-8% of the workforce.  So they are all big.  What characterises the UK’s fascination with the NHS is the tendency to speak of the NHS as though it were ‘one thing’, whereas it is more likened, perhaps more accurately, to a confederation.  Regretfully, policy makers have failed to really make sense of the role of private and non-profit providers so there is really only weak integration of services across all providers.  This constrains policy and service delivery somewhat in England as there is always the fears of privatisation and so on.  It is worth keeping in mind though that general practitioners are private sub-contractors, while the acute sector is increasingly run by autonomous arm’s length hospital ‘foundations’ (a weak attempt at copying a hospital arrangement from Spain).

So the NHS is an acute service provider, a contractor for primary care from service providers, and a buyer of services from acute providers.  That it is characterised by a purchaser/provider split is helpful in understanding the constraints under which the system works, as the purchasers (primary care trusts) are in the main general practitioners commissioning (English jargon for buying) care from acute providers.  This engenders some confusion in the public domain between who is responsible for the planning and problems that get thrown up.  The McKinsey report can be seen either as a message to acute providers to reduce their overheads, or a message to purchasing organisations to set contracts with tighter cost controls for the value received (i.e. for the care provided at what level of quality to their patients).

The politicians are indeed running around in a bit of a frenzy because the NHS is seen as a sacrosanct public sector organisation, and that cutting the budget would be equivalent to committing treason.  Of course, this adds to the problem and increases the denial.  This strengthens the hands of those who oppose reforming healthcare, and makes the case for increasing efficiency and productivity, and in general ensuring that the public receives good value for the tax money spent on healthcare more difficult.

Yes, healthcare is a hands-on activity, and yes we need hospitals (at least for now).  But it is hubris to suggest that the acute hospitals are as productive and efficient as they could be, or that the distribution of clinical work across the health professions is a well done as it might be.  Hospitals by and large still draw on industrial age models of organisation — they are little different from commercial conglomerates.  Efficiencies in McKinsey’s report comes from things such as:

  • vertical integration (hospitals into community care, for instance)
  • integrated care pathways (something healthcare has been up to for at least 20 years)
  • reduction of waste and duplication (no surprise there)
  • role clarification of clinical work (yes, professional cartels called Royal Colleges)
  • elimination of clinically ineffective or doubtful work (the tough call but is a natural consequence of evidence-based medicine).

Criticisms of the report are right to the extent that McKinsey has done what they are generally good at: stating the obvious.  Any of these items should be on any hospital CEO’s to-do list, and subject of Board level discussions.  Unfortunately, where McKinsey is less good is in looking at the NHS and assessing the underlying logic and meaning of its organisational structure, its clinical care paradigm, and how it can evolve, as a dynamic entity, into a better care system (they would surely argue that that wasn’t their brief, but good consultants work with, not just for, their clients).

But salaries and infrastructure (buildings) are the costs to look at: perhaps 80% of a hospital’s budget.  Choices here require a different logic, and include:

  • using e-health, telehealth technologies to replace both staff and infrastructure (home telecare monitoring, for instance)
  • use of supportive clinical decision-support technologies (from robotic vision systems to work with radiologists to scan mammograms, thus doubling the number of radiologists, to artificial intelligence systems to data-mine health records to identify patients are risk of A/E readmission to a COPD exacerbation)
  • using medicines to replace hospital stays, surgical interventions
  • using best-imaging-technology first to diagnose (the best technology to diagnose a problem is not generally used in initial diagnosis, an x-ray might be used, then CT, then MRI.  Just use the best first.)
  • and so on.

These all address the possibility of labour (clinical work) substitution, (which might improve the quality of the jobs clinical and support staff actually do), greater patient empowerment (as they take greater control of their healthcare, direct resources to achieve their own healthcare goals), and a real use, slowly being addressed by the Connecting for Health initiative, for information for clinical and patient decision-making.  This emerging information value-chain will produce improved measurement of clinical outcomes, and thus inform better in-hospital decision-making and resource allocation.

Of course this ignores the actual physical unbundling of hospitals themselves.  The organisational logic that requires the aggregation of clinical skills in the modern hospital is dated under many service scenarios.

