Tag Archives: UK

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)

 

Why the scandal at the Veterans Administration health system matters to everyone

Health care systems

How to choose? (Photo credit: Wikipedia)

The scandal that has now led to the ‘resignation’ of the head of the US VA Health System matters to more than just the US and US veterans. The VA health system is the closest thing the US has to the UK’s NHS and to the health systems of many other countries where the state is the controlling force.

According to reports in the New York Times, three factors are relevant and expanded in Forbes:

  1. shortage of physicians
  2. perverse incentives
  3. culture of dishonesty

Boiling this down to critical factors that are relevant to systems outside the US leads to specific considerations to countries which try to control healthcare through greater state intervention:

  1. Physician shortages are caused in the main by health systems limiting access to medical schools (and indeed to other professions). There is far too much evidence that labour force forecasting is inaccurate and given the highly specialised nature of healthcare, we really don’t know how many doctors, nurses, etc. we need, just that it is unlikely the current system of rationing produces sufficient supply. While the costs of training of health professionals are high, the rewards are also high and of good quality. These benefits accrue to the individuals as well as society. Why, though, the public purse should subsidise this as much as it does, and also limit access needs to be rethought.
  2. Health systems use a variety of incentives to coerce or alter clinical behaviour. While putting doctors on the payroll is assumed to limit financial conflicts of interest, it embeds clinical behaviour within a managed system full of rules and regulations which invariably will put administrative convenience above clinical and patient needs. Falsifying records is nothing new, but using data to influence rewards only creates the incentive to game those rules to maximise the benefits. Gaming of incentives is not new, but it is possible to model/test whether the proposed incentives will work and how they might be perverse.
  3. Dishonesty is embedded in the culture of work, and rooting out dishonesty needs to go back to, perhaps incentives again, to understand why it is more beneficial to lie. This may exist more easily within highly bureaucratised systems, where people are dislocated from the patients, and see themselves simply tasked with ensuring the stability of the system. This is a tough one but in some countries doctors’ employment contracts explicitly put them in a conflict with their employers by emphasising the relationship between their work and costs.

As the US has noted on the VA, the system often put the doctor in a conflict of interest between the patient and their paymaster, the government. Many countries have the same arrangements and should not, therefore, be complacent.

It is certainly timely and appropriate for policymakers and those who think systematically about healthcare systems, to study carefully what happened at VA, and apply that learning on their own healthcare systems. I am sure there would be much to think about.

If anyone wants to do this, give me a call.

 

 

 

 

Academic Entrepreneurialism

The Academic Health Science Centre undertakes three important missions:

  • they treat patients

  • they conduct research

  • they teach the next generation of clinicians

The AHSC model, as a structured and integrated organisational form, is most developed in the US, Canada, Netherlands, UK, Sweden and a few others, and emergent in other countries.

They are a distinct and probably unique type of organisation, quite expensive to run (annual revenue streams on the order of €2 billion or more), very complex and home to a diversity of stakeholders. Often, AHSCs are thought of simply as teaching hospitals in a loose affiliation with universities but this underpowers their role.

The AHSC represents the most robust model of an institution that could be seen as sitting at the nexus of innovation and entrepreneurialism in health sciences. They essentially own the challenges facing us in the biomedical and treatment arenas, and have access to, or indeed may own, their own research capacity to solve those problems – they can be seen as both producer of new knowledge and consumer of it. And through their role in the intergenerational transfer of knowledge (i.e. teaching), they can influence future priorities, and clinical treatment practices within healthcare systems. As large and potentially well connected organisations, they have the potential to access considerable sums of start up capital, and spin-out a variety of new companies.

Not all teaching hospitals have the capacity to be an AHSC. Not all universities become an AHSC simply by linking their medical schools to a hospital, anymore than simply bolting on some labs to a hospital creates productive research capacity.

Virtually all countries, and regional economies, prioritise biomedical research probably within at least their top 5 areas of investment – despite frequently have significant deficiencies. While thinking that an AHSCs may be seen as the best local solution, local capacity can be lacking or weak. A critical worry is that AHSCs will be created from small, dysfunctional, and poorly performing institutions into large dysfunctional and poorly performing institutions, wasting public money, frustrating researchers and would-be entrepreneurs, weakening treatment capacity, and failing to deliver the innovations.

