Tag Archives: Complex systems

Intelligent medicines optimisation

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

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

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

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

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

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

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

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

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

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

Upward pressure on the medicines budget include:

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

Downward pressures include:

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

Additional sources of pressure in either direction come from:

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

What Cognology says.

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

 

Smarter and more Intelligent Healthcare in 2035

The King’s Fund, a UK health charity ran a scenario essay writing competition, and here is the link and of course congratulations to the winner: (winner, runner up and other scenarios, but not mine).

My scenario builds on the notion of service unbundling and draws on strong and weak signals of changes likely to impact health and social care perhaps to about 2035. The scenario is written as a retrospective view from the year 2047. My objective was to avoid a doctrinaire scenario.

Unbundling 2035

Between 2016 and 2035, the way that people worked had substantially changed by widespread digitisation of information. Smart machines and robots had moved from doing physical work to being central to much cognitive work and which led to fundamental restructuring of the economy. By 2035, taxation was changing from taxing people to taxing the work done by devices, cognologies, and robots.

The fault lines between reality and expectations were starkly evident during the 2020s, as public investment in health and social care struggled to cope with the rapidly changing world. People were becoming accustomed to flexible access to personalised services that came to them and expected the same from care provision. Rising displeasure at service decline led to middle-class flight to alternatives with rising use of private medical insurance, progressively fracturing the social contract that legitimated publicly-funded care. Indeed, by 2028, 38% of the population used private care, with over 55% amongst Millennials.

Fearful health and social executives and worried Ministers of Health had reacted to these stresses by pulling the system even more tightly together, to protect jobs and avoid the failure of publicly-funded institutions.

This fed further public displeasure by the dominant middle-aged Millennials who challenged the traditional approaches to health and social care. In the United Kingdom, for instance, this unrest led to the 2028 Referendum on their tax-funded healthcare system, leading to the replacement of this system with social insurers and personal Social and Health Care Savings Accounts.

The process of changes in health and social care around the world has become known as Unbundling. This brief historical retrospective outlines three of the key components of that unbundling.

The 1st Unbundling: of knowledge and clinical work

Professional knowledge was affected by digital technologies which had unbundled knowledge from the expert. This changed how expert knowledge was organised, used and accessed; research institutions and knowledge-based organisations were the first to feel the changes, with librarians being one of the first professions to face obsolescence. Rising under-employment, particularly in traditional male-dominated occupations was still being absorbed by the economy.

Routine cognitive work and access to information and services was increasingly provided by cognologies (intelligent technologies) or personal agents as they were called. Widely used across society, they were embedded in clinical workflow from diagnosis to autonomous minimally invasive surgery. By this time, jobs with “assistant” in the title had generally disappeared from the care system, despite having been seen as an innovative response to workforce shortages through the late 20-teens. These jobs had turned out to be uninteresting, and being highly fragmented, required time-consuming supervision.

The benefits of precision medicine were substantial by this time, enabling earlier diagnosis and simpler and less invasive treatments. Theranostics, the merging of diagnosis and therapy, unbundled the linear care pathway and the associated clinical and support work. This also led to the unbundling of specialist clinical services, laboratory testing and imaging from monopoly supply by hospitals. Indeed, the last hospital was planned in 2025, but by the time it opened in 2033, was deemed obsolete.

The 2nd Unbundling: of financing and payment

The unbearable and unsustainable rise in health and social care costs necessitated better ways to align individual behaviours and preferences with long term health and well-being. Behavioural science had shown that people did not always act in their own best interests; this meant the care system needed people to have ‘skin in the game’, best done by monetising highly salient personal risks.

Existing social insurance systems which used co-payments were more progressive in this direction, while countries with tax-funded systems were forced to reassess the use of co-payments, and financial incentives. The Millennials, having replaced the baby-boomers as the primary demographic group, were prepared to trade-off equity for more direct access to care. It also became politically difficult to advance equity as a goal against the evidence of poorer health outcomes as comparisons with peer countries drove performance improvements.

The use of medical/social savings accounts was one way that gave individuals control of their own money and building on consumerist behaviour, this directly led to improved service quality and incentivised provider performance as they could no longer hide behind the protecting veil of public funding. The social insurers were able to leverage significant reforms through novel payment systems, and influence individual health behaviours through value-based (or evidence-based) insurance not possible under a taxation system.