So where are we?  We are at the point of knowing that much can be done to improve the patient’s experience of healthcare, by driving out dated clinical and organisational practices, adopting new practices and technologies, procedures and methods.  It should not be inconceivable for any healthcare system to achieve 20% savings.  Fear of alienating clinicians is less the issue than engaging them in service improvement, to which they should be committed.  This will in the end ensure the high-touch requirements of healthcare where it is needed, without protecting sacred cows and vested interest groups.  In the end, it will come down to political will, managerial commitment, and clinical professionalism to ensure, in a publicly funded healthcare system, that the public gets what it thinks it is already paying for.  Otherwise, resistance looks a lot like protectionism.

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E-health and Ontario

The wordmark of the Government of Ontario, fea...
Waiting for the e-health revolution

From across the Atlantic comes news of apparent financial maladministration at E-Health Ontario, the body charged with implementing the province’s e-health strategy.  It seems to be the usual nonsense of untendered contracts, friends in high places, and chums helping chums.  It is also an example where no one seems to have asked the simple question, “why would you do that?”  — the strategy is a nonsense, and I am surprised that no-one challenged this before the policy had gone this far in implementation.

I would, naturally be more inclined to be concerned if the province’s e-health strategy were actually about e-health, or likely to deliver results worth having, but the $700 million or so per year will be spent on things like a diabetes registry, wait times, electronic prescribing/electronic health records.  Only the last have anything really to do with e-health.  The last can also be procured, so there really isn’t a need to make a supplier meal out of putting something in place.  I will concede though that an EHR is a critical component of e-health, but it isn’t quite the same as e-health — it is a bit like confusing the foundation of a house with the home it will become.  But having worked on eRx,  the province’s failure to prioritise some sort of a patient-held smart card is a mistake as without this it is difficult to deal effectively with identity.

Without system redesign in the province, the e-health strategy is really just throwing good money away and given the current economic (and political) climate, this is no longer an option, if it ever really was.

Two things are of critical importance.  First the province needs to have a thorough-going governance review of e-health Ontario, mainly to determine how to make sure it is fit for purpose in actually providing the leadership for development of an e-health infrastructure service delivery platform.  Secondly, and this is the challenge, it is necessary to make sure that the e-health services are ones that the public will use and value.  The province has failed on both counts.  The next challenge though will be to find people to review e-health Ontario who haven’t been tainted by this scandal and benefited from the feeding frenzy e-health Ontario created. It may require looking further afield, to interested, but uncontaminated parties.  They may even not live in Ontario — golly gosh, so much for made-in-Ontario mediocrity.

So, having vented on that last point,what would an outline e-health strategy look like for Ontario, assuming that some governance arrangements are put in place,.  These are really just illustrations as certainly I would want to get a good understanding of priorities from interested patient groups:

  • There are about 90 rural and small hospitals in the province.  A good plank in an e-health strategy would be to enable them to become a single, integrated, but distributed healthcare provider, perhaps with some sort of local and shared corporate governance.  A distributed healthcare provider, using e-health infrastructure technology would deliver specific outcomes to rural people, such as access to networked diagnostic imaging technologies, electronic prescribing and remote access to health records.  I would certainly save people in Thunder Bay a lot of trouble getting down to Toronto for a scan.  With a little bit of imagination and thought, this could work.
  • About 60% of diagnostic facilities are located in Toronto, but which has only about 25% of the population; these are licensed clinics which often only offer a single procedure.  Using networked imaging technologies, remote diagnostic telecare booths (you can buy one from Cisco) many of these suboptimal centres could be relocated either to the rural network, in the previous plank, or provide a more accessible urban service across the provinces main urban centres.
  • Smart card technologies (whether a smart card or an electronic secure passport) would give a better reason for constructing electronic health records than ones focused on improving data access for health professionals alone.  Patients, when given access to their health information, will have a vested interest in ensuring that the information is correct (my Ontario health record when I lived there had an error showing I had a condition affecting women, but I am a man — I still don’t know if the error was corrected; in an electronic system, that error would have been a problem, but I would have made certain that it was corrected, too).  As an ‘auditor of one’ patients can make sure information is correct, and drive substantial service quality improvements.  This is not to say that health professionals can’t do that, just that the evidence shows it comes slowly and is complicated by cartel-like professional practice barriers.  Start by putting the e-health card in the hands of the heavier users of the health system, to better manage their healthcare, access to information, and gradually as people see their family doctor, or get born, migrate the whole population over.  Of course, this will mean that family doctors, clinics, pharmacies will have to adopt some sort of information system.
  • Don’t do what the English NHS is doing with Connecting for Health, by creating a large-scale government-led initiative.  E-health Ontario’s predecessor took a look at Denmark, but failed to learn the lessons despite what they wrote in their sham of a consultation document — they missed the point partly because they appeared to have another agenda heading toward a particular solution.  Denmark has shown how disparate stakeholder groups can work together to create an information system that works, and does things people value.   Better that than spend vast amounts of money on a grand plan to nowhere.