Internationally, AHSCs should be seen as sitting at the top of the healthcare pyramid, providing care from the simplest up to the most complex, and with unique expertise. While challenging to national/regional innovation strategies (which are often parochial in perspective), AHSCs should be at the forefront of international collaborations and integral to globalisation of knowledge transfer and evidence-based care.

Therefore, creating an AHSC as a driver of innovation and home to entrepreneur is not to be undertaken lightly.

One aspect of the AHSC that is particularly important to conceptualise and operationalise effectively is how they commercialise their intellectual property as a result of being both owners of problems, and creators of solutions to these problems. Risks here include inappropriate de-risking of research, premature efforts at commercialisation, confusion over ownership of the work itself, and conflict between institutional components on the methods to choose. These all track back into the AHSC itself, and how it is governed and how the executive suite and board, decide what can and cannot be done, or done well.

The paper draws on the author’s professional experience of working in an AHSC, working with an AHSC in thinking through their commercialisation strategy, and comparative policy research on commercialisation of research and strategies.

What is an Academic Health Science Centre?

AHSCs come in many forms. Understanding why particular arrangements are needed is important to ensuring that AHSCs are not created out of poorly performing component institutions. They are not simply an aggregation logic for pooling knowledge and capabilities. AHSCs can be vertically integrated providers through to a confederation of autonomous institutions. In some countries, the structure of AHSCs is accredited, mandated or otherwise designated, while in others, they emerge as a logical and rational solution to various research/ treatment/ teaching challenges. In addition, AHSCs also form networks for further collaboration.

Depending on national funding systems in higher education and in healthcare, AHSCs may have to deal with a large number of government ministries or agencies (in addition to health and higher education: social/community care, research councils, labour, industry/commerce ) which may be at differing levels in government (national/federal, state, local) as well as charitable and international sources. With this comes a diversity of public supervisory and oversight arrangements, which unsurprisingly may conflict on a number of levels: research priorities, service delivery objectives, degrees of institutional autonomy, and not to ignore the diversity of political interest which may complicate this further.

And within this mix, the challenge of coordination looms very large, to accommodate the autonomy of constituent parts, public accountability and institutional mission.

How should AHSCs organise themselves to conduct research and development for commercialisation?

AHSCs should be understood as accelerators of innovation. In virtue of owning the problems, they can disseminate new practices, enhance the evidence base for treatment options, and alter the very structure of service delivery itself.

Therefore, a critical issue for an AHSC is how they go about commercialisation, that is, operationalising the acceleration and dissemination of innovation and how they enable the entrepreneurial nature of researchers.

Particular challenges arise when higher educational institutions and healthcare organisations are state owned and run, with the result that staff (academics and researchers) are public employees or civil servants. This has the potential to create difficulties for individuals who may wish to be entrepreneurial yet retain their relationship to those issues which sparked the innovation in the first place.

Problems in this area have been raised by the French government with respect to the visibility and commercialisation of national research from state-owned laboratories and from the universities themselves. Institutional restrictions on commercialisation can create conflicts as in the UK where the universities pursue one approach while NHS hospitals use NHS/Department of Health commercialisation strategies.

External sources of seed capital are faced with constructing sensible funding arrangements in this environment. This has led institutions such as Karolinska in Sweden or Imperial Innovations in the UK to create an entrepreneurial subsidiary to deal with the commercialisation process. We are a long way from simple technology transfer here.

What are implications for policy: on research, on commercialisation and on higher education?

At some level, AHSCs are ill-defined in the European context, what their characteristics are, how they are organised and perform. Sensible investigation is needed to identify the performance, role and function of AHSCs in Europe, and to understand whether they are in fact a nexus of innovation or a quagmire of bureaucratic interference.

We need lessons and cases to draw on to understand how to structure appropriate innovation policies that may require the formation of high performing AHSCs that can be breeders of entrepreneurs. We also need to think beyond biomedical research as the potential scope of AHSCs includes innovations in systems and ways of working, health information technology and software, medical devices and not just medicines and so on. This nexus of innovation is very broad.