The 3rd Unbundling: of organisations

With people used to having their preferences met through personalised arrangements, care was organised around flexible patterns of provision able to respond easily to new models of care. This replaced the “tightly coupled” organisational approach known in the early part of the 21st century as “integration”, which we know led to constrained patient pathways, and limited patient choices unable to evolve with social, clinical and technological changes.

The big-data tipping point is reckoned to have occurred around 2025. Because the various technologies and cognologies had become ambient in care environments they were invisible to patients, informal carers, and care professionals alike; this enabled the genesis of smaller and more diverse working environments.

By 2032, medical consultants were no-longer hospital-based, having become clinical care social organisations, with their cheaper, smaller, portable, networked and intelligent clinical resources. Other care professionals had followed suit. These clinical groupings accessed additional clinical expertise on as-needed basis (known as the “Hollywood” work model); this way of organising clinical expertise helped downsize and reshape the provision of care and met patient expectations for a plurality of care experiences.

It takes time to shift from the reliance on monopoly supply of care from hospitals in those countries that continued to pursue a state monopoly role in care provision. However, most repurposed themselves quite quickly as focused factories, while the more research-oriented specialised in accelerating the translation of research into daily use, helped along by the new research discovery tools and the deepening impact of systems biology which was making clinical trials obsolete.

What Cognology Says

This Unbundling arose as a product of the evolution of social attitudes, informed by the emerging technological possibilities of the day. The period from 2016 to 2025 was a critical time for all countries, exacerbated by shortages in the workforce coupled with economic difficulties and political instability.

Today, in 2047, we are well removed from those stresses that caused such great anxiety. We must marvel, though, at the courage of those who were prepared to build what today is a leaner, simpler and more plural system, removed from politicised finance and management decisions.

It is hard to imagine our familiar home-based theranostic pods emerging had this trajectory of events not happened. As our Gen-Zeds enter middle age, they will, in their turn, reshape today’s system.

Plus ça change, plus c’est la même chose.

27 December 2047

Note on the Scenario

This scenario is informed by strong and weak signals, including:

Ayers A, Miller K, Park J, Schwartz L, Antcliff R. The Hollywood model: leveraging the capabilities of freelance talent to advance innovation and reduce risk. Research-Technology Management. 2016 Sep 2;59(5):27–37.

Babraham Institute. The zero person biotech company. Drug Baron. http://drugbaron.com/the-zero-person-biotech-company/

Cook D, Thompson JE, Habermann EB, Visscher SL, Dearani JA, Roger VL, et al. From ‘Solution Shop’ Model to ‘Focused Factory’ in hospital surgery: increasing care value and predictability. Health Affairs. 2014 May 1;33(5):746–55.

Cullis P. The personalized medicine revolution: how diagnosing and treating disease are about to change forever. Greystone Books, 2015.

Does machine learning spell the end of the data scientist? Innovation Enterprise. https://channels.theinnovationenterprise.com/articles/does-machine-learning-spell-the-end-of-the-data-scientist

Eberstadt, N. Men without work. Templeton, 2016.

Europe’s robots to become ‘electronic persons’ under draft plan. Reuters. www.reuters.com/article/us-europe-robotics-lawmaking-idUSKCN0Z72AY

First 3D-printed drug just unveiled: welcome to the future of medicine. https://futurism.com/first-3d-printed-drug-just-unveiled-welcome-future-medicine/

Ford M. The rise of the robots: technology and the threat of mass unemployment. Basic Books, 2015.

Frey BC, Osborne MA. The future of employment: how susceptible are jobs to computerisation? Oxford Martin School, Oxford University, 2013.

Generation uphill. The Economist. www.economist.com/news/special-report/21688591-millennials-are-brainiest-best-educated-generation-ever-yet-their-elders-often [accessed December 2016]

Lakdawalla DN, Bhattacharya J, Goldman DP. Are the young becoming more disabled? Health Affairs, 23(1-2004):168-176.

Susskind R, Susskind D. The future of the professions: how technology will transform the work of human experts. Oxford UP, 2015.

Topol E. The creative destruction of medicine: how the digital revolution will create better health care. Basic Books, 2012.

With Samsung’s ‘Bio-Processor,’ wearable health tech is about to get weird. Motherboard. http://motherboard.vice.com/read/with-samsungs-bio-processor-wearable-health-tech-is-about-to-get-weird

Small might be smarter, think hive mind for innovation

Healthcare systems are often seen as requiring an economy of scale. This in part is a function of how prevalent diseases are, such that in some small countries they would have one case in 2 years, rather than one case per million of population. Healthcare technologies can be incredibly pricey; for instance, a proton therapy facility will run between €100 and €200 million to set up. Healthcare buildings and research infrastructure are expensive to build and run. Health professionals can be expensive to train and employ and are generally globally mobile.