The general plan is to build an infrastructure that starts with the patient/family as user.  My experience in developing an interactive health television channel showed me the importance of starting there, and defining the benefits from that perspective.  Change will drive from that end too.  Finally, engage all the stakeholders (like the Danes did), find commercial partners with interesting technologies that do things that people value (rather than whizzy technologies), look for alternative systems to pay for healthcare services, as failure to develop a suitable and workable reimbursement system for e-health services is a barrier ( just ask Norway).  Oh yes, don’t forget political will.

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Health and Security: the civil liberties dimension

Barbed tape at a prison

Quarantine zone

While it is good to see progress at the European level to deal with threats to human health that do not recognise borders, the steps that may be taken to ensure security in the name of health many lead to greater threats to civil liberties.

Integral to coordinated responses to public health threats are efforts to quarantine populations, restrict movement of individuals (infected or not), and triage.  Where are the risks to civil liberties?

First, quarantining and free movement.  Establishing the boundaries of quarantine zones if notably difficult.  Toronto, with SARS, had great difficulty not just identifying where the boundaries should be, but in keeping people from wandering across them.  Officials lacked the legal authority to restrict freedom of movement as, of course, no crimes were being committed.  Indeed, in order to enforce quarantine boundaries, illiberal measures may be required.

Are quarantine zones to be identified by physical barriers with armed guards (to keep people in and others out)?  And what is to be done to infected people who try to ‘escape’?  What enforcement procedures are likely and when do they escalate to the use of lethal force?  We know from general behaviour of armed forces that they are not so easy to control when confronted with unruly citizens, and may actually be loathe to fire on their own citizens.  The challenge facing planners of quarantine zones is defining their scope: are they big enough to catch all likely infected people and then some who aren’t or are they small enough to ensure that no uninfected person is included, but risks missing some infected people?  The public health planners would prefer the former, despite creating the possibility that uninfected people would then be essentially trapped with infected people — a potential death sentence.  No surprise if some of these people might try to escape, to be confronted by what response from officials?

Second, is triage.  This is the decision-making about who lives and who dies.  Certainly in combat, soldiers understand the risks and accept that battlefield decisions are not easy to make.  In peacetime, such decisions take on a completely different complexion.  Public health threats such as pandemics are not combat, despite the rhetoric from governments that such threats much be met with a ‘war on disease’.  How, then, are the life and death decisions to be made?  Within a quarantine zone, would a large number of untreatable and infected people be left to die when numbers swamp the capacity of the health system to cope?  It must be remembered that a widespread pandemic would create chaos within health systems as health professionals fall ill or become trapped in quarantine zones.  Medical supplies will become scarce, and treatment facilities will be unable to cope with the demand at the rate at which it is appearing — people getting sick faster than people are being treated and getting better.

The risks are that we won’t consider these issues within the context of civil liberties and human rights, but use the excuse of a public emergency to enact essentially authoritarian measures, without reflection in the longer term of the consequences for our society.  The evidence, though, is before us: terrorists threats are met with authoritarian legislation which is often found by courts to violate human rights or constitutions.  Will health be the next victim?