As someone who sees the challenge of AHSCs through both the institutional as well as policy lens, some key areas of priority are implicated and which are presented as conclusions:

  • Funding of AHSCs is not quite the same as funding the constituent parts, so national policies need to be harmonised if AHSCs are to become effective accelerators of innovation and enablers of entrepreneurs. This will raise coordination challenges for governments as the incentives they deploy may come from different pots of money with differing purposes.

  • Institutional design is important and only suitably high performing institutions should comprise an AHSC; this has implications for whether a national accreditation system should be used (England), or policies and initiatives to advance the role of AHSCs (Canada).

  • Commercialisation design is important and plays to national policies on public ownership of publicly funded research, whether state-owned research infrastructure should be disposed off to non-state ownership, with corresponding implications for the employment status of entrepreneurs. National taxation and entrepreneurial policies can be remarkably short-sighted and counter-productive; we really need to understand how bad some national legal frameworks are, and how good others are. AHSCs will be embedded in these legal frameworks, so how productive they can be is linked.

  • We really need to understand how national policies can encourage the introduction of high performing AHSCs where none exist, or prune the numbers of AHSCs if they have proliferated without also achieving high levels of (international) recognition and performance, or enable existing AHSCs to be real drivers of innovation.

NOTE:

Presented at the 2012 Entrepreneuriship conference in Maastricht in March 2012: see here for more details.

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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.]

Health IT Industry Canada/UK

Mike recently chaired an event for UK companies to explore the opportunities for health information technology companies in Canada. Sponsored by UK Trade and Investment, GLE London, and the Canadian High Commission, the event attracted a group of firms with expertise in this sector, to hear presentations from EMIS and RIM and also learn about R&D tax credits, FP7 opportunities and partnering opportunities that are often not exploited.

Opportunities abound in Canada as it seeks to enhance the uptake of information technology in healthcare. Canadian physicians have a low adoption rate of office-based clinical systems, while connectivity between hospitals and primary care is not well developed. The focus in Canada has seen public investment, mainly linked to InfoWay, being poured into hospitals systems, with very little actually where the bulk of clinical encounters occur, namely in primary care. Slow adoption of electronic prescribing systems, coupled with often weak and poorly defined provincial electronic health record implementation strategies suggest that market entry opportunities lie in bringing order out of chaos and demonstrating clear benefits for clinician adoption.  The companies attending this event had that experience and could bring this level of structure to the market.

The partitioning of health markets into provincial systems means market entry strategies must pay particular attention to provincial characteristics and objectives, and incentives, such as tax credits, but also links to provincial infrastructure and innovation opportunities. There are pros and cons to each provincial system from a market entry strategy where the Alberta system has clearly centralised to Ontario with a purchaser/provider split and major reform underway in Quebec. There are also opportunities in specific market segments such as military health, prison health, workplace health and aboriginal health, which are frequently ignored as firms tend to focus on the publicly funded system as a whole and ignore these specific areas of opportunity and which offer market entry. Working with smaller Maritime provinces for instance offers scalable opportunities.

In addition, Canada’s position next to the US offers firms access through NAFTA, to take advantage of the huge stimulus in healthcare technology that is linked to health reform in the US; providers are early adopters and invest in technologies, including clinical systems so there are market-based opportunities around, for instance, clinical decision-support systems.

My own presentation focused on the opportunities working with Canadian academic health science centres [AHSC], which anchor provincial specialist service delivery, research and professional training. Since they combine research, teaching and service delivery, they offer partnering opportunities across a wide range of areas, and have sufficient commercial freedom to engage in alpha or beta partnering as well co-investment with start-ups. While many are still tied to the traditional technology transfer or licensing model, other ways of structuring deals are available.  They are valuable sources of new technologies for early stage investment, and with a relatively small early stage health investment community, the AHSCs are always looking for new people to have commercial discussions with. There is considerable interest by the federal government to ensure that early stage firms do stay in Canada so jobs and opportunities stay domestic, rather than being exported mainly to the US. But risk aversion and apparent shortage of second round financing sees many firms find their future with US investors. The removal, though, of disincentives in the income tax act which made life overly complicated for investors (similar to disincentives used in Australia) by the current government may encourage investors to feel more relaxed about the income tax regime.