Associated with investment in healthcare within the EU, we find that almost every region or member state has life sciences, in some form, in their top 5 or so areas of national priority. Life sciences is challenging and demanding, and requires high degrees of global visibility and connectivity to other researchers. Commercialisation of life sciences in Europe is not great; the EU’s research budget does not strictly speaking focus on research translation and there is precious little to help good ideas bridge the ‘valley of death’ where unfunded good ideas go to die. Financing for life sciences developments consume vast quantities of risk capital, some of which will be unlikely to return any value for a decade or more. The problem is not for the EU, but for the risk appetite in member states: it is difficult to raise more than €30 million or so in venture funding in Europe. The brooding presence of state interference in entrepreneurial start-ups can be discouraging. And with the UK leaving the EU, a liberal enterprising culture will be lost within the EU. Statist solutions in Europe tend to dominate.

Many EU countries try to avoid downside risks of failure by punishing it, rather than creating opportunities to learn. Countries that encourage risk taking, and make it easy to start and close down companies, with associated flexible labour practices, will outstrip protectionist fearful countries. Many countries protect jobs not workers, so actually create unemployment and discourage job creation. Life sciences is one such area that requires particular flexibility owing to the nature of the work.

Small countries are particularly interesting. In one of the EU’s small states, there has been active progress developing a bioscience research and commercialisation centre (partly funded by the EU, thanks for that). Higher education is active across life sciences, though the research is of middling status globally, but that is typical of most of Europe’s universities. The country has a well-developed and well-financed healthcare system, recognised as one of the best globally based on outcomes.

Building life science (or any research-based commercial capacity for that matter) means that setting priorities is more important the smaller you are, as you can’t do everything. That means grappling with disappointment as not everything can be done, and if trying to do everything, mediocrity abounds. It means, too, that infrastructure projects are precious, as they are enablers of future potential — the longer term vision must be sustainable, as getting it wrong can be expensive — research buildings don’t make very good hotels and what do you do with failing science parks like we see across Europe.

What Cognology says.

  • build on what you already are doing well as that is evidence you have the expertise, networks and working practices in place
  • keep in mind that life sciences is much, much more than drugs; progress may be quicker in other areas, such as informatics, telecommunications, bio-engineering, materials science, agricultural biotech, etc.
  • you can’t sensibly do life sciences with a weak university, so this entails difficult and hard rethinking of priorities and a sensible review of research productivity
  • you can’t sensibly do life sciences without a teaching hospital; the academic health science centres in the US account for over 80% of productive life sciences research, so the infrastructure should enable closer collaborations and alignment between university and hospital and industry; this may, by the way, raise real issues for government if the teaching hospital(s) is state run and therefore subject to bureaucratic overhang
  • you can’t sensibly do life sciences without understanding the logic of ‘bench to bedside’; productive work lies in translational research and solving clinical problems; this can challenge academics whose careers are rewarded from the production of papers and volume of research funding rather than solving problems; in life sciences, solving problems is paramount; understand what the Grand Challenges in life sciences are and see which one(s) you can focus on and ignore the rest
  • you’ll need to consider the economic developments that come with building a life sciences sector to energise high net worth individuals in the country to develop a risk appetite for national investments along with a cadre of managerial expertise to take start-ups forward; I’d discourage doing this through the public sector hiring as it disincentivises university graduates from pursuing entrepreneurial careers (there is good global evidence that this can be a problem, so don’t make that mistake); best role for government is ensuring a flexible corporate start-up environment, a non-punitive bankruptcy regime, sensible taxation of start-ups, and seed funding; it might also be a good idea to give away all that publicly owned intellectual property
  • finally, the good news is that size doesn’t matter for innovation; there is no correlation between the size of a country and the ability of the country to innovate; many very large countries have clumsy policies that disincentivise and frustrate; the EU is full of them and in the main, the governments have assumed the wrong type of highly interventionist policies rather than creating an enabling culture that does not punish failures and really does reward success.

Does the European Commission ‘game’ the member states?

It is in the interests of the Commission to play countries off against each other in order to demonstrate the inescapable logic of the “European project”. The Commission suffers from the so-called “secretariat problem”: it is not a member state but a “secretariat” for the member states, and in this way pursues its own interests despite having been established by its members to further their own objectives. Secretariats do this, and take on a life of their own.

