Tag Archives: Policy

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)


Commercialisation is a bet on the future

In this Age of Austerity, good ideas risk being lost. The dynamics of funding of innovations has always been full of risk. But as various debt-laden governments try to balance bloated public balance sheets, should we worry about where the ‘next big thing’ will come from? Yes, if you believe that governments can find and fund winners (the evidence says they can’t by the way, but can act as catalyst or midwife), no if you believe that the wisdom of crowds, otherwise known as markets, might be a useful driver of innovation development and adoption.

The diagram below summarises the funding of innovation, identifying in particular the so-called ‘valley of death’ where good and bad ideas go to die for lack of funding. The risk we, as taxpayers, face is that governments will continue to fund innovations into the valley of death, perpetuating what I call the ‘research funding welfare state’, where research happens, but innovations don’t. Hyperactive civil servants with indelible portfolios will continue to pursue dead-end projects despite evidence that the world has moved on. The real problem for governments isn’t finding money for funding research (though that is hard enough), but realising a simple algorithm:

  1. the world is characterised by change
  2. the world will change faster than our ability to respond
  3. this will not change.

Europe has a shortage of innovation gorillas compared to other countries, and if the politics of some countries are to be believed, would rather retreat into a safe haven of social solidarity and protected interest groups, than face the harsh realities of the modern world. This Fortress mentality will not keep the disruptive wolf from the door and will only add to domestic turmoil as native talent packs up and leaves for more encouraging countries.

The harsh reality of innovation is that it can be violent, overthrow trusted ways of doing things, and challenge what may be thought of as defining cultural norms and social innovation is just as much part of innovation as the inventions themselves. The other true thing about innovation is that it knows no favoured nation or culture — anyone and any country can do this.

Find the risk

What’s a Health Policy Forum for, anyway?

pictogram for silence areas

Silence, please, presentation in progress.

In these days when the use of taxpayers’ money to bail out failing economies, and politicians are grappling with rising public debt, it is always timely to reflect on how the Commission spends our money. Without obvious evidence that it understands the notion of ‘belt-tightening’, meetings where the minutes are taken and the hours are lost will continue to proliferate without some mechanism to constrain this upward spiral of expenditure. Can Council members constrain this growth with the funding of the European institutions, when they themselves are beneficiaries of the very same profligacy with taxpayers’ money in their own countries?

As health is my area of expertise, I am always interested in how the Commission determines its direction in the health space, how it uses the various agencies operating at the EU level to counterbalance the influence of the member states. And of course how criticism is absorbed or neutralised within this great steampunk machine.

I wondered about this when I was reading the latest (draft) minutes of the renewed (!) Health Policy Forum. I was struck by the possibility that this group is not designed to be a critical participant in the developing of ideas and therefore, I wondered what purpose it served.

There is a clue on the Forum website: “The Health Policy Forum brings together pan-European stakeholder organisations in the health sector at EU level to ensure that the EU’s health strategy is open, transparent and responds to public concerns.”

But the efforts at renewal were designed specifically, as far as I can see, to align this group with the Commission’s workplan and to ensure that it acts favourably toward Commission initiatives. We read (of the opening of the meeting): “In her introduction to the meeting Ms Testori Coggi presented herself and underlined the importance, role and mandate of the EU Health Policy forum. She stressed in particular the importance of activities in the field of disease prevention and health promotion including lifestyle related activities and health literacy.” In other words, this is what is important, regardless of whether you think otherwise.  I have no difficulty with these as general goals but they are largely opaque generic terms. The devil is always in the detail, and that is what we didn’t read about.

The meeting must have been most enjoyable, as it seemed to consist of a parade of presentations (no doubt more ‘death by powerpoint’) by people telling the Forum attendees what they were doing. Why bring your brain to a meeting like this?

I was also taken by this interesting line in the minutes: “Member organisations of the EUHPF are in particular invited to talk to their constituencies in the Member States in view to engage as well the national, regional and local level with the aims and objectives of the EU 2020 strategy in order to strengthen the health and social impact in the implementation of the strategy.” In other words, your job it to get the word out, not to engage with ‘us’ critically about what the strategy should be. Do your job, we bought you lunch.

The minutes indicate that questions were asked, such as CPME’s on e-health and cross-border healthcare, to which the presidency ‘agreed’, but whether anything will actually happen isn’t clear. The questions were absorbed into the rhetoric of the meeting, with soft noises of agreement and acknowledgement. But nothing really challenging was asked (assuming the minutes reflect the dynamism of the meeting) and, no doubt, no one was offended.

I wonder if those attending knew they were quiety being co-opted to act as agents of policy rather than engage in a meaningful policy-oriented discussion within a market-place of ideas.

I guess that’s what a Health Policy Forum is for.

Is there a directory of entities like these, do we know what are they for, do we know what they cost, and do we know if they make a difference?

Am I bad tempered about this? No. I want these processes to work, I just worry that in the rush to be accepted as a stakeholder, these groups may neglect their critical perspective. One must always be mindful of rent-seeking behaviour by the Commission, especially when it comes to forms of consultation.

NOTE: The forum lasted one day, involved 10 Commission employees, a secretariat of 4 people, 2 people from the Council (Belgium, Spain) and some 67 people from the ‘renewed’ stakeholder membership.

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Forecasting the present to improve healthcare

Internet Splat Map

Real-time data with hidden patterns

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

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

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

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

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

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

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

Do you have suggestions?

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

Want to know more?

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

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

Nowcasting consumption using Google data is here.

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

On the difference between truth and fantasy

Negative prediction value in binary classification

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

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

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

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

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

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

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

Bonfire of the health system vanities: poly-mess

Firefighters trying to save an abandoned conve...

Lawmakers burning discredited health policies

‘Significantly, the core principles (and expected savings) of polysystems have proven difficult to achieve with more focus on the buildings rather than the changes to care and behaviours.’

So says a recently hitherto secret report that NHS London (UK) has been sitting on. What a surprise though. Healthcare change is difficult and the focus on so-called polysystems missed the point. In origin, they are really polyclinics, and well-designed would cut admission rates to secondary care; they would also bulk up on specialist services, including day-care work and short-stay facilities.

A bureaucratic orientation driven by doctrinaire thinking and misaligned incentives are clearly to blame, plus, of course, a fear, within the NHS of actual service reconfiguration and change that alters the structure and nature of clinical work.

Whether the new UK government coalition should actually stop the polysystems (a euphemism too far, I fear) is another question, as the underlying logic, used successfully in other countries is sound.  What really failed was management, and the vaunted commissioning system, which failed to demand, perhaps even conceptualise, service changes. No doubt, resistance from the clinical professions may have no small part in failure, but clinicians are been substantially disenfranchised from NHS reform, with the top-down, initiative driven thinking.

Less is more. Few but more substantial changes, may ultimately lead to the service and quality improvements.

Polyclinics are a missed opportunity, and having been badly conceived are now a tainted option. The political pull back to the status quo becomes a real a risk, when in fact greater effort than ever is needed to improve service delivery and productivity.

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Hospital as Nexus of Innovation

Alex Kosmas's nexus

Alex Kosmas "nexus"

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

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

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

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

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

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

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