Universities: are they as smart as we all hope they are?

Edsel

News item in the UK: The sector’s funding body, the Higher Education Funding Council for England (HEFCE), announced (on 1 February 2010) that budgets are to be cut by £449 million for 2010/11.  This includes:

* A 1.6 per cent reduction (£215 million) in teaching funding;

* Research budgets will remain the same as last year;

* A 16.9 per cent cut in capital funding;

* A 7 per cent reduction for funding of special programmes and initiatives.

In a letter to vice-chancellors setting out the budgets, HEFCE said it recognised that the reductions will be “challenging” to institutions.

Now what is to be done? Predictably, the higher education sector in the UK is arguing that this will affect perhaps 200,000 students who won’t be able to get a university education. A few weeks ago, the sector argued that the UK’s place as a top tier home of higher learning was at risk — but that came from the elite Russell Group, which represents perhaps the top of the top universities in the UK.

There are a number of possible ways of thinking about this. A few:

  1. Universities already get a lot of money, and they perhaps could reduce their running costs — think of the disorganised structure of the academic year, think of teaching loads or confused performance management (is it teaching quality, research or publications??), and pretty good employment contracts. (I had one once.)
  2. There are too many universities trying to do too much, and perhaps it would not be a bad thing if some either closed or merged with another institution. The loss of the old polytechnics deprived the higher education system of a sensible alternative. Since comparisons to the US are frequently made, it is worth noting that some of the US’s top institutions are not called “university”, anyway, but ‘institute’ and indeed ‘polytechnic’. One could also look for new innovative institutions to emerge to challenge much that universities do. For instance, research institutions without university links, or which are focused on compelling issues — check out the Santa Fe Institute, for instance. Universities are not the only fruit!
  3. Cutting capital funding is not such a bad thing, given the horrendous financing of a state-sponsored capital funding body. Better universities learn how to build collaborative relationships with sources of capital, than expect their funding automatically to come from the state.
  4. Perhaps too much inadequate research is done, poor deployment of intellectual effort at reaching wider learning communities, responding to new ways of structuring learning beyond the rather tired full or part time dichotomy, and so on.

But of course, the key dilemma remains, what is to be done?

I take an optimistic view, but I would put the challenge at the door-step of the universities.

Rather than complain, prove that 800 years of public and private investment hasn’t been wasted, and come up with sensible solutions that would establish a sustainable approach going forward.  I doubt 200,000 or 200 students would be disenfranchised as a result, new ideas would emerge.

A recent book review in the Financial Times of Louis Menand’s The Marketplace of Ideas, would be a good place to begin some fresh thinking. The reviewer, Christopher Caldwell, notes:

Starting in the 1970s, professors, newly alert to injustices in society at large, took aim at credentialism and departmentalisation in every nook and cranny of American life – except, Mr Menand notes pointedly, their own. The professorial hierarchy continued to rest on a system of arduous PhDs (raising high barriers to entry), “disciplinarity” (denying the authority of the non-credentialed to teach or even discuss academic subject matter), and tenure (jobs for life). It was a system well-suited to monopolising bureaucratic power, but less well-suited to the free flow of ideas. Menand cites a 2007 study to show that, in the 2004 presidential elections, 95 per cent of the social science and humanities professors at elite US universities voted for John Kerry and 0 per cent (statistically speaking) for George W. Bush. Monopolies produce smugness and sameness in universities, just as they do anywhere else.

The title of this blog entry takes from a line in the film Independence Day, where the President says to the Geoff Goldblum character, ” And we’ll see if you’re as smart as we all hope you are” It is now time for the universities with their massive subsidised top-tier braintrust put on their thinking caps, stop playing victim and take responsibility for the solution.  The university-based economists let us down quite badly with failing models of our economies, and we are all paying for it in one way or other. Let’s not see two in a row.

Who owns a health profession?

Florence Nightingale, pioneer of modern nursin...
What would Florence do?

Who owns a profession and who should take responsibility for its development?