Various treaty language broadly excludes healthcare from EU policy making. The European Court of Justice has defined cross-border consumer rights. The European Commission, mindful of these, walks a thin line creating policy in the interstitial spaces that have the indirect effect of wagging the member state dogs. But that is the Commission defines its role in the absence of countervailing and/or collective action by member states. Consistent with bureaucratic behaviours, it focuses on technical issues, which in time come to define and constrain the policy spaces that member states have to deal with. The result is that member state autonomy and decision-making is constrained by prior technical issues.

The challenge is altering or indeed revoking the European Commission pan-European agenda set by the treaties, and which gives them license to literally expand like a gas into adjacent policy areas (arguing expediency rather than formal competency). This behaviour is well known in bureaucracies. It is not helped by the Commission being a monopoly supplier of legislation. Monopolists always do this.

What is more perverse is that the Commission has the mandate for ever closer union, which operationalises activities which undermine inter-state cooperation and collective or joint initiatives, undermines national interests, or more strongly, replaces the national interest with the “closer union” logic.

We now know that ever closer union cannot be an operational goal as it only feeds greater justification for the Commission to act — remember it is a monopolist defining its own scope of practice. When the Commission acts, members states must react.

What Cognology says

In these days of the UK in/out referendum (23 June 2016), it is timely to review the functioning of EU institutions including the fundamental logic of the Commission.

 

Ant hills: design logic

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

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

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

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

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

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

What Cognology says

Think of hive minds and ant hills when designing systems to be intelligent.

Thinking like a virus

Ebola  is really quite a horrible little bit of DNA. Its route to humans is via the fruit bat and between humans through body fluids. So much for the public health model.

The virus is taking advantage of humans with poor lifestyle, illiteracy, folk medicine, weak healthcare systems and lack of awareness. If it is true a 2 year old is person zero, how did that come to be? The public health model wants to find the person, but what we really need to understand are the conditions for zero to become infected. That means mapping the ecology within which the virus operates.

Outbreaks, epidemics, pandemics should be understood as an ecology combining information, biological and social strands which track the infection production process.

We’re in the middle in the countries at risk of the Ebola outbreak, and at the beginning everywhere else (even a case or two does not a crisis make). Nigeria may now be coming out the other end. The key is to build into our response an anticipatory and first response capacity throughout.

The real test of how these three countries will emerge from the Ebola crisis depends on what they are now putting in place for the Post-infection phase. Typically, events such as these emerge, get dealt with quite quickly (as in the case of other Ebola outbreaks), but building in anticipatory and response capacity is not a resulting priority. Better organised healthcare systems will handle situations like this better.

The three at-risk countries have weak governance, score low on Transparency International’s corruption scale, and low on WHO’s Human Development Scale, all characteristics of failing states.  It is not inconceivable that these countries could collapse; the historical record shows that other civilisations have collapsed from disease.

Since weak healthcare systems are contributive to the problem, improving access to care and reducing the cash component would require improving the economic performance of the country itself. That comes with greater trust in government and confidence in the future. So there are tools and techniques that can be deployed to help.

Consideration should also be given to more integrated, ecological models of how viruses and infections work, what some call “conservation medicine”. Many of the problems of pandemics arise from unnecessarily narrow specialised focus and adoption of particular disease transmission paradigms that marginalise knowledge in related areas.

Without being too draconian in this respect, some rethink is appropriate of the prevailing public health driven model, characterised by high degrees of alarmist rhetoric and hyperactivity, to achieve a measure of integration particularly around pinch points in the flow of information for effective decision-making.  A ‘systems model’ would start with the likely inaccuracy of diagnostic tools (which both over- and under-report). There is also a general weakness in animal and human disease surveillance and corresponding weaknesses in subsequent information management.  What we know from thinking like a virus is that humans can be just as dangerous as the bats that originate the virus, but we use different logic when dealing with humans as with the bats.

Compounding he problem with Ebola and other zoonoses of that type is that our ability to collect information and act is slower than the pace of spread.

Obviously screening people at airports makes sense within the public health model, but makes little sense from the point of view of the virus itself. Regretfully, quarantining whole countries may need to contemplated. Screening at airports does little when the origin is people arising from stricken regions. What do they say about closing the barn doors after the cows have left?

But we must learn how to think more like the virus, so we react more quickly, and ensure the virus will not have the opportunity to spread.  After all, that is what the virus wants to do.