In the UK, the Prime Minister’s Commission on the Future of Nursing and Midwifery has been working away for awhile to determine the future of these two professions, so lets reflect on this question and look at what this Commission appears to be thinking.

The most obvious observation is that it appears to be thinking of nursing and midwifery within an NHS context. Many nurses work outside of the state-sponsored NHS, such in prisons, nursing homes, private and independent settings and workplaces. The Commission’s focus, therefore, on defining the future role of the profession suffers from a dilemma and in resolving this dilemma in a particular way, may further limit these professions to what the NHS defines as its role. This is particularly worrisome given the dire need for fresh and innovative thinking particularly from such a broad and diverse profession as nurses and midwifes which may indeed need to challenge current political and policy thinking.

I wonder whether, too, it is indeed appropriate for the ‘state’ to sponsor this type of work in the first place. The selection of those on the Commission is probably subject to various criteria — one can only hope that these folk are able to address the work of these professions in non-NHS settings in the first place, and secondly can address the dire need for fresh thinking about future demands and innovative approaches to service delivery, however and wherever.

The other concern is the tendency of these sorts of activities to become a restatement of warm words of praise, and in the end fail to move beyond that to address the underlying interconnectedness of clinical work, the interprofessional relationships and clinical responsibility and indeed to more disruptive and potentially more professionally satisfying professional development itself. Regretfully, the so-called “summary vision” is a weak and predictable statement.

There is nothing inherently wrong with addressing the needs of the NHS, but to address it to the exclusion of the legitimacy of the wider and likely future roles is a mistake.  Indeed, the NHS is a stakeholder in the development of these professions, but should not be given too much authority or control over how the professions develop. When the state steps in, as it has in this case, it should do so with the assurance of fairness to the widest possible range of interests, and not just those that fits its current, and probably ideological, preferences.

In the end, the professions own themselves (in an important relationship with their regulator) and should act to ensure that they confront these issues responsibly. Is it a sign of weakness perhaps that this Commission was even needed? Perhaps therein lies a clue to the future of these professions: take responsibility for your profession, as if you don’t others will.

Speaking truth to power

Stained glass window of St. Thomas Becket in C...
Thomas Beckett spoke Truth to Power

Professor David Nutt, chairman of the UK’s Advisory Council on the Misuse of Drugs, is now a former chairman. He has joined by other scientists (2 so far) resigning in protest as the government’s heavy handed dismissal of Professor Nutt.  The minister, Alan Johnson, has said he had ‘lost confidence’ in the scientist for something he wrote in a scientific article.

The thought police are out in force once again.  But more important is the apparent abuse by this government minister of the whole point of advisors.  They must speak truth to power. In the absence of the speaking of truth, we will have self-censorship, political correctness, and general bowing and scraping to the political powers.  What the politicians don’t get, and Alan Johnson in particular, is that a candid and often challenging relationship is part of this delicate balancing of truth and power.

Indeed, there is clear abuse of power in silencing critics. There is a candle that burns in Canterbury Cathedral, testimony to this very issue (referring to St Thomas Beckett).  Truth is the first casualty of ministerial hubris.

In the end, we, that is taxpayers, and the general well-being of society, suffer when ministers can be so cavalier in dismissing people they don’t agree with.

Distinguishing between giving advice based on science, and political commentary is difficult navigation, as both scientists hold political views, which ministers may not like, while ministers may express scientific commentary with little grasp of its meaning.  Both can get it wrong, and much nonsense has come out of the mouths of both scientists and politicians.  But rather than shoot the messenger, politicians need to remember that they are in the main wholly dependent on right-minded scientists for advice, ones who will often hold dissenting views from the ‘spin’ that ministers seek to put on science itself. Einstein and colleagues understood this when they wrote to Roosevelt about atomic energy in 1939. It is worth noting that the US government dragged its feet on this letter until at least 1941, and it was not until 1942 that the Manhatten project began.

It is worth listening, even if you don’t like what you are being told. If scientists and advisors must speak truth to power, so power must listen to truth.

Such is the politician’s duty. Pity such duty is so poorly observed.

Smart Hospitals

The elephant in the room in healthcare is the hospital, about which I have suggested that we will build the last one in 2025.  What will “smart hospitals” look like, and why should we care?