About the three most at-risk countries

The countries that are the core to the current Ebola crisis are Guinea, Sierra Leone and Liberia. Using WHO Human Development data (from here), we learn that these three countries are classified as low development countries: Liberia is ranked 175, Guinea 179 and Sierra Leone 183; there are 187 countries on the list. They spend less than 3.0% of GDP on education (closer to 5% is associated with higher education attainment levels) and with literacy levels below 50%. Expenditure on health as a percentage of GDP shows they are essentially cash-based systems, which given the relative poor human development means access to healthcare will be income rather than need linked — they have health systems for those who can afford it. Transparency International ranks these countries toward the bottom (more rather than less corrupt) with scores below 30 (see here). All very worrisome but indicative of national priorities at odds with the needs of the country. Many are more prone to conflict than care.

What Cognology says

Dear Virus

There are some excellent countries for you to consider: poor literacy, poverty, unhealthy population with low life expectancies (under 50 years or so), internal strife and conflict, corruption.

Guinea: spends 6% of GDP on health, of which 67.4% is cash

Sierra Leone: spends 18.8% on health, of which 74.9% is cash

Liberia: spends 19.5% on health of which 17.7% is cash (best of the three in that respect)

Want to know more?

Laurie Garrett’s The Coming Plague, 1994. See here at Garrett’s website. And they say prophecy is dead.

The Magpie revisited

The Russian “United Art Rating” is an artist rating service of the Artist Trade Union of Russia and which uses the following scale for rating artists

artist at work

(nationally and internationally) [source here]

  • 1 – an artist of world fame, tested with time (for more than a century).
  • 1A – a world famous artist.
  • 1B – a high-class professional artist with remarkable organizational skills, who is popular and in demand.
  • 2A – a high-class professional artist with a bright creative individuality.
  • 2B – a high-class professional artist, recognized and in demand with the art-market and public.
  • 3A – a professional artist with a recognizable individual style.
  • 3B – a professional artist, recognized and asked for in the art market and by the public.
  • 4A – an established professional artist with creative potential.
  • 4B – an established professional artist, who is in demand in the art market.
  • 5A – a formed professional artist with creative potential.
  • 5B – a formed professional artist.
  • 6A – a forming professional artist with creative potential.
  • 6B – a forming professional artist.
  • 7 – an amateur artist with perspective evaluation of specialists.
  • 8 – an amateur artist.
  • 9 – an artist-beginner.
  • 10 – an artist-scholar.

I like the fact this scale enables me to distinguish between artists qua artists and artists that focus on the market. The categories also distinguish creative aspects (A) and one category higher than the same artist with a market focus or popularity (B). This helps distinguish between the pull of the market from the push of the artist.

What they don’t give away is how they assess creativity, innovation, but perhaps that is best left to them, but I would dearly love to look inside this assessment ‘black box’.  I think the Artists Union would approve of my notion of magpies, and may even agree that there are vampire artists.

Now, how can we apply this to art education to ensure that the ‘vampire’ art schools are distinguished from truly inspirational educational environments. Then I’ll be even happier!

For those so inclined, it is known that there are historical chains of connection between Nobel laureates and innovative research work. Would it be possible to chain link the artists together (apart from the traditional approach to grouping artists in schools as such) to identify particularly productive chains of innovation and association.

 

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Equity but what about outcomes?

The US-based Commonwealth Fund has released a new 11-country comparative ranking of health systems.

Before the UK pops the champagne corks, let’s decode this ranking a little bit. Oh yes, before we also get too excited, rankings like this are useful only as a discusion tool. What does it say say operationally, if you had to choose a system to be ill in?

In effect the UK is tops and the US bottom, overall. But there are some disturbing issues with the data that necessitate a reflective pause.

If the UK is 1 for Quality of Care, and 1 or 3 for Access, and 1 for Efficiency, why doesn’t that translate into Healthy Lives? If the US is middling for these, which it appears to be, are we surprised that they have poor efficiency, equity and healthy lives?

What strikes me is that the UK despite having scored 1, that all this effective care, etc. is really ineffective as it doesn’t translate into better results. Efficiency, too, seems a technical measure, and one which also seems to fail to translate. So two quite different systems on the ground, and which are poles apart on the ranking, are competing with each other for impact on people’s healthy lives.