Hospital Universitario Marqués de Valdecilla, ...
Hospital Complex, Spain

Why should we care?

Hospitals are expensive and complex labour intensive organisations originating in industrial era thinking.  Little has been done to modernise the institution itself, although much has been done of course to improve what hospitals do. We also know that hospitals account for a considerable carbon burden and consume a huge amount of energy since they operate 24 hours a day. We know that as labour intensive institutions they suffer from the challenges all such organisations face as they try to improve operating practices and reduce running costs. Healthcare delivery is characterised by regulated cartels, which serve both to protect the public, and protect professional practice from incursion by other health professionals.  A bit like an early 20th century factory with craft guilds.

We should care because these institutions need to become smarter in the use of modern technologies and practices, but this process is slow and cumbersome, and while they evolve, the taxpayer is faced with paying the costs of institutions which in many cases should be replaced. This is not to say that those who lead hospitals are not focused on these issues, but only to say that their job is not easy and with the many vested interests around, challenged.

What would be refreshing would be leadership for clinical workflow change to come from the professions themselves, due recognition of their need to evolve and reform rather than simply protect the status quo.  We need these groups to drive change in healthcare, rather than waiting for politicians or Ministries of Health to set the agenda. Of course, informed and empowered patients will eventually not put up with much of the nonsense that confronts them when they seek healthcare, but that is another story.

What will they look like?

We are left with wondering how to improve how they do what they do.  Enter ‘smarts’. This brings together a constellation of forces currently abroad in the world, ranging from automated building management systems, smart grids, energy recovery systems, to wireless technologies in hospitals to remove the wires.

Coupling smart systems together creates networks that can link patients in their home to monitoring facilities and first-responder capabilities. With the added advantage of wireless, we have untethered remote monitoring.  In the end, we have real-time healthcare.

Smart hospitals will not need to define themselves in terms of their geography or location, that is in terms of buildings. They will define themselves in terms of two factors:

  1. their capabilities and
  2. how they deliver these capabilities.

Indeed, the organising logic of the modern hospital will be replaced with one akin to a dating agency — it will link people with needs to capabilities to meet those needs — built on a sea of clinical, and patient information, and connectivity to various organisations that can deliver the services (healthcare) that is needed.  This breaks the current approach to vertical integration (based on the industrial conglomerate model) and replaces it with the virtual hospital, a network of focused and tasked organisations.

I had scoped such an approach to a redesign effort for a teaching hospital, which would have replaced a campus model (mainly an old building and some attached add-ons) with a distributed and electronically-linked (ehealth stuff here)  network of perhaps 24 centres scattered across a city of a million or so.  But industrial era logic prevailed and they went with the single building.

I guess we won’t get smart hospitals until we have smart planning.

Interventional Radiology: Why the delay in adoption?

Magnetic Resonance Imaging. Timing Diagram for...
MRI timing diagram for spin echo pulse sequence (don’t ask)

Progress in healthcare can come from changes to the way clinical work is done.  An example is interventional radiology, which combines radiological investigation with treatment, in a single step.  It moves radiological technologies, such as MRI, CT, Ultrasound, from being mere diagnostic technologies to integration into the surgical work itself.

So why the slow uptake in the UK where a couple of years ago the Healthcare Commission, in one of its investigations, noted that this approach to treatment would have probably saved lives?

The NHS is a slow and late adopter of technologies.  Difficulties giving the necessary clinical freedom to health professionals means that important leading edge, but proven technologies, are slow to be adopted.  The exploration of novel approaches to offering clinical services, outside of hospitals, for instance, in free-standing “theranostic” (therapy and diagnostic) clinics would not only advance the cause of patients, but achieve a step change in service delivery by NHS providers.  Why aren’t the newly freed Foundation Trusts getting on the business of developing services wrapped around this approach to care?

People are obviously of good intent by urging reviews of funding to elected officials in the suitably hushed setting of the House of Commons, but in the gritty reality of healthcare delivery, creative solutions are needed to address not only the timely implementation of interventional radiology, but also overcome the fear of change, of novel technologies and of changes to  clinical practice that change and technology brings.

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