If we look at the other countries through that same lens, we’re struck by how much better they are at driving improved results (in the jargon of the Fund: mortality amenable to medical care, infant mortality, and healthy life expectancy at age 60. It seems to me on this basis, that while France has poor access (really!), it produces the highest ranking for Healthy Lives. Now isn’t that the point of having a healthcare system in the first place? Something else is going on that this ranking is illustrating but which isn’t being drawn out from any commentary,

What Cognology says

  1. The reason the US is last on Healthy Lives is mainly ideological and not for a lack of trying to things better, but regretfully, only for those who have insurance cover, with eye-watering variances from state to state. I do find this surprising to some extent as the US is very well served by a research community that analyses costs and treatment flows and the ability of payers to drive incentives into the system. Perhaps the distributional inequity of access will pass the reform, while the relative inefficiency may be a measure of the tolerance of a wealthy country has for ensuring people who can afford the care do in fact get it. Hmmmm.
  2. The failure of the UK to translate all those 1’s into Healthy Lives is evidence of the dysfunctional nature of the design of the health care system to actually deliver care itself and a fetish with structural reform, rather than organisational reforms which would enable other models of care to emerge. This focus on driving out variance actually drives out innovation rather than enables it: the UK’s public health system eats its young and fails to bury its dead, so the system goes round and round, in some massive holding pattern and people wonder why things don’t change. The system is efficient once you get the care and access, at least defined in terms of general practice is great, but waiting times for tests and access to the hospital based specialists doesn’t really translate well into timeliness. I question the 3 for the UK as countries with direct access to specialists enjoy much quicker access to care and this indeed does translate into the higher Healthy Lives rankings we see.
  3. I’m not sure how you can have a healthcare system that scores 10 for effective care and 2 for Healthy Lives. If you’re getting ineffective care, wouldn’t that translate into poorer results like in Sweden? Hmmmm, again.
  4. It is interesting to see how poorly performing very wealthy Norway is, but then it has a state-run monoply health system. But again, how can you square all those 11’s?  Are the poor results evidence that a state-run bureaucracy is not working? Probably.
  5. Canada’s system is a fragmented mess at the best of times, and affected by a powerful mythology about its performance, premissed mainly on it not being like the US. Restrictions on patient access to care are systemic, and designed in by the slavish belief in the Canada Health Act prohibiting alternatives. A real policy straitjacket, I think.
  6. Finally, the one’s that in the middle, so to speak, Australia, Netherlands, Switzerland may be more worthy of further consideration.

 

Physics Envy: or why art theory isn’t

The September issue of Frieze art magazine is all about ‘theory’ or what appears to pass for theory in the art world.  The whole issue reads like some undergraduate magazine or

Confucius 02

He understood. (Photo credit: Wikipedia)

papers prepared by graduate students with too much time on their hands; political polemic blends with obscure language, which even core Frankfurt-school-istas would find hard to follow.  All this is to be regretted, as underlying this enterprise is an important problem, namely what are the theoretical, as opposed to philosophical, underpinnings of art itself.  Unfortunately, what might have been an informative examination of the problems of theory and art is really just another barrage of intemperate criticism.  But is anyone listening or is this just so much solipsism?  What’s an intellectual to do?

Physics envy is the desire to have the theoretical rigour that characterises physics.  Many will reject this in the art world, but why else would they confuse theory with philosophy if they didn’t see theory as bestowing rigour, logic, structure, and deep meaning?  The whole issue of Frieze waffled back and forth between the two terms, citing as theorists people who wouldn’t recognise the word, and citing theorists whose theories lack any basis for verification or falsification.  The leap from philosophy to theory is a big one, taken by science years ago when it ceased to be called ‘natural philosophy’.  Politics got rebranded ‘political science’,  and economics has always had ‘physics envy’.  What now for art?

The other distressing theme running through the issue is the Western-centric mind-set; they are still fighting the tiresome battle between Continental philosophy and Anglo (sic) analytical philosophy.  In this myopic battle they miss wider philosophical progress. Readers may enjoy the challenges ranging from Richard Rorty’s Philosophy and the Mirror of Nature to VS Ramachandran & William Hirstein, The Science of Art: a neurological theory of aesthetic experience, Journal of Consciousness Studies 6(6-7, 1999):15-51.

What we have is something vaguely called “critical theory” even more vaguely a “theory of artists’ minds”; I guess the word ‘critical’ suggests serious self-reflection when it really is quite empty. The ‘theory’ it ain’t.

But perhaps cultural studies sounds more scientific, (physics envy?) and less, well, less philosophical, and its practitioners more legitimate (in the sense Habermas would use it